When is the best time to check into the hospital? (Lee Celano/Reuters)Hospital patients who suffer cardiac arrest at night are more likely to die than patients whose hearts stop on the day shift, a new study shows.
The study, published today in The Journal of the American Medical Association, is the latest to show that patient care and survival appears to be profoundly affected by hospital timing and staffing issues. Other studies have shown that patients who receive hospital care on weekends do worse than patients treated during the regular workweek.
Cardiac arrest occurs when the heart stops beating suddenly, and it can be triggered by a heart attack or other emergencies like blood loss or respiratory problems. When a patient suffers cardiac arrest in a hospital, a “Code Blue” is typically called, and a team of doctors and nurses rushes to the bedside with a “crash cart” equipped with a defibrillator, drugs and other tools used to restart a stopped heart.
The current study examined cardiac arrests among 86,748 adult hospital patients at 507 hospitals during a seven-year period ending last February. The researchers compared survival rates by the time of day and day of the week that cardiac arrest occurred. Among patients who had cardiac arrest between 11 p.m. and 7 a.m., only 15 percent survived long enough to be discharged. That compares to about 20 percent of day-shift cardiac arrest patients who were discharged. Other measures, including 24-hour survival and favorable neurological outcomes, also were worse if the patient had a heart attack at night. The study also confirmed earlier research showing that weekday cardiac arrest survival was better than if cardiac arrest occurred on weekends.
The reality is that a patient whose heart stops in the hospital is typically very sick, and even among patients who have cardiac arrest during the day shift, survival rates are low. However, the data suggest that something changes at night that makes it less likely a stopped heart will be restarted. It may be that patients aren’t checked as often or that there aren’t as many staffers in the hospital to respond quickly to emergencies. Or it may suggest the skill and experience level of night hospital workers is lower than that of workers on the day shift.
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Also not a good idea to have cardiac arrest, or an acute life threatening illness, in the last weeks of June or first part of July when the most experienced residents and fellows leave and the new residents just out of med school start.
— MARK KLEIN, M.D.“It may be that patients aren’t checked as often or that there aren’t as many staffers in the hospital to respond quickly to emergencies. Or it may suggest the skill and experience level of night hospital workers is lower than that of workers on the day shift.”
Couldn’t it also be possible that people do not function as well at night, due to tiredness or circadian rhythms? And it’s common for hospital workers to be scheduled for grueling 12 to 24 hour shifts with insufficient sleep.
— hdavisworking in a full service hospital for approx. 10 yrs., it amazes me that monies would be spent on a study that basically has common sense results
— martinIt may also suggest that in the quiet times, patients are more resigned to their fate. Sometimes people slip away when we give them the peace to do it.
— David FitzsimmonsI have worked night and day shifts in the hospital as a technician/nursing assistant. I have also worked weekends. Staff is lower at night and on weekends. Many workers with seniority do not want to work nights and/or weekends. So you are on the right track that there are fewer and less experienced workers on nights and weekends.
I had thought I would change from a high-tech marketing career to nursing (I had been part of a massive layoff due to globalization). I completed a year’s worth of prereqs and was waiting to enter school (long waiting lists for nursing school). The working conditions in two hosptials that I worked at were appalling: understaffing, apathetic nurses, lack of handwashing, flouting contact precautions (relative to MRSA, C-diff.) I worked at hospitals with top reputations.
Another thing to note: stroke patients often go undiagnosed on nights and weekends as no one is there to run the diagnostic equipment needed to identify strokes. Very few hospitals staff this equipment 24-7 as it is just too costly. It disgusts me that hosptials that only staff the diagnostic in the day have the gall to call themselves a stroke center. The NY Times did an excellent piece on that about a year ago.
Healthcare in this country needs some fixing. It truly frightens me.
— Phoenix ResidentIt’s likely response time. As I recall, survival rate is about 80% if the heart is restarted by defibrillator in the first two minutes. But it declines 10% for every minute delay. A 20% survival suggests an 8 minute delay.
— William H CalvinMy wife’s aunt called one Sunday AM and said she was weak on the right side, her lips were drooping and she was slurring her speech, classic stroke symptoms. We told her to get to the ER, they did a scan told her she was ok and sent her home. By the next day she was totally paralyzed on the right side, where she remains 10 years later. Later during the week someone else read the scan and saw the stroke. Oops!
— RichI’d be interested to know if anyone was held i the least accountable for your Aunt’s mistreatment, Rich. I am furious at the stuff I hear that happens, not just on the night watch, in these places. Then the Supreme Court does its best to keep us from seeking damages or getting these fruitcakes they hire for the low wages they now pay, fired. I could write a book about my own experiences alone, and am convinced it’s the fault of not only downsizing of staff, but low wages. That means that the pool that Human Resources now hire from is so less competent, but more willing to accept the lower wages, and guess who suffers? Many act like they don’t care if they’re at the Convenient food store on the corner or a medical facility. They took whatever job they could get first. Health “Care”? Who are they kidding? Guess who loses? We do; our health; our families. And while I’m on this rant, I’ve been wondering why so many nurses are obese slobs who inspire zero confidence in me as a patient? Now they wear their street clothes and I even wonder about their hygiene.
— polarbearMy wife is an ICU nurse who use to work the night shift until recently. She use to come home, wake me up, and complain to me about her co workers. She said many night nurses were more interested in goofing off or sleeping than working. Also,the only doctors in the hospital were in the ER, and not always available to go up to her floor. When she was required to phone the on-call doctors at home, some would yell at her for disturbing them, and then order meds or a scan, without going in. I also heard postive comments about her shifts, but not as many.
— David ArmsTheres a 150,000 accidental deaths in hospitals each year, that number dosn’t include the people injured or made worse by the care they get. this is what happens when Medicine is for profit, patients become Chattle for Corporate Greed.
— curtSeveral points of clarification:
Patients in critical care units are universally electronically monitored for their heart rate and rhythm, and most often, “codes” aren’t called for these patients since most, if not all, of the members of the resusciation team are already physically present in the unit. Sometimes this is referenced as an internal code or a silent code.
Also, patients’ circadian rhythms and metabolic rates also come into play, and generally, they are at lowest ebb between two and five in the morning. Since nurses do not awaken all patients during each check, and not all patients are being monitored for heart rate and rhythm, it is possible that patients die without awakening or calling out in distress.
There are many variables in resuscitation success rates. The time of day, staffing, qualifiecations of staff, tenure of staff, degree of instability of patients, the presence of resuscitation teams, presence of board certified intensivists, hospitalists and emergency medicine physicians, the policy for the summoning and use of those teams, the adherence to AHA and IHI resuscitation standards, the presence of rapid response teams, and the overall institutional culture of root cause analysis and process improvement versus employee sanction and punishment for errors and process failures/weaknesses are all important pieces. And one more - the policy and aggressiveness of using do not resuscitate protocols. In institutions where these are weak or are not used by key high volume/high acuity admitting physicians, there may be more attempted resuscitations of patients with illnesses and injuries which are systemically overwhelming.
No single variable will account, in most cases, for the success or failure of cardiac resuscitation in any given facility.
— AnnieFrom TPP — this is all very useful. thanks for adding to the discussion.
To Rich-
— jimThe reason your aunt was not diagnosed the first day is because the stroke is not “seen” on CT scan until the tissue is infarcted, and this lags behind the first symptoms. If she was nonetheless still having symptoms, the ER doctor has to decide whether the risk of the medicines outweighs the risk, or degree of handicap, of the stroke. You can imagine how difficult this decision is if the patient’s symptoms have gone away at the time of the first visit, as is often the case. In spite of all the publicity about stroke centers, there is still very limited intervention, and it depends a lot on the timing. If the clot-dissolving medicines are given more than a few hours after the onset of the blockage, they dramatically increase the risk of bleeding in the brain. So if a person wakes up with a stroke, and has not been awake and symptom-free within the last three to four hours, the person will not get the clot-dissolvers.
In this case, “seeing the stroke” would not argue for giving the medicines- the area seen on the CT would be interpreted as an old stroke. You do not “see the stroke” until after it has happened. You do the CT at the outset to make sure the patient has not bled into his brain, in which case you would not be able to give the clot-dissolving medicine because it would increase the likelihood of more bleeding.
I’m writing this explanation because, 10 years after the fact, Rich is feeling bad because he thinks his aunt’s case was mishandled. I think if he were to talk to an ER doctor, or a neurologist, he would learn that there is no way of predicting whether or not a patient with a TIA (mini stroke) will go on to have a complete stroke.
The actual study presented in JAMA considered monitoring status and witnessing of the cardiac arrest as confounding factors, and there was still a difference in outcome between day/evening and night. It’s quite premature to blame the hospitals for this. It’s disappointing that the article really doesn’t present anything new that hasn’t been known for well over a decade regarding increased incidence of cardiovascular events in the late night/early morning hours.
There are well-established circadian variations in cardiovascular function (i.e., Am J Cardiol. 1997 May 1;79(9):1190-3 and Clin Cardiol. 1999 Feb;22(2):103-6), and this study provides no additional information to rule in or out the hypothesis that the progression of events leading to cardiac arrest is different in the late night hours due to circadian rhythms in cardiovascular physiology, and that this is the underlying cause of the higher death rates during those hours.
An interventional study in which patients are continuously monitored in-hospital during those late night/early morning hours would be required to determine if the higher rate of detection of patients in asystole rather than ventricular fibrillation really is due to insufficient monitoring/slow response times, or due to a more rapid or different order of progression of events leading to cardiac arrest during those hours.
— HeatherLet’s get to the heart of this, if you will.
I have worked in healthcare for 15 years in the ICU and the ER of many hospitals. I have also worked as the “off-shift” supervisor or night supervisor. The realities are these folks:
1. There are not enough healthcare workers in the US to care for the numbers of patients we see daily. That goes for nurses, aids and physicians.
2. The for-profit insurance industry has one goal: to pay as little as possible for patient care regardless of what is necessary.
3. Underfunded state and federal insurance programs don’t pay anywhere near enough to cover costs a hospital incurs in treating patients.
4. Education is cost prohibitive for many people to enter medicine.
5. Last, but certainly not least is the basic underlying level of expectations of Americans that they have no responsibility for their own health and that the medical community is responsible for “fixing” them no matter how much they have damaged themselves. Take note smokers, alcoholics, morbidly obese and others: we can’t make you better if you won’t help yourselves.
So, here’s the point: Fund a realistic universal healthcare system so that all have access to most care; make sure there is enough money to pay for real healthcare; reduce the cost of medical education; increase reimbursements for primary care physicians; eat less, exercise, quit smoking and don’t show up in my ER complaining of difficulty breathing after having just finished a cigarette.
— JohnI think there could be lots of causes, from circadian differences to staff levels to lack of doctors on call.
Perhaps there’s even something to the notion that more cardiac arrests that happen during business hours happen during physical therapy or other activity, meaning that someone is Right There and watching the patient. I’d like to see a direct comparison of patients who were sitting quietly or sleeping during the day, and patients who were sitting quietly or sleeping during the night, and see if there’s a closer relationship related to the difference between “Heart gave out due to physical exertion or excitement,” and “Heart just plain gave out,” as far as success in resuscitation goes.
— RowanBravo, John. (#14).
— asRight on, John. (#14).
I would just add that people would be more careful about their health if EVERYONE had a financial stake in it. I would be for universal health care if we had a national FLAT health tax.
— jackI was operated on on a Wednesday, bi-lateral mastecomy with reconstruction. As you can imagine, that is quite a trauma on one’s body. By Thursday, I had begun to have breathing problems. On Friday they put me on an oxygen tube to my nose. I kept telling them that I could not breathe. I was sleeping sitting upright in a chair because that was the only way I could breathe to sleep. By Sunday I could not breath without an oxygen mask.
There was no Doctor there on Saturday or Sunday to assess my situation, then here they come on Monday and wow, she’s really sick!! then they test my blood and I am severly anemic and have an extremely low amount of oxygen in my blood.
Finally on Tuesday, when I went into Acute respiratory distress syndrome (ARDS) took rushed me to ICU and put me on the ventilator. Then they moved me to CCU where I was semi-concious for 3 weeks. I remember very, very little of that time but remember a lot of the morphine induced hallucinations and nightmares.I had a soaring fever, placed under a cooling blanket and pumped with I don’t know how many anitbiotics. I went into sepsis. It has been almost two years and I still feel the effects.
Word - make sure you stay with your family members after surgery. And raise hell if you know they need help that they are not getting.
— Kathryn RanelliBack to the stroke,
Even if the scan was underread, or too early to see the stroke, her clinical findings of slurred speech and weakness were enough to keep her in the hospital and order a neurological consultation.
— riniI have many medical problems and have been treated by specialists for years. It seems to me that my doctors consider me as part of a steady income stream rather than a person who they are interested in curing. Blood tests every 3 months at a lab and a 10 minute exam is what I get for the $150 charged. No time to discuss problems with more patients waiting. And the normal Emergency Room treatment is a 5 hour wait just to have someone tell you what is wrong and usually it is then too late to do anything constructive for you.
The system is broken folks.
— AlexJohn, kudos,
I agree. Other plans are just an excuse for siphoning money out of the system and away from patients.
— rini“It may be that patients aren’t checked as often or that there aren’t as many staffers in the hospital to respond quickly to emergencies. Or it may suggest the skill and experience level of night hospital workers is lower than that of workers on the day shift.”
Or, it may be that 90% of the staff who is there, regardless of their level of skill, are asleep. Not long ago I spent every night for over a month at a hospital but was not a patient, nor staff. My husband was the patient with late-stage cancer and enormous levels of pain. After being at several different hospitals with him for short intervals of one or two days it became very apparent to me that often no one was paying any attention at night other than in the ER or in intensive care.
Though I was working full time, I spent every night while he was there, with him. I was told by the hospital that each floor had available convertible beds for use by family who wanted to spend the night. And I must say that it was welcome news to hear after attempting to sleep in a chair too many recent nights. The first night someone brought me a chair that turned into a reasonably comfortable bed.
Though he was being treated with enoromous amounts of amounts of pain meds, they often needed tweaking frequently, something that was not easily handled by “regular checks” by nurses during the night. All too often I was pacing the nursing station looking for someone to call the pain intern on duty that night. I quickly gave up trying to get someone to respond to the bedside call button. And it didn’t take me too long to find all the missing staff — and the bed that always vanished from my husband’s room in the morning.
In my five week observation, I learned that the staff devised their own hours during the night. There would always be one person awake on duty whle the rest slept. That one person was covering a large number of rooms. I often heard patients calling out for assistance for sometimes very long periods before anyone would bother to help them. I delivered more than one cup of water and went looking for someone to help other patients more often than I liked. Luckily none were in the midst of cardiac failure. But that was just chance.
The authors of the study should just spend a few nights in a hospital walking the halls to learn the reasons for the rise in night time mortality rates. The experience left me not wanting to spend a night alone in a hospital when I couldn’t be mobile enough or aware enough to seek help when needed! And the hospital is an extremly well respected one. I’m sure it is far worse in most others.
— ElizabethThe patients doing better are discharged during the daytime, usually in the am. The patients that are more ill are kept in the hospital or transferred to other facilities and then stay the night. The family will often alert nurses to any deteriorating conditions they perceive in their loved ones. Telemetry is used to monitor the patient, however there is a factor of the family monitoring (the patient) at bedside and this decreases at night. I do not agree that the skill and experience level of night hospital workers is lower than that of workers on the day shift. You simply have a different circadian rhythm in the night shift worker. Some the most experienced and best qualified nurses I have ever worked with were night shift nurses. There is a significant change in the number of available physicians, as like the majority of the world, they must work during the daytime, seeing office patients, etc.
— Dennis Lynn MDI wonder…just thinking out loud. I wonder if there isn’t also a dynamic that occurs similar to SIDS in vulnerable people–that when you are in a deep sleep, your heart can be vulnerable to arrest in the same way that newborn babies are vulnerable to SIDS when asleep. Something about the physiological state into which we descend when we sleep –especially since at night, with darkness and (relative) quiet (as compared to day) we are likely to fall into a deeper state of sleep. During the day, even if napping, there is more noise and activity to keep up from falling into the same extended depth of sleep. One of the theories of SIDS is that some babies fall into too deep a sleep for their vulnerable, immature respiratory system. Could the same be true for certain vulnerable adult hearts?
But I also know from experience that response rates to calls for nurses at night are very slow. When I had my daughter, my obstetrician warned me that the nurses working the night shift were by and large working mothers who picked the night shift for its reduced demands. She told me, ‘if you need help, you have to be insistent. Don’t buzz once and wait.’
And when my mother died in the hospital of a stroke, we were haunted by the words of her roomate telling us that she called for the nurse over and over in the night and no one came.
My husband and I have a pact — if either of us ever winds up in the hospital for something serious, the other one will be there watching over as much as humanly possible. You are vulnerable in the hospital in so many ways and really need an advocate at your side who cares about you personally.
— francoisI whole-heartedly share the natural concern and sentiment of “Martin” in his earlier comment about this article and, more importantly, about the underlying “scientific” study and analysis. The reported study is a prime example of how “science” and “scientific analysis” have become the current version of religion of the so-called “dark ages.”
How “dark” have we evolved? Check back in a few months when this “scientific” study will serve as the primary basis for diverting more funds, public and private, towards medical providers in affluent communities and away from inner city hospitals and trauma emergency centers.
— Saviz