The weekend effect in geriatric traumatic brain injury in tertiary hospital: an observational study

Introduction There were no previous studies discussing the comparison of the complications among traumatic brain injury (TBI) cases during weekdays and weekends. The current study aims to retrospectively compare the TBI outcome of geriatric patients on weekdays versus weekends in the neurosurgery department in a tertiary hospital in Oman. Methods This is a retrospective study, from December 2015 to December 2019. Medical records of 670 patients above 65 years and admitted to the neurosurgery ward were reviewed. From that, only 45 patients over 65 years, diagnosed with TBI and managed surgically were included. Results The study included 28 patients admitted during weekdays and 17 patients admitted during weekends. Nev‑ ertheless, the highest number of admissions was during Friday. The male‑to‑female ratio was 3.6:1 during weekdays and 3.2:1 during weekends. The average length of stay (LOS) was 12.4 days among patients operated on weekdays compared to 36.5 days on weekends. For average ICU stay, it was 3.9 days during weekdays compared to 32.2 dur‑ ing weekends (p = 0.011). Complications were found to be more common among patients admitted on weekends (p = 0.015). Conclusion Significant differences between weekdays and weekends were found. So, more trauma imaging facilities and neurosurgeons need to be available during the weekends.


Introduction
Currently, there has been an increase in the elderly population in high-income developing countries in the last 10 years and will continue to rise in the coming 20 years due to improved life, and by 2050, the American geriatric age group will triple in the population [1].Also, in Oman, there was an increase in the life expectancy in the geriatric age group population by 15.4% from 2013 to 2017 [2].Furthermore, traumatic brain injury (TBI) is responsible for the age of 65 and more than 80,000 emergency visit annually in the UK, which negatively influences the TBI outcome [3].The mortality rate due to severe TBI ranges from 30 to 80% in older age [4].TBI has poor outcomes among all TBI result in disability and death [5].In India, a study done for one year in 2004 showed factors influencing the outcome in TBI patients are early recognition, resuscitation and triage, coupled with prompt computed tomography (CT) scanning and aggressive surgical management [6].Likewise, a retrospective study adds TBI severity, pupillary reactivity, coagulation status, need for blood product transfusion and acute bleeding as factors responsible on TBI outcomes [7].It is important in this study to know other studies' prognostic factors.To focus on the prognostic factors, two valuable studies predict the prognostic factor for TBI outcomes which are mainly divided into 7 categories: Glasgow Coma Scale (GCS), the Abbreviated Injury Scale (AIS) and CT results, subdural hematoma (SDH), pupillary reaction, vital signs and laboratory parameters [8,9].Gender has less contribution related to outcomes since male has more TBI in general.Also, aging has poor TBI outcomes [9].In a meta-analysis study by Yang N et al, which examined the potential impact of surgery timing on the outcomes of TBI patients across 16 studies, only five demonstrated a significant effect of surgery timing on severe TBI patients, accounting for 31.3% of the total cases [10].A meta-analysis study showed the effect of surgery timing on the postoperative outcomes, the timing of the surgery effect on the outcomes of the patient contributed by the fatigue of medical staff, limited resources and the urgent nature of the surgery at night or on weekends [11,12].Other literature compares the outcomes of surgery done during the week and weekend day; it showed no significant difference neither in the outcome nor in the mortality rate of the patients [13,14].
The current study aims to retrospectively compare the TBI outcome of geriatric patients on weekdays (Sunday-Monday-Tuesday-Wednesday-Thursday) versus weekends (Friday and Saturday) in the department of neurosurgery in a tertiary hospital in Oman as an example of high-income developing countries using the experience from Khoula Hospital (KH).The neurosurgery department in KH is the main neurosurgical center in the country with annual admission of around 1600 patients [15].Oman has one of the best well-rounded healthcare systems according to WHO's report.The definition of the geriatric age group in Oman and the region includes only those older than 65 years old.

Study group
This is a retrospective study conducted at KH.The hospital is in Muscat, Sultanate of Oman.
The study period was from December 2015 to December 2019.Medical records of 670 patients above 65 years and admitted to the neurosurgery ward were reviewed.From that, only 45 patients were over 65 years old, diagnosed with TBI and managed surgically.
The exclusion criteria were as follows: non-elderly patients (below 65 years), non-neurosurgical condition, neurosurgical condition other than TBI patients, patients outside the study period and patients with missing or incomplete data.

Data collection
Data were obtained using the health information system.Data collected were patient age, sex, date and time of admission, presentation, diagnosis, GCS upon admission, pupil state upon admission, length of stay (LOS), LOS in ICU, surgical intervention, complication and GCS upon discharge.The data were split into weekdays and weekends.Weekends are Thursdays from 2:30 p.m. onward, Friday and Saturday according to the national weekend days.

Data analysis
The data were analyzed using SPSS software (version 23).The categorized variables were cross-tabulated using frequency tables and bar charts were drawn using PowerPoint.A Chi-square test was used to obtain the significance of the association between 2 × 2 tables, and P-value ≤ 0.05 was used as a cutoff value for significance.Kolmogorov-Smirnov test was used to find whether a variable is following a normal distribution.To find out whether one variable had a different average between weekday and weekend groups, an independent sample t-test was used if it followed a normal distribution; if a normal distribution is not followed, then the Mann-Whitney test was used.Kruskal-Wallis test was used to compare three variables in terms of weekdays and weekends.

Results
As shown in Table 1, based upon the inclusion and exclusion criteria, there were 28 patients' weekday admissions and 17 patients' weekend admissions in our study across 2015-2019.The number of patients aged ≥ 75 was 16 and 9 on weekdays and weekends, respectively.The number of patients aged < 75 is 12 and 8 admitted during weekdays and weekends, respectively (p-value 0.051).
GCS upon admission was ≥ 8 in 25 and 14 patients among admissions during weekdays and weekends, respectively, while a GCS of < 8 was found in 3 patients of each group (p-value 0.658) (Table 1).
Average LOS was 12.4 days among patients operated on weekdays when compared to 36.5 days among those operated during weekends.The average number of days stay for patients operated at weekends is almost 2.9 times the weekday mean number of stay (p-value 0.452) (Table 1).
Among patients admitted to the ICU following surgery, the average number of days stayed at ICU for patients operated during weekdays was 3.9 days in comparison with 32.2 days among patients who underwent surgery during weekends, indicating 8.3 times more mean length of stay at the ICU when operated during the weekends (p-value 0.011) (Table 1).
Pupils' reactivity was seen in 17 patients admitted during weekdays while 3 patients were documented as having non-reactive pupils.Among patients admitted during weekdays, 8 of them were with normal pupil reactivity while 5 of were having no reactivity.There was missing undocumented pupil reactivity in 8 and 4 patients admitted during weekdays and weekends, respectively (p-value 0.629) (Table 1).
The presentation was varied in terms of symptoms as mentioned in the table (p-value 0.663).When we come to compare the diagnosis that has been made, the majority in both groups were diagnosed with subdural hemorrhage (SDH): 20 cases on weekdays and 10 on weekends.Among the rest weekday cases, 1 was subarachnoid hemorrhage (SAH), 3 were intracranial hemorrhage, 2 were multi-compartmental bleeds and 2 cases were not specified.Among weekend cases, 1 was intracranial hemorrhage, 2 were multi-compartmental bleeds and 1 case was not specified (p-value 0.417) (Table 1).
The treatment outcomes are given in Table 2; burr hole and evacuation of hematoma were done in 19 patients among weekday admissions, while in 6 patients the surgical intervention was craniotomy.In comparison, among patients admitted during weekends, burr hole was the surgical intervention in 7 patients and craniotomy in 8 patients (p-value 0.177).
In patients admitted during weekdays, 82.1% (23 patients) were discharged with a GCS of ≥ 8, and the remaining 17.85% (5 patients) were discharged with a GCS of < 8 (p-value 0.284) (Table 2).It is worth mentioning that patients with GCS 8 or less receive tracheostomy, and then, they are discharged to secondary hospital because KH is a tertiary hospital, so they will continue receiving the supportive care in peripheral or secondary hospitals.
Patients admitted during the weekends were found to develop complications higher than those on weekdays, evidenced by a p-value of 0.015.Eight patients developed complications among admissions during weekdays compared to twelve during weekend admissions.Up to 70% of weekday patients showed no documented complications, while five patients were only in weekend admissions (p-value 0.015) (Table 2).
Statistics show that postoperative infections were found to be more common among patients surgically operated during weekends (9 patients) compared to weekdays (6 patients) (p-value 0.065).One patient who operated during weekdays was re-operated, whereas three patients who operated during weekends were reoperated (p-value 0.144).Among those operated during weekdays, three patients deteriorated, whereas only two patients in the weekend group deteriorated (p-value 1) (Table 3).
Figure 1A shows that the frequency of TBI cases trended on Friday followed by Monday.In addition, the frequency of complications was found to be higher on Friday followed by Saturday as shown in Fig. 1B. Figure 2 sheds light on the fact that the bur hole intervention was more frequent than other surgical interventions on weekdays except Wednesdays.On Friday and Saturday, there was no domination in terms of frequency between burr hole and craniotomy.

Discussion
Global statistics depict that the elderly population is on the rise and by the year 2060 would be 18% of the world population.Meanwhile, national statistics in Oman have already seen a 15.4% increase in the geriatric population from 2013 to 2017.All this suggests that there is an increasing demand for healthcare services for this growing population.
There were no other previous articles discussing the comparison of the complications among TBI cases during weekdays and weekends in geriatric populations.However, there is an almost similar study in pediatric populations (Virendra Desai et al.) which concluded that weekday after-hours and weekend emergency pediatric neurosurgical procedures are associated with significantly increased 30-day morbidity and mortality risk compared with procedures performed during weekday regular hours [16].
Previous researchers studied the prognosis of patient care between daytime and on-call times.Most of them found that during nighttime there is a shortage of staff or otherwise a less equipped staff.Given that hospitals are not at full working capacity during weekends as compared to weekdays, it inspired us to write an article about how different the prognosis of patient care could be between weekdays and weekends.Our research concerns whether geriatric TBI patients operated during weekends have similar results to those operated during weekdays [14].
The importance of understanding how TBI cases operated on geriatric patients during weekends has shown comparatively poorer results than when operated during the weekdays.Our data show more TBI case admissions on Friday (weekend).It is highly possible due to the fact that some geriatric individuals may  rely on caregiver support during the week, which may vary on weekends.When such assistance or supervision is reduced, there could be an increased risk of accidents leading to TBIs.Additionally, participation in social activities and family gatherings during weekends may expose geriatric individuals to unfamiliar environments or activities, potentially leading to accidents.Furthermore, weekend activities such as home maintenance or repairs may expose geriatric individuals to an increased risk of accidents, particularly when engaging in physical tasks that they may not regularly undertake during the week.Moreover, changes in the sleep patterns during weekends, such as staying up later or waking up earlier, may contribute to fatigue and an increased risk of accidents.Likewise, results shown in Fig. 1B illustrate the complications were reported highest during the weekend days (Friday and Saturday) than the weekdays, which is consistent with the incidence rates reported previously in several studies [17,18].On average, 5.5 TBI cases developed complications per day of the weekend, whereas 1.4 average cases developed complications per day during the week.That shows 292.86% of TBI cases develop more complications during the weekend in comparison with weekdays.A study done Zoe Little et al. showed that mortality is significantly higher in Friday and Saturday demonstrated that patients admitted on weekends had similar mortality with no clinically significant weekend effect [20].
The outcomes of TBIs in geriatric patients can be influenced by various factors.Distinctions in outcomes on weekdays versus weekends can be multifaceted.However, it is important to acknowledge that there is no universally agreed-upon pattern of differences between weekdays and weekends for TBI outcomes, as outcomes are highly individualized and reliant on the specific circumstances of each case.Nevertheless, several factors might contribute to potential differences.
The availability of medical resources and personnel is a pivotal factor influencing the outcomes of TBIs, particularly when comparing weekdays to weekends.This aspect plays a crucial role in determining the speed and quality of response, diagnosis and intervention for geriatric patients facing TBIs.On weekdays, healthcare facilities typically operate with a higher concentration of healthcare professionals and specialized staff.The usual workweek structure ensures that hospitals are adequately staffed with neurosurgeons, neurologists, nurses and other essential medical personnel.This higher staffing level contributes to quicker response times when patients, especially geriatric individuals, present with TBIs.The immediate availability of skilled professionals can facilitate prompt assessments, early diagnostic procedures such as CT scans or MRIs and timely initiation of treatment plans.
Conversely, weekends often witness a reduction in staffing levels, which may include a decrease in the number of specialized healthcare professionals.Limited access to neurosurgical and neurological expertise during weekends can lead to delays in decision-making and interventions.These delays are particularly concerning in the context of TBIs, where timely and accurate diagnosis is critical for optimal outcomes.Additionally, reduced staffing levels may result in longer wait times in emergency departments, potentially hindering the overall efficiency of care delivery.A study done by Jung E et.Al showed that patients admitted to the ED at night or during weekends experienced higher odds of mortality than those admitted during the daytime or weekdays [18].
Furthermore, the nature of TBI cases necessitates a multi-disciplinary approach, involving various specialists and support staff.The collaborative effort of different medical professionals is crucial in managing the complexity of TBIs, and the potential scarcity of these resources during weekends can present challenges.
Continuous operation of healthcare services throughout the week, coupled with long working hours, can contribute to physician fatigue and burnout.Fatigued healthcare professionals may be more prone to errors, and their decision-making abilities may be compromised.This factor can be particularly relevant to TBI cases, where precise and timely interventions are crucial.Fatigued healthcare professionals may experience reduced cognitive function, impaired judgment and slower reaction times, all of which are essential components in the effective management of TBI patients.This emphasizes the need for healthcare systems to implement strategies that prioritize staff well-being and mitigate the impact of long and demanding work hours on patient care.Transportation services play a critical role in the timely and effective management of medical emergencies, including TBIs.The accessibility and responsiveness of transportation services can vary between weekdays and weekends, and these differences can impact the speed at which patients, particularly those with TBIs, reach healthcare facilities.
All in all, the heightened incidence of complications in TBI cases operated on weekends as opposed to weekdays can be attributed to the reduced staffing levels during weekends which delays the critical interventions, as experienced and specialized medical personnel may be less readily available.Additionally, limited access to ancillary services such as diagnostic imaging or specialized consultations during weekends can impede comprehensive care.The weekend effect may also be influenced by the increased prevalence of emergency cases during this period, potentially overwhelming hospital resources and fatigued healthcare professionals.
It is essential to recognize that these factors interact in complex ways, and their impact can vary depending on the specific circumstances of each patient and the healthcare system in place.The combination of these factors underscores the need for a comprehensive evaluation of healthcare systems to address the challenges associated with weekend surgeries for TBI patients, with the ultimate goal of improving patient outcomes and minimizing complications.
By addressing these aspects, healthcare systems can create a more resilient and responsive environment for managing TBI cases during weekends.These strategies aim to ensure that the level of care provided on weekends is on par with weekday standards, ultimately improving patient outcomes and minimizing the risks associated with weekend surgeries for TBI patients.

Limitations
Our study did have certain limitations.Our understanding of the topic is based on geriatric TBI cases reported and operated at KH during four years.The study was retrospective.Regarding the small number of cases, the study was based on data collected on all 670 patients admitted with KH neurosurgery requiring intervention across four years and our focus was on traumatic brain injuries and among elderly population which narrowed it down to forty-five patients.Thus, our case study includes all cases possible from the data collected.Nevertheless, regarding the study period, our study is based upon the latest data collection available to us.Furthermore, we would recommend more studies in the future based upon newer data available to us following collection and local ethics committee approval.Moreover, several other confounding factors could have influenced the results such as imaging machines and/or personnel available at weekends, the shift timing of the physicians/surgeons when treating the TBI cases and the availability of ICU facilities.In addition to that, the emotional component of stress faced by on-call medical personnel during shifts with high number of patients seen was not taken into account.
On-call medical personnel treat all types of emergency and trauma cases and not just traumatic injuries to the brain.So, it is a limitation that our study includes neither data about the number of on-call medical personnel, from orderlies to nurses to physicians, during shifts over the weekend, nor the amount/percentage of the on-call personnel treating TBI cases among all the emergency cases at a given point of time in the shift.
Our recommendation is that more studies about this topic should be sought in the future to discuss the improvements and declines with considerations about the confounding factors.
Articles could be made in the future collecting data about the actual factors responsible for different outcome rates among the TBI cases during the weekdays and weekends.In addition to that, data about the causes of TBI are also valid and should be collected.This is with sole focus to help make a change and improvements in the patient care of TBI cases at hospitals.

Conclusion
We conclude that hospitals are well equipped with a more available number of diagnostic imaging, hospital care responders and neurosurgeons to treat any geriatric TBI case that is during the weekdays.However, the weekends need more neurosurgeons and medical orderlies that handle imaging facilities to deal with the emergency cases.

Fig. 1 A
Fig. 1 A: Frequency of TBI during weekdays/weekend, illustrating the number of TBI cases admitted during each day of the week.B: Frequency of complications, illustrating the number of complications developed during each day of the week

Fig. 2
Fig. 2 Frequency of surgical intervention, depicting different surgical intervention carried out and their frequency in each day of the week

Table 1
Baseline characteristics, making comparisons between weekdays and weekends in terms of age, gender, GCS, LOS, presentation and diagnosis

Table 2
Treatment outcome, comparing surgical intervention done, GCS in discharge and complications between weekdays and weekends

Table 3
Complications during weekdays and weekends