August 7 marks an annual rite in the U.K.: the upgrade in status of medical students and junior doctors. It also heralds a potential uptick in in-hospital deaths, a phenomenon known as “the August effect.” Using a workflow tool, researchers set out to discover why.

Results from their study appeared online in the August Journal of the Royal Society of Medicine Short Reports.

The City Hospital and Queen’s Medical Center, two teaching hospitals that are part of the Nottingham University system, replaced their standard process for managing off-hours hospital workflow with a wireless tool. The two hospitals’ wireless system included a log of the type and number of assignments to junior doctors for medical and surgical patients. City Hospital also tracked the time a task was completed.

The off-hours team covers care between 5 p.m. and 9 a.m. weekdays and all weekend. John D. Blakey, PhD, of the Liverpool School of Tropical Medicine, and colleagues reasoned that junior physicians assigned to off-hour slots would likely have less supervision, more stress and longer shifts that might contribute to adverse outcomes. That trend would likely be more pronounced with the August changeover, they hypothesized.

To study the August effect, they looked at task request data two months before and one month after the changeover in 2011. Because the workflow system assigned tasks in three categories based on urgency, they could assess how many tasks were urgent (red or amber) or a lower priority (green).

Blakey et al determined that 29,885 tasks were completed in the three-month period. The volume of work for junior physicians didn’t change, at a median 15 task requests per hour before and 14 after the changeover.

“These data suggest that the ‘August effect’ is not driven by an increase in the volume of work, or because a greater number of routine in-hours tasks have been left incomplete by those working in the day,” they wrote.

The number of urgent requests increased significantly, though. That translated into the equivalent of five more urgent task requests each weekday and 13 more each weekend after the changeover.  They proposed that the increase in urgent tasks may reflect inexperienced physicians who fail to avert or recognize early signs of problems.

Junior physicians spent a median 74 minutes to complete a green task before the changeover and 66 minutes after. Red and amber tasks took a median 75 minutes before and 76 minutes after the changeover.  

“As each task took a median of over 1 h to be completed, this amounts to a considerable cumulative duration of unresolved patient risk per month,” Blakey et al suggested. “This duration of increased risk may be sufficient to drive a proportion of the excess mortality and morbidity reported soon after changeover in several studies.”

Their data eliminated workload and the possibility that junior physicians worked more slowly as drivers behind the August effect.

“Although further research in this important area is certainly required, this pattern could have arisen through omissions, errors, failure to recognize deterioration and poor task prioritization skills,” they concluded. “These factors are amenable to improved training, supervision and quality control.”