The “weekend effect” in pediatric surgery — increased mortality for children undergoing urgent surgery during the weekend



      For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures.


      Using the Nationwide Inpatient Sample and the Kids’ Inpatient Database, we identified 439,457 pediatric (<18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed.


      Patient characteristics of those admitted on the weekend (n = 112,064) and weekday (n = 327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21–2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01–1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14–1.74).


      Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bell C.M.
        • Redelmeier D.A.
        Mortality among patients admitted to hospitals on weekends as compared with weekdays.
        N. Engl. J. Med. 2001; 345: 663-668
        • Mikulich O.
        • Callaly E.
        • Bennett K.
        • et al.
        The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix.
        Acute Med. 2011; 10: 182-187
        • Freemantle N.
        • Richardson M.
        • Wood J.
        • et al.
        Weekend hospitalization and additional risk of death: an analysis of inpatient data.
        J R Soc Med. 2012; 105: 74-84
        • Buckley D.
        • Bulger D.
        Trends and weekly and seasonal cycles in the rate of errors in the clinical management of hospitalized patients.
        Chronobiol Int. 2012 Aug; 29: 947-954
        • Cram P.
        • Hillis S.L.
        • Barnett M.
        • et al.
        Effects of weekend admission and hospital teaching status on in-hospital mortality.
        Am J Med. 2004; 117: 151-157
        • Worni M.
        • Schudel I.M.
        • Østbye T.
        • et al.
        Worse outcomes in patients undergoing urgent surgery for left-sided diverticulitis admitted on weekends vs weekdays: a population-based study of 31 832 patients.
        Arch Surg. 2012; 147: 649-655
        • Tung Y.
        • Chang G.
        • Chen Y.
        Associations of physician volume and weekend admissions with ischemic stroke outcome in Taiwan: a nationwide population-based study.
        Med Care. 2009; 47: 1018-1025
        • Chang G.
        • Tung Y.
        Factors associated with pneumonia outcomes: a nationwide population-based study over the 1997–2008 period.
        J Gen Intern Med. 2012; 27: 527-533
        • Schneider E.B.
        • Hirani S.A.
        • Hambridge H.L.
        • et al.
        Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends.
        J Surg Res. 2012; 177: 295-300
        • Barnett M.J.
        • Kaboli P.J.
        • Sirio C.A.
        • et al.
        Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation.
        Med Care. 2002; 40: 530-539
        • Bhonagiri D.
        • Pilcher D.V.
        • Bailey M.J.
        Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis.
        Med J Aust. 2011; 194: 287-292
        • Laupland K.B.
        • Shahpori R.
        • Kirkpatrick A.W.
        • et al.
        Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings.
        J Crit Care. 2008; 23: 317-324
        • Fendler W.
        • Baranowska-Jazwiecka A.
        • Hogendorf A.
        • et al.
        Weekend matters: Friday and Saturday admissions are associated with prolonged hospitalization of children.
        Clin Pediatr (Phila). 2013 Sep; 52: 875-878
        • Salihu H.M.
        • Ibrahimou B.
        • August E.M.
        • et al.
        Risk of infant mortality with weekend versus weekday births: a population-based study.
        J Obstet Gynaecol Res. 2012 Jul; 38: 973-979
        • Arias Y.
        • Taylor D.S.
        • Marcin J.P.
        Association between evening admissions and higher mortality rates in the pediatric intensive care unit.
        Pediatrics. 2004; 113: e530-e534
        • Hixson E.D.
        • Davis S.
        • Morris S.
        • et al.
        Do weekends or evenings matter in a pediatric intensive care unit?.
        Pediatr Crit Care Med. 2005; 6 (619–621): 523-530
        • Papandria D.
        • Goldstein S.D.
        • Rhee D.
        • et al.
        Risk of perforation increases with delay in recognition and surgery for acute appendicitis.
        J Surg Res. 2013 Oct; 184: 723-729
        • Kluger Y.
        • Ben-Ishay O.
        • Sartelli M.
        • et al.
        World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS).
        World J. Emerg Surg. 2013; 8
        • Ingraham A.M.
        • Cohen M.E.
        • Bilimoria K.Y.
        • et al.
        Effect of delay to operation on outcomes in adults with acute appendicitis.
        Arch Surg. 2010; 145: 886-892
        • Gurusamy K.S.
        • Samraj K.
        • Davidson B.R.
        Early versus delayed laparoscopic cholecystectomy for biliary colic.
        Cochrane Database Syst Rev. 2008 Oct; 8: CD007196
        • Kim S.
        • Hong K.
        • Hwang S.
        • et al.
        Weekend admission in patients with acute ischemic stroke is not associated with poor functional outcome than weekday admission.
        J. Clin Neurol (Korea). 2012; 8: 265-270
        • Worni M.
        • Ostbye T.
        • Gandhi M.
        • et al.
        Laparoscopic appendectomy outcomes on the weekend and during the week are no different: a national study of 151,774 patients.
        World J Surg. 2012 Jul; 36: 1527-1533
        • Carr B.G.
        • Reilly P.M.
        • Schwab C.W.
        • et al.
        Weekend and night outcomes in a statewide trauma system.
        Arch Surg. 2011; 146: 810-817
        • Rhee
        • et al.
        Comparison of pediatric surgical outcomes by the surgeon's degree of specialization in children.
        J Pediatr Surg. 2013; 48: 1657-1663