Impact of an Intervention to Improve Weekend Hospital Care at an Academic Medical Center: An Observational Study

Decreased patient discharges on weekends part 1: what do the data tell us?

BACKGROUND

We believe that hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. In part 1 of 3 concurrent studies, we documented the number of weekend discharges and the extent of hospital and ED crowding on the days following weekends.

METHODS

We conducted a data analysis study at The Ottawa Hospital, a major academic health sciences center with two EDs. We created reports of the 18-month period (January 1, 2022-June 30, 2023) regarding the status of in-patients at the two campuses. We compared the total admissions, discharges, and hospital occupancy on weekends (or long weekends), the Monday following weekends (or Tuesday following long weekends), or Tuesdays-Fridays. For these three time periods, we also compared the proportion of ED beds occupied by admitted patients to all ED beds, as well as the proportion of days with > 70% admitted patients housed in the ED at 8:00am.

RESULTS

Our data for 55,692 patients demonstrated that on weekends compared to weekdays, there were almost 50% fewer discharges with the ratio of admissions to discharges averaging 1.16 (95% CI 1.10-1.22). This was accompanied by a 2.4% absolute increase (P < 0.001) in hospital occupancy on Mondays or Tuesdays, often exceeding 100%. Both EDs are particularly crowded on these Mondays and Tuesdays with the proportion of admitted patients to regular ED beds averaging 68%. We observed serious crowding with > 70% occupancy with admitted patients on almost 50% of Mondays.

INTERPRETATION

We have demonstrated that there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This blocks safe and timely access to beds for newly arriving patients in the ED. These results should spur Canadian hospitals to evaluate their own data and seek solutions to this important problem.

Decreased patient discharges on weekends part 3: what do the leaders tell us?

BACKGROUND

Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays.

METHODS

In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions.

RESULTS

We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week.

INTERPRETATION

We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.

Exploring the Ramifications of Delayed Hospital Discharges: Impacts on Patients, Physicians, and Healthcare Systems

Prolonged hospital stays can significantly impede patients' recovery, negatively affecting anything from physical health via issues like hospital-acquired infections and increased complications due to immobility to psychological health. Several studies investigated the psychosocial impact of prolonged hospital stays, revealing a variety of patient perspectives, such as feeling uncertain and frustrated about their conditions, which can erode their trust in healthcare providers. Delayed discharges not only affect patients but also have multifaceted effects on healthcare providers, potentially reducing physician efficiency and contributing to higher rates of burnout among healthcare professionals. This article investigates the consequences of delayed versus early discharge on physicians, patients, and the overall hospital system. We conducted an extensive search through PubMed and Google Scholar using the keywords "delayed discharge," "hospital discharge," and "bed blocking" to identify all the recent studies highlighting the dynamics of patient discharge. Our results support the hypothesis that reducing delayed discharge rates will not only improve patient outcomes but also have widespread fiscal impacts. This review also outlines measures to reduce delayed discharges, ultimately leading to a significant enhancement in the healthcare system.

Clinical Outcomes according to Timing to Non Invasive Ventilation Initiation in COPD Patients with Acute Respiratory Failure: A Retrospective Cohort Study

Nighttime and non-working days are characterized by a shortage of dedicated staff and available resources. Previous studies have highlighted that patients admitted during the weekend had higher mortality than patients admitted on weekdays ("weekend effect"). However, most studies have focused on specific conditions and controversial results were reported. We conducted an observational, monocentric, retrospective cohort study, based on data collected prospectively to evaluate the impact of the timing of NIV initiation on clinical outcomes in COPD patients with acute respiratory failure (ARF). A total of 266 patients requiring NIV with a time gap between diagnosis of ARF and NIV initiation <48 h were included. Interestingly, 39% of patients were not acidotic (pH = 7.38 ± 0.09 vs. 7.26 ± 0.05, p = 0.003) at the time of NIV initiation. The rate of NIV failure (need for intubation and/or all-cause in-hospital death) was similar among three different scenarios: "daytime" vs. "nighttime", "working" vs. "non-working days", "nighttime or non-working days" vs. "working days at daytime". Patients starting NIV during nighttime had a longer gap to NIV initiation compared to daytime (219 vs. 115 min respectively, p = 0.01), but this did not influence the NIV outcome. These results suggested that in a training center for NIV management, the failure rate did not increase during the "silent" hours.

COVID-19 deaths on weekends

BACKGROUND

Mortality statistics about daily deaths might change on weekends due to delays in reporting, uneven staffing, a different mix of personnel, or decreased efficiency. We hypothesized that reported deaths for COVID-19 might increase on weekends compared to weekdays.

METHODS

We collected data from the World Health Organization COVID-19 database. All deaths from March 7, 2020 to March 7, 2022 were included (two years). The primary analysis evaluated mean daily deaths on weekends compared to the preceding five workdays. Analyses were replicated in ten individual countries: United States, United Kingdom, France, Germany, Italy, Spain, Russia, India, Brazil, and Canada.

RESULTS

The mean COVID-19 daily deaths was higher on weekends compared to weekdays (8,532 vs. 8,083 p < 0.001), equal to a 6% relative increase (95% confidence interval 3% to 8%). The highest absolute increase was in the United States (1,483 vs. 1,220 deaths, p < 0.001). The second highest absolute increase was in Brazil (1,061 vs. 823 deaths, p < 0.001). The increase in deaths on weekends remained significant during the earlier and later months of the pandemic, as well as during the greater and lesser weeks of the pandemic.

CONCLUSIONS

The apparent increased COVID-19 deaths reported on weekends might potentially reflect patient care, confound community trends, and affect the public perception of risk.

Analysing Monday discharges to identify lost opportunities for weekend discharge

Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

Characterizing patients hospitalized without an acute care indication: A retrospective cohort study

BACKGROUND

Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays.

OBJECTIVE

To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs.

DESIGNS, SETTINGS, AND PARTICIPANTS

A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital.

MAIN OUTCOME AND MEASURES

Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics.

RESULTS

Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001).

CONCLUSIONS

Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.

Internal Operational Metrics and Center for Medicare and Medicaid Services Hospital Compare Quality Ratings

ABSTRACT

The Center for Medicare and Medicaid Services (CMS) has made several refinements to their model for calculating hospital quality star ratings (Hospital Compare) amidst criticism and evidence of bias against some institutions. We argue that the CMS model does align with important internal quality metrics and encourage a measured approach to redesign, potentially using categorizations or tiers, rather than a complete abandonment of the ratings system. We find that institutional characteristics (available resources, average severity of illness, and academic affiliation) are associated with internal quality metrics related to patient flow. Furthermore, regression results from the original and revised CMS star rating methodologies suggest that patient flow metrics (discharges before noon [p < .01] and weekend discharges [p < .001]) have a positive relationship with the Hospital Compare rating. Hospitals with better patient flow, as measured by higher levels of discharges before noon and weekend discharges, are associated with higher CMS quality ratings. These findings suggest that CMS star ratings do reflect key aspects of operational performance, specifically efforts to improve patient flow, but the ranking system should consider hospital characteristics that influence internal operations as we move toward a system capable of quality and price transparency for consumers.

Initiatives for improving delayed discharge from a hospital setting: a scoping review

OBJECTIVE

The overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work.

DESIGN

Scoping review.

METHODS

Electronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other.

RESULTS

Sixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up.

CONCLUSIONS

This scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

Quality assessment of weekend discharge: a systematic review and meta-analysis

PURPOSE

Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges.

DATA SOURCES

PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019.

STUDY SELECTION

Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies.

DATA EXTRACTION

Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate.

RESULTS OF DATA SYNTHESIS

There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity.

CONCLUSION

In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.

Seven-day services in surgery and the "weekend effect" at a Japanese teaching hospital: a retrospective cohort study

BACKGROUND

Hospitals deliver 24-h, 7-day care on a 5-day workweek model, as fewer resources are available on weekends. In prior studies, poorer outcomes have been observed with weekend admission or surgery. The purpose of this study was to investigate the effect of 7-day service at a hospital, including outpatient consultations, diagnostic examinations and elective surgeries, on the likelihood of the "weekend effect" in surgery.

METHODS

This was a retrospective cohort study of patients who underwent surgery between April 2014 and October 2016 at an academic medical centre in Tokyo, Japan. The main outcome measure was 30-day in-hospital mortality from the index surgery. The characteristics of the participants were compared using the Mann-Whitney U test or the chi-squared test as appropriate. Logistic regression was used to test for differences in the mortality rate between the two groups, and propensity score adjustments were made.

RESULTS

A total of 7442 surgeries were identified, of which, 1386 (19%) took place on the weekend. Of the 947 emergency surgeries, 25% (235) were performed on the weekend. The mortality following emergency weekday surgery was 21‰ (15/712), compared with 55‰ (13/235) following weekend surgery. Of the 6495 elective surgeries, 18% (1151) were performed on the weekend. The mortality following elective weekday surgery was 2.3‰ (12/5344), compared with 0.87‰ (1/1151) following weekend surgery. After adjustment, weekend surgeries were associated with an increased risk of death, especially in the emergency setting (emergency odds ratio: 2.7, 95% confidence interval: 1.2-6.5 vs. elective odds ratio: 0.4, 95% confidence interval: 0.05-3.2).

CONCLUSIONS

Patients undergoing emergency surgery on the weekend had higher 30-day mortality, but showed no difference in elective surgery mortality. These findings have potential implications for health administrators and policy makers who may try to restructure the hospital workweek or consider weekend elective surgery.

Weekend readmissions associated with mortality following pancreatic resection for cancer

BACKGROUND

The weekend effect is associated with an increased risk of adverse events, with complex patient populations especially susceptible to its impact. The objective of this study was to determine if outcomes for patients readmitted following pancreas resection differed on the weekend compared to weekdays.

METHODS

The Healthcare Cost and Utilization State Inpatient Database for Florida was used to identify patients undergoing pancreas resection for cancer who were readmitted within 30 days of discharge following surgery. Measured outcomes (for readmission encounters) included inpatient morbidity and mortality.

RESULTS

Patients with weekend readmissions had an increased odds of inpatient mortality (aOR 2.7, 95% C.I.: 1.1-6.6) compared to those with weekday readmissions despite having similar index lengths of stay (15.9 vs. 15.5 days, P = .73), incidence of postoperative inpatient complications (22.4% vs. 22.3%, P = .98), reasons for readmission, and baseline comorbidity.

DISCUSSION

Weekend readmissions following pancreatic resection are associated with increased risk of mortality. This is not explained by measured patient factors or clinical characteristics of the index hospital stay. Developing strategies to overcome the weekend effect can result in improved care for patients readmitted on the weekend.

Comparisons of Clinical Outcomes between Weekday-Only and Full-Time, 24-Hour/7-Day Coverage Hospitalist Systems

BACKGROUND

Since the launch of pilot programs in 2016, varying ranges of hospitalist coverage exist in Korea. We evaluated the effects of differing depths of hospitalist coverage on clinical outcomes.

METHODS

This study retrospectively reviewed the records of 513 patients admitted to a medical hospitalist unit through emergency department at Seoul National University Hospital. The full-time group included patients admitted in 2018 who received 24/7 hospitalist service, whereas the weekday group included patients admitted in 2019 with only weekday hospitalist service. In-hospital clinical outcomes were compared between the two groups.

RESULTS

Unplanned intensive care unit admission rate was lower in the full-time group than in the weekday group (0.4% vs. 2.9%; P = 0.042). Discharges to local hospitals for subacute or chronic care were more frequent in the full-time group than in the weekday group (12.6% vs. 5.8%; P = 0.007). The weekday coverage was a predictive factor of in-ward mortality (odds ratio, 2.00; 95% confidence interval, 1.01-3.99) after adjusting for potential confounding factors.

CONCLUSION

Uninterrupted weekend coverage hospitalist service is helpful for care-plan decision and timely care transitions for acutely and severely ill patients.

Day of the Week of Surgery Affects Time to Discharge for Patients With Adolescent Idiopathic Scoliosis

Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P=.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days (P=.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days (P<.001). There was no longer a significant difference in length of stay between the "early" and the "late" groups (P=.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [Orthopedics. 2020; 43(1);8-12.].

Impact of an emergency department electronic sepsis surveillance system on patient mortality and length of stay

Objective

The purpose of this study was to determine whether an electronic health record-based sepsis alert system could improve quality of care and clinical outcomes for patients with sepsis.

Materials and Methods

We performed a patient-level interrupted time series study of emergency department patients with severe sepsis or septic shock between January 2013 and April 2015. The intervention, introduced in February 2014, was a system of interruptive sepsis alerts triggered by abnormal vital signs or laboratory results. Primary outcomes were length of stay (LOS) and in-hospital mortality; other outcomes included time to first lactate and blood cultures prior to antibiotics. We also assessed sensitivity, positive predictive value (PPV), and clinician response to the alerts.

Results

Mean LOS for patients with sepsis decreased from 10.1 to 8.6 days (P < .001) following alert introduction. In adjusted time series analysis, the intervention was associated with a decreased LOS of 16% (95% CI, 5%-25%; P = .007, with significance of α = 0.006) and no change thereafter (0%; 95% CI, -2%, 2%). The sepsis alert system had no effect on mortality or other clinical or process measures. The intervention had a sensitivity of 80.4% and a PPV of 14.6%.

Discussion

Alerting based on simple laboratory and vital sign criteria was insufficient to improve sepsis outcomes. Alert fatigue due to the low PPV is likely the primary contributor to these results.

Conclusion

A more sophisticated algorithm for sepsis identification is needed to improve outcomes.

How Much Time are Physicians and Nurses Spending Together at the Patient Bedside?

BACKGROUND

Bedside rounding involving both nurses and physicians has numerous benefits for patients and staff. However, precise quantitative data on the current extent of physician-nurse (MD-RN) overlap at the patient bedside are lacking.

OBJECTIVE

This study aimed to examine the frequency of nurse and physician overlap at the patient beside and what factors affect this frequency.

DESIGN

This is a prospective, observational study of time-motion data generated from wearable radio frequency identification (RFID)-based locator technology.

SETTING

Single-institution academic hospital.

MEASUREMENTS

The length of physician rounds, frequency of rounds that include nurses simultaneously at the bedside, and length of MD-RN overlap were measured and analyzed by ward, day of week, and distance between patient room and nursing station.

RESULTS

A total of 739 MD rounding events were captured over 90 consecutive days. Of these events, 267 took place in single-bed patient rooms. The frequency of MD-RN overlap was 30.0%, and there was no statistical difference between the three wards studied. Overall, the average length of all MD rounds was 7.31 ± 0.58 minutes, but rounding involving a bedside nurse lasted longer than rounds with MDs alone (9.56 vs 5.68 minutes, P < .05). There was no difference in either the length of rounds or the frequency of MD-RN overlap between weekdays and weekends. Finally, patient rooms located farther away from the nursing station had a lower likelihood of MD-RN overlap (Pearson's r = -0.67, P < .05).

CONCLUSION

RFID-based technology provides precise, automated, and high-throughput time-motion data to capture nurse and physician activity. At our institution, 30.0% of rounds involve a bedside nurse, highlighting a potential barrier to bedside interdisciplinary rounding.

Quality and safety of in-hospital care for acute medical patients at weekends: a qualitative study

BACKGROUND

The increased mortality risk associated with weekend admission to hospital (the 'weekend effect') has been reported across many health systems. More recently research has focused on causal mechanisms. Variations in the organisation and delivery of in-hospital care between weekends and weekdays have been identified, but this is not always to the detriment of weekend admissions, and the impact on mortality is uncertain. The insights of frontline staff and patients have been neglected. This article reports a qualitative study of patients and clinicians, to explore their views on quality and safety of care at weekends.

METHODS

We conducted focus groups and interviews with clinicians and patients with experience of acute medical care, recruited from three UK hospital Trusts. We analysed the data using a thematic analysis approach, aided by the use of NVivo, to explore quality and safety of care at weekends.

RESULTS

We held four focus groups and completed six in-depth interviews, with 19 clinicians and 12 patients. Four threats to quality and safety were identified as being more prominent at weekends, relating to i) the rescue and stabilisation of sick patients; ii) monitoring and responding to deterioration; iii) timely accurate management of the therapeutic pathway; iv) errors of omission and commission.

CONCLUSIONS

At weekends patients and staff are well aware of suboptimal staffing numbers, skill mix and access to resources at weekends, and identify that emergency admissions are prioritised over those already hospitalised. The consequences in terms of quality and safety and patient experience of care are undesirable. Our findings suggest the value of focusing on care processes and systems resilience over the weekends, and how these can be better supported, even in the limited resource environment that exists in many hospitals at weekends.

Effect of Hospital Readmission Reduction on Patients at Low, Medium, and High Risk of Readmission in the Medicare Population

BACKGROUND

Hospitalization and readmission rates have decreased in recent years, with the possible consequence that hospitals are increasingly filled with high-risk patients.

OBJECTIVE

We studied whether readmission reduction has affected the risk profile of hospitalized patients and whether readmission reduction was similarly realized among hospitalizations with low, medium, and high risk of readmissions.

DESIGN

Retrospective study of hospitalizations between January 2009 and June 2015.

PATIENTS

Hospitalized fee-for-service Medicare beneficiaries, categorized into 1 of 5 specialty cohorts used for the publicly reported hospital-wide readmission measure.

MEASUREMENTS

Each hospitalization was assigned a predicted risk of 30-day, unplanned readmission using a risk-adjusted model similar to publicly reported measures. Trends in monthly mean predicted risk for each cohort and trends in monthly observed to expected readmission for hospitalizations in the lowest 20%, middle 60%, and highest 20% of risk of readmission were assessed using time series models.

RESULTS

Of 47,288,961 hospitalizations, 16.2% (n = 7,642,161) were followed by an unplanned readmission within 30 days. We found that predicted risk of readmission increased by 0.24% (P = .03) and 0.13% (P = .004) per year for hospitalizations in the surgery/ gynecology and neurology cohorts, respectively. We found no significant increase in predicted risk for hospitalizations in the medicine (0.12%, P = .12), cardiovascular (0.32%, P = .07), or cardiorespiratory (0.03%, P = .55) cohorts. In each cohort, observed to expected readmission rates steadily declined, and at similar rates for patients at low, medium, and high risk of readmission.

CONCLUSIONS

Hospitals have been effective at reducing readmissions across a range of patient risk strata and clinical conditions. The risk of readmission for hospitalized patients has increased for 2 of 5 clinical cohorts.

Off-hours presentation is associated with short-term mortality but not with long-term mortality in patients with ST-segment elevation myocardial infarction: A meta-analysis

BACKGROUND

The association between off-hours presentation and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We performed a meta-analysis to assess the impact of off-hours presentation on short- and long-term mortality among STEMI patients.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from their inception to 10 July 2016. Studies were eligible if they evaluated the relationship of off-hours (weekend and/or night) presentation with short- and/or long-term mortality.

RESULTS

A total of 30 studies with 33 cohorts involving 192,658 STEMI patients were included. Off-hours presentation was associated with short-term mortality (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12, P = 0.004) but not with long-term mortality (OR 1.00, 95% CI 0.94-1.07, P = 0.979). No significant heterogeneity was observed. The outcomes remained the same after sensitivity analyses and trim and fill analyses. Subgroup analyses showed that STEMI patients undergoing primary percutaneous coronary intervention do not have a higher risk of short-term mortality (OR 1.061, 95% CI 0.993-1.151). In addition, higher mortality was observed only during hospitalization (OR 1.072, 95% CI 1.022-1.125), not at the 30-day, 1-year or long-term follow-ups.

CONCLUSIONS

Off-hours presentation was associated with an increase in short-term mortality, but not long-term mortality, among STEMI patients. Clinical approaches to decrease short-term mortality regardless of the time of presentation should be evaluated in future studies.

Multi- and univariate analyses of the weekend effect for elective lower-limb joint replacements

Introduction The weekend effect is a perceived difference in outcome between medical care provided at the weekend when compared to that of a weekday. Clearly multifactorial, this effect remains incompletely understood and variable in different clinical contexts. In this study we analyse factors relevant to the weekend effect in elective lower-limb joint replacement at a large NHS multispecialty academic healthcare centre. Materials and Methods We reviewed the electronic medical records of 352 consecutive patients who received an elective primary hip or knee arthroplasty. Patient, clinical and time-related variables were extracted from the records. The data were anonymised, then processed using a combination of uni- and multivariate statistics. Results There is a significant association between the selected weekend effect outcome measure (postoperative length of stay) and patient age, American Society of Anesthesiologists classification, time to first postoperative physiotherapy and time to postoperative radiography but not day of the week of operation. Discussion We were not able to demonstrate a weekend effect in elective lower-limb joint replacement at our institution nor identify a factor that would require additional weekend clinical medical staffing. Rather, resource priorities would seem to include measures to optimise at-risk patients preoperatively and measures to reduce time to physiotherapy and radiography postoperatively. Conclusions Our findings imply that postoperative length of stay could be minimised by strategies relating to patient selection and access to postoperative services. We have also identified a powerful statistical methodology that could be applied to other service evaluations in different clinical contexts.

Outcomes of off- and on-hours admission in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A retrospective observational cohort study

Studies evaluating the outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are scarce, particularly in China. The purpose of present study was therefore to compare the impact of off-hours and on-hours admission on clinical outcomes in STEMI patients from China.We retrospectively analyzed 1594 patients from 4 hospitals. Of these, 903 patients (56.65%) were admitted during off-hours (weekdays from 18:00 to 08:00, weekends and holidays) and 691 (43.35%) were during on-hours (weekdays from 08:00 to 18:00).Patients admitted during off-hours had higher thrombolysis in myocardial infarction risk score (4.67 ± 2.27 vs 4.39 ± 2.10, P = 0.012) and longer door-to-balloon time (72 [50-96] vs 64 [42-92] minutes, P < 0.001) than those admitted during on-hours. Off-hours admission had no association with in-hospital (unadjusted odds ratio 2.069, 95% confidence interval [CI] 0.956-4.480, P = 0.060) and long-term mortality (unadjusted hazards ratio [HR] 1.469, 95%CI 0.993-2.173, P = 0.054), even after adjustment for confounders. However, long-term outcomes, the composite of deaths and other adverse events, differed between groups with an unadjusted HR of 1.327 (95%CI, 1.102-1.599, P = 0.003), which remained significant in regression models. In a subgroup analysis, off-hours admission was associated with higher long-term mortality in the high-risk subgroup (unadjusted HR 1.965, 95%CI 1.103-3.512, P = 0.042), but not in low- and moderate-risk subgroups.This study showed no association between off-hours admission and in-hospital and long-term mortality. Stratified analysis indicated that off-hours admission was significantly associated with long-term mortality in the high-risk subgroup.