Over the Christmas and New Year’s Holiday this year, I had the privilege of serving as the attending physician in the Cardiac Sciences Unit (CSU) at my hospital – Kingston General – a regional academic tertiary care hospital in Southeastern Ontario. The CSU is a cardiac intensive care unit where we care for seriously ill patients with acute cardiac problems like heart attacks as well as those recovering from cardiac surgery.
I always enjoy working clinically. It is a great privilege to be allowed into the lives of patients and their families – particularly at times when they are vulnerable and scared. It is a responsibility that I take very seriously. We all do. There is no better job in the world.
As I walked around the hospital on Dec 26, from the CSU to the Emergency Department and up to the wards to consult on other patients, it occurred to me that the holiday period was a lot like a perpetual night shift.
Everyone who works in a hospital knows that there are two cultures: the daytime culture and the nighttime culture. At night, everything slows down. Most of the attending physicians are home. There are fewer nurses on the wards. Many of the techs, pharmacists, physiotherapists, dieticians, social workers, and others who help to care for patients are at home. Tests are harder to get. Consultations are on an urgent basis only. Everyone hunkers down for the night.
Now, this isn’t necessarily a bad thing. Not too many patients want to have their scheduled ultrasound at 2 in the morning, or have an elective gall bladder surgery in the middle of the night. The CT of the head to investigate seizures that have been happening intermittently for a few months can probably wait until the morning. And let’s not forget, patients need to sleep.
But what happens when we stay in nighttime mode for a week? What about when this night shift-like state lasts for several days in a row, as it does over the Christmas and New Year period?
In the hospital world, we talk a lot about patient flow. I’m not a big fan of the term, because I find it de-personalizes patients’ health care journeys. It seems somehow to reduce a profoundly important life experience to a bland and mechanical series of events; the efficiency of and speed at which all the therapeutic and diagnostic events that comprise a health care experience occur. Starkness of the term aside, it is useful to understand because it is precisely the impairment of patient flow that leads to suboptimal experiences for patients who are hospitalized over the holidays.
What does all this mean? What does slower patient flow over the holidays mean to patient care?
Well, if you have an emergent or urgent problem, you will be well cared for. If you have a heart attack, a gastrointestinal or cerebral bleed, a ruptured aorta or acute respiratory failure, you will be treated promptly and treated well, with all the best that modern medicine has to offer. This is the case all the time – night or day; regular day or holiday.
The patients most affected by the holiday slowdown, predictably, are those who are most vulnerable – our seniors with multiple chronic conditions who don’t really need to be in hospital anymore but are waiting to go home or to a long term care facility.
Over the holidays, family doctors’ offices close or have reduced hours. Home care scales down. Partner community hospitals – themselves in holiday mode – are less able to repatriate patients and in some cases even close beds. Social workers and physiotherapists are less available. Unionized employees from nurses to techs are entitled to 5 consecutive days at either Christmas or New Year’s, making staffing a challenge for managers. Not as many doctors are around. In the world of patient flow, there is push and pull. Over the holidays, the pull grinds to a halt. There is only push. All the usual barriers to getting patients to the next step in their journey get higher and thicker.
And so, patient flow slows. And when patient flow slows, bad things happen. Patients fall. They get hospital-acquired infections. They get sundowning and muscle wasting. They experience depression and despair. They languish.
None of this is readily apparent at first glance. Everyone is doing their job. Caregivers are compassionate and capable and I saw them do their jobs admirably. The diminished quality of the patient experience over the holidays is very hard to see when looking at sequenced events individually. It is the totality of the experience; the sum total of the subtle underperformance of patient flow that leads to the collective suboptimal outcomes.
Health care should be a 24/7, 365 day-a-year enterprise. A truly patient-centred system that was designed to serve patients optimally would never take a 7-day vacation.