Rationalizing Orthopedic (and Anesthesiology) Weekend Coverage

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In a recent article, Dexter et al1 described the national weekend workload for anesthesiologists using data from the American Society of Anesthesiologist’s Anesthesiology Quality Institute. They compared the total percentage of national anesthesia minutes performed on Saturday and Sunday thereby estimating the prevalence of elective Saturday surgeries. They concluded that weekend elective surgery is an uncommon practice and recommended that before implementing weekend elective coverage, “a thorough statistical analysis of [the] local work-load” should be performed. Although we agree with their recommendation that organizations should consider local factors, institutional capabilities, and financial frameworks before creating an elective weekend block allocation, we also believe that an uncommon practice may still be beneficial. This is especially true in the field of orthopedic trauma.2
In large academic Level 1 trauma centers, the orthopedic trauma service typically maintains numerous operating rooms (ORs) during the day in an effort to minimize after-hours surgery. At some of the busiest trauma centers in the country such as Memorial Hermann Hospital in Houston, Texas, this can mean running as many as 4 to 6 orthopedic trauma ORs concurrently during the weekday and 2 ORs on the weekends. This push is, in part, the result of improved patient outcomes for daytime operative cases,3 decreased staffing costs, and the judicious use of multiple rooms staffed by a single attending (provided appropriate supervision of residents and fellows given case complexity). It helps prevent physician burnout by minimizing after-hours surgery, optimizes the sunk cost of OR staffing, and capitalizes on the flexibility of daily per-diem staffing when necessary.4,5 Also, many Level 1 trauma centers find it imperative to dedicate weekend OR time to orthopedic trauma in an effort to minimize the backlog of cases at the beginning of the next week and provide more expeditious patient care. These tactical and operational decisions decrease length of stay and increase patient satisfaction.5 Moreover, this paradigm allows for the opportunity to match the case complexity with the provider’s expertise and experience. For orthopedic trauma, the hospital seemingly should have better outcomes by matching the specialty-specific fracture patterns to those surgeons best trained to handle the case complexity (ie, acetabular fractures, complex articular fractures, and polytraumas).
Dexter et al 1 convincingly showed that weekend elective surgery is not a common practice in the United States. However, creating elective or unscheduled weekend block time can be beneficial for particular surgical services such as orthopedic trauma. We reject the thought that because weekend elective surgery is uncommon, it should not be implemented. Anesthesiologists, surgeons, and hospital administrators need to work in concert to determine whether elective or unscheduled weekend block time at their particular institution is appropriate to optimize patient care.
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