Nigerian Patients Dying Over The Weekend

Staffing levels fall to single or paired staff on weekends in many hospitals, and only emergencies can be seen

Terseer Daniel is bleak eyed as he recalls the day he became a father. The same day he became a widower, and his twin children orphans. It was an ordinary Saturday in May.

Daily Trust report continues:

Daniel and his wife Kumawesi, 20, were expecting their first babies. Scans showing a set of twins to be born in May already had the couple anxious about the birth and resigned about raising the babies.

Kumawesi went into labour early that Saturday morning. Daniel took her to hospital, a health centre close to their home in Mararaba, Nasarawa-just on the border of Abuja.

The caesarean section to deliver the babies went swimmingly. The result was a shock when Daniel delivered the news to neighbours over the phone.

“We were congratulating, we were celebrating,” recalls John Oche, a neighbour who relayed the news of the birth in the neighbourhood.

“I couldn’t go to hospital to see them. We were waiting for the family to return with their new baby twins. It was unexpected.”

So was the next call from hospital. Kumawesi was out of surgery, but the C-section had set off bleeding the surgeon was trying to get under control.

Two units of blood had been transfused. By night fall, shift duty staff handed Kumawesi over, and they continued. Sunday morning, Daniel returned home.

“We were swarming around him to greet him, to congratulate him,” recalls Oche.

But Daniel did not feel the euphoria of a new father. Neighbours asked about the twins. They were fine, he replied in a bleak voice. What about their mother?

Daniel spoke his shocking response in one breath. “She’s gone.”

The number of women like Kumawesi who die every day from childbirth-related complications is the equivalent of a jumbo jet crashing.

Some of the deaths are in hospital, but the location is not at issue. Instead, it is the timing. It is the “weekend phenomenon” – the overwhelming sense of dread that you are more likely to die in hospital on a weekend, compared to a weekday.

It is a touchy subject for health workers, many of whom chose anonymity to speak to Daily Trust for this story.

Hospital records have been difficult to get in the run-up to this story, and staff don’t openly speak about it.

Six doctors combing through records of Nnamdi Azikiwe University Teaching Hospital found 3,934 deaths going back 10 years.

They published their findings in the Nigerian Journal of Clinic Practice.

A total 1094 of the deaths were on weekends. Some 760 deaths occurred in either the male or female medical ward.

Between 1998 and 2007, the number of weekend deaths steadily increased year-on-year from 51 to 248 every year.

“The average weekend deaths were more in the male medical ward, male surgical ward, intensive care unit, labor ward, and obstetrics ward,” wrote Bertrand Nwosu, one of the six researchers behind the study.

“The labour ward, followed by the intensive care unit had the highest weekend to weekday death ratio.”

Myriad factors push the conclusion of higher chances of death when admitted to hospital on a weekend.

“By Friday, you are already rounding up work for week, that means getting into weekend mode,” explains a pathologist at a federal hospital in Abuja.

“It doesn’t mean the work reduces. It just means you push yourself to come tidy up more paper work on a Saturday, even though you are not exactly required to. Or you just wrap up till Monday.”

The pathologist is in residency and his weekend means almost no pathologic services at his hospital. His consultant doesn’t show up either.

In similar fashion diagnostic services like lab testing also close briefly. In severe situations, even pharmacies.

While doctors work every day-at least weekdays-consultants don’t. They visit on schedule and hold fixed-day clinics on appointment. At weekends, the offices are shut and only a really desperate call can bring them out.

Or passion, says a doctor who is hunting for a job at the moment. She interned at a federal hospital and has firsthand knowledge what the hospital setup is.

The setup requires at least a doctor on call at weekend, physically present on the hospital premises at least or half hour away at most. The young woman doctor drew many on-call duties.

“It is like working 48 hours at a stretch on your feet, when you are on call. And you just have to be everywhere,” she says. The typical situation she recalls is a single doctor or a pair of them be on call for almost all departments of a hospital over an entire weekend. That means handling babies and adults, conducting deliveries and everything in between in the absence of senior consultants.

“You have to drag yourself through the weekend on-call duty, then dash home to take a shower and clean up and return to resume normal working hours on Monday morning,” the intern said. “You get so tired, overworked.”

That’s where mistakes come. Her friend, a gynaecologist, lost a baby while on call duty, she recalls, and is still haunted by the memory years later.

The pressure on overworked staff at weekend is increasing as more urban-based workers routinely put off hospital visits until weekend when they are less busy.

They are not emergencies but hospitals could see more patients than they expect at weekends. That is when mass casualties are likely to occur, according to Steve Ngene, a haematologist at a federal medical centre.

But he doesn’t think staff strength has anything to do with deaths at weekend.

“Most of the cause of death we have is by accident, because most people travel by weekend,” he says.

Many trips are the source of mass casualties and being rushed to hospital on a weekend straight from an accident scene has no connection with staffing level, he explains.

“Within the week, there is a barrage of regular staff, corpers, interns and all. When it [mass-casualty accident] happens at weekend, staff strength is reduced but it has no effect except you are looking at cause of death as a matter as a matter of neglect. But you still have enough staff to attend to emergency cases during the weekend.”

The emergencies are a different case altogether. A number of workers are specially designated for emergency at weekend. But support services to back them up fall short on weekends-and in some hospitals stay suspended till the following Monday.

Mudiaga Bello’s only son was born and discharged from a private hospital in Mararaba in one weekend of April 2014.

The newborn was sickly, jaundiced, and cleft palate. He spent days in and out of hospital. His first surgery at University of Abuja Teaching Hospital did not hold because it was “wrong time,” Bello said.

He still doesn’t understand what that means. He was convinced a surgery would work. His son died waiting for the surgery later in July 2014.

Bello is still convinced that his son’s discharge early from hospital because nothing could be done for him on a weekend contributed to the complications that later killed him.

A 24-hour, seven-day work schedule is yet far from public hospitals, which run like every other part of the civil service. Private hospitals also run a five-day week, with services scaled over weekend. Some are doing more than just skeletal services at weekends.

They would have to do more to convince clients like Kingsley Bala to schedule his hospital visit on a weekend, unless it is an emergency. “I only go to hospital on a weekday. That’s when you will find doctors there,” he says.

District hospitals in Abuja have for long fought with discontent about having pharmacies, diagnostic and other support services pared down at weekends.

Now some support sections open in district hospitals over the weekend-they run half day on Saturday and not at all on Sunday.

Beyond the aversion, nothing is really certain. Several studies have mapped causes of death in hospitals from different regions of the country.

One study over 2,172 deaths among more than 18,000 patients at a federal medical centre in the south east found the overall leading cause of death was infection, which accounted for sevenfold the number of deaths that resulted from trauma.

For three years, 11 researchers combed through medical records of 15 public and private hospitals in the FCT to determine exact cause of hospital death without segregating time of death.

Some 4,623 people died in the hospitals, excluding general hospitals at Kuje and Nyanya. Communicable diseases accounted for one in four deaths of males and 19% of deaths among females. Nine percent of deaths among males came from injury, compared to 3% among females.

Peak time of hospital deaths are after regular work hours, weekends and public holidays, hospital data show.

The Nwosu study cited reasons as poor communication between doctors, inadequate handovers at night and delays in contacting consultants have been implicated in some reviews to influence the rate of hospital deaths after regular work hours.

Highly critical report also exposed substandard decision making and a lack of involvement by senior clinical staff in the treatment of patients who died shortly after being admitted as causes of higher weekend death rates, the study notes.

It found hospital deaths on weekends have increased steadily over years for both men and women. But it did not find that they outstripped weekday deaths. Deaths during the week outnumber weekend deaths by nearly three to one.

Not all agree. Dr Chukwuka Ukpaka, of Crystalife Health Centre, says there isn’t enough data to conclude whether weekends pose more death risks than a weekday, but the period has all the factors that reduce the chances of optimal care.

The debate is ongoing, but is academic as far as Terseer is concerned. His motherless twins now live with an aunt, while he struggles for money to buy much-needed baby formula. He buried his late wife last month, on a weekend.