On the subject of continuity of care in hospitals

Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

Weekends and mortality

Several studies (Barba 2006, Marco 2010) have warned that pa-tients admitted on weekends have a hi-gher risk of dying than those admitted during the week. Now, two meta-analyzes (Ho-shijima 2017, Pauls 2017), the first with 88 studies and 57 million records and the second with 97 studies and 51 million records, corro-borate the previous findings showing death rates due to the weekend effect that could become almost 20% higher. There is no agreement between the researchers as to the causes of the phenomenon. An English study (Walker 2017), through an adjustment for clinical complexity, concludes that, with their data in hand, it’s difficult to attribute the poor results of the weekends to the supposed structural deficits of the hospitals (less templates or inexperienced professionals) and that more should be noted in the characteristics of patients who go to the emergency room on weekends or in the restrictions of community services. 

Discontinuity: a structural deficit

The large number of elderly and frail individuals who end up being admitted is making it clear that hospitals are governed by a fragmented model that is unable to respond satisfactorily to the needs of the most vulnerable. The persistence of immobility is surprising, especially when the recipe is well-known and proven: it’s a question of ensuring that when older people are admitted, they are offered a service in line with what they are receiving in the community, and that is why it’s necessary for the hospitals with multidisciplinary teams; the general practitioners, advanced practice nurses and social workers connected with their community colleagues, must share all the decisions they make, not only with the patients themselves and their families, but also with the primary care professionals.

The example of mortality studies during weekends is a reflection of a fundamental problem, since without guarantees of continuity of care; hospitals don’t have the most basic of conditions to be able to offer appropriate services to the vulnerable.

Jordi Varela

Editor