Weekend working: a retrospective cohort study of maternal and neonatal outcomes in a large NHS delivery unit

Comparison of perioperative outcomes between colorectal operations performed on weekends vs those performed on weekdays

BACKGROUND

Weekend surgical time is an underused asset. Concerns over a possible weekend effect (substandard care) may be a barrier.

METHODS

This study examined whether a weekend effect applies to elective colorectal surgery via a single-center retrospective analysis comparing outcomes between patients who underwent elective colorectal surgery on a weekend vs a weekday. Demographics, length of stay (LOS), operative and anesthesia time, the rate of reoperation within 30 days, and the rate of major complications were compared between patient groups.

RESULTS

Of the 2008 patients identified, 1721 (85.7%) underwent surgery on a weekday, and 287 (14.3%) underwent surgery on a weekend. The proportion of operations with an open approach was higher on weekends than weekdays (49.5% vs 41.8%, P = .017). Patients who underwent surgery on the weekend tended to have a shorter mean (SE) for LOS (4.2 [0.2] vs 6.1 [0.2], P < .001), anesthesia time (233.8 [6.5] vs 307.6 [3.3] minutes, P < .001), and operative time (225.4 [6.4] vs. 297.6 [3.3] minutes, P < .001). On multivariable analysis, patients who had an operation on a weekend had a 38% lower chance of having a prolonged LOS (>75th percentile of LOS) compared with those who had an operation on a weekday (adjusted odds ratio = 0.62; 95% CI 0.42-0.92). There were no differences in rates of complications or reoperation for patients undergoing surgery on a weekend compared with a weekday.

CONCLUSION

At centers with experienced anesthesiologists, appropriately trained nursing staff, and expert surgeons, colorectal surgery performed on a weekend has similar safety outcomes as surgeries performed on a weekday.

The Effect of "Off Hours" on Maternal and Perinatal Outcomes in a Diverse U.S. Cohort

OBJECTIVE

This study aimed to evaluate the "off-hour effect" on maternal and neonatal adverse events in a large cohort representing U.S.

POPULATION

STUDY DESIGN

A secondary analysis of the Consortium on Safe Labor (CSL) dataset with 208,695 women and 229,385 deliveries was performed. The study included the deliveries of ≥23 gestational weeks from 19 hospitals in the United States from 2002 to 2008. Babies with congenital anomalies were excluded from neonatal outcomes. We compared maternal and neonatal outcomes of patients delivered during weekdays versus off hours (nights and weekends). The primary outcomes of the study were composite maternal and composite neonatal adverse events. The secondary outcomes were delivery type and individual maternal and neonatal adverse events including maternal death and perinatal mortality rate. Associations between off hours and all the outcomes were analyzed in bivariable and multivariable analyses. The same analyses were performed in strata by indication for admission (spontaneous labor or induction of labor).

RESULTS

Composite maternal adverse events (6.19 vs. 6.06%, p = 0.41) and maternal death (0.01 vs. 0.01%, p = 0.19) were not significantly different between off hours and weekday groups. In contrast, composite neonatal adverse events (6.91 vs. 5.84%, p < 0.001) and perinatal mortality rate (1.03 vs. 0.77%, p < 0.001) were higher in the off-hour group. After adjusting for confounding variables, only the composite neonatal outcome continued to be associated with off hours (adjusted odds ratio [aOR] = 1.10, 95% confidence interval [CI]: 1.04-1.16). Stratified analyses showed that the off-hour effect for the neonatal composite outcome was not present in those presenting in spontaneous labor (6.1 vs. 5.9%, p = 0.40).

CONCLUSION

Off-hour delivery was not associated with severe maternal morbidity and was only modestly associated with severe neonatal morbidity. This association was observed in women undergoing induction, not in those presenting in spontaneous labor. These data draw into question the existence of a clinically meaningful and correctable "off-hour effect" in obstetrics.

KEY POINTS

· The presence of a significant off-hour effect in obstetrics is still questionable.. · If the off-hour effect exists, it seems that not to be related with staffing issues.. · There is not a big difference for adverse events at off hours in spontaneously laboring patients..

Time of Delivery Contributes to Mortality and Morbidity in Preterm Infants

INTRODUCTION

Knowledge about the time of birth and its impact on premature infants is essential when planning perinatal and neonatal care and resource allocation. We studied the time of birth and its contribution to early death and morbidity in preterm infants.

METHODS

We explored the time and mode of birth of infants with birthweight of <1,500 g and gestational age of <32+0/7 weeks. Additionally, we divided the infants into three groups stratified by their time of birth, i.e., during office hours, evening, and nighttime and assessed associations between these groups and mortality and morbidity.

RESULTS

The study comprised 1,610 infants of whom 156 (10%) died during their stay in neonatal intensive care unit. The highest number of deliveries occurred on Fridays (21%, n = 341/1,610), primarily due to high number of cesarean sections. Deliveries peaked on workdays at 10 a.m. and 2:00 p.m. Mortality was lowest among infants born on Fridays (6%, n = 21/341) and highest on Mondays (13%, n = 28/218). Intraventricular hemorrhage (IVH) (odds ratio [OR]: 1.50, 95% CI: 1.10-2.03, p = 0.010) and necrotizing enterocolitis (NEC) (OR: 2.11, 95% CI: 1.13-3.91, p = 0.019) were more common among infants born at nighttime. These associations attenuated after adjustment for covariates.

CONCLUSION

Deliveries of premature infants peaked on Fridays. Mortality was lower among those born on Fridays, compared with Mondays. Many low-risk deliveries on Fridays may decrease, and the tendency to postpone high-risk deliveries to Mondays, increase the proportional risk of mortality. Indication of higher risk of IVH and NEC among infants born during nighttime may be due to different patient population.

Weekend delivery and maternal-neonatal adverse outcomes in low-risk pregnancies in the United States: A population-based analysis of 3-million live births

BACKGROUND

Childbirth is the most common cause of hospital admission in the United States. Previous studies have shown that there might be a "weekend effect" in perinatal care, indicating that mothers and newborns whose deliveries occur during the weekends are at increased risk of having adverse outcomes. This study aims to isolate the association between the weekend delivery and maternal-neonatal adverse outcomes by investigating low-risk pregnancies in nationwide data.

METHODS

A population-based study of all low-risk pregnancies (in-hospital, nonanomalous, term, normal birthweight, and singleton) was conducted based on US national natality data in 2017. Four maternal outcomes (ICU admission, uterine rupture, blood transfusion, and perineal laceration) and three neonatal outcomes (5-minute Apgar <7, NICU admission, and neonatal death) were defined as adverse outcomes. Logistic regression analyses were conducted to determine the association, adjusting for 23 maternal and neonatal characteristics and risk factors.

RESULTS

Among 3 011 577 low-risk pregnancies, 6.0% were reported to have at least one of the maternal-neonatal adverse outcomes. Weekend deliveries were significantly associated with six maternal-neonatal adverse outcomes with an exception of neonatal death. In general, weekend deliveries were 1.13 times significantly as likely to have any of seven maternal-neonatal adverse outcomes than weekday deliveries (OR 1.13, 95% CI 1.11-1.14), being attributed to adverse outcomes of more than 4500 mother-newborn pairs.

CONCLUSIONS

Weekend delivery is a consistent risk factor for both mothers and babies at the national level. Furthermore, studies are needed about possible modifiable factors that mediate these associations to ensure safe childbirth regardless of the day of delivery.

Quality and timeliness of emergency obstetric care and its association with maternal outcome in Keren Hospital, Eritrea

Despite the critical role quality comprehensive emergency obstetric care (CEmOC) plays in ensuring safe motherhood, only a few studies have attempted to measure the impact of substandard and delayed care on maternal outcome thus far. This study evaluates the association between various process and timeliness indicators of CEmOC and adverse maternal outcome in Keren Hospital. This study compared women with potentially life-threatening condition (PLTC) and women with severe maternal outcome (SMO) with respect to various process and timeliness indicators. Logistic regression analysis was employed to assess the association of timeliness and process indicators with SMO using SPSS version-22 computer software. In this study, we included 491 cases of PLTC and 210 cases of SMO (171 maternal near misses and 39 maternal deaths). The following process indicators showed significant association with SMO: failure to give uterotonics for the treatment of postpartum hemorrhage, failure to administer prophylactic antibiotics, and delayed laporatomy for uterine rupture. Moreover, delays in referral, triaging, seeing an obstetrician, and receiving definitive treatement were strongly associated with SMO. The following causes of delay were also found to be independently associated with SMO: erroneous diagnosis, inappropriate management, multiple referrals between health facilities, unavailability of a senior obstetrician, and poor communication during referral. Among the miscellaneous factors, nighttime admission and referral during the rainy season showed significant association with SMO. Findings of this study indicate that huge gap exists in providing quality and timely care in Keren Hospital. In general, most incidents of substandard and delayed care were due to poor referral system, insufficiency of medical staff, inadequacy of drugs and equipment, and unavailability of standard management protocol. Improving the referral system, upgrading the technical skills of health professionals, making sure life-saving drugs and equipment are available all the time, and posting standard treatment and management protocols in the maternity and emergency rooms will play a vital role in reducing the occurrence of SMO in Keren Hospital.

Birth during off-hours: Impact of time of birth, staff´s seniority, and unit volume on maternal adverse outcomes-a population-based cross-sectional study of 87 065 deliveries

BACKGROUND

The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks.

METHODS

We conducted a population-based cross-sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes.

RESULTS

Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16-1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15-1.57) compared with reference units (500-1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident-guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98-1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07-0.64).

CONCLUSION

Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high-volume centers were associated with the highest risk of maternal complications, and units with 500-1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high-volume center becomes at least as safe as delivering in a smaller unit.

Association between time of delivery and poor perinatal outcomes -An evaluation of deliveries in a tertiary hospital, South-east Nigeria

OBJECTIVES

Nigeria account for a significant proportion of adverse perinatal outcome. Nigerian studies assessing impact of time of delivery on perinatal outcome are scarce. This study evaluates any associations between time of delivery and perinatal outcome.

METHODS

This was a cross-sectional study at the Federal Teaching Hospital, Abakaliki from 01 January 2016 to 30 June 2018. Data were analysed with IBM SPSS version 25.0.

RESULTS

A total of 4,556 deliveries were analysed. Majority (72.2%) delivered on week days and 27.8% on weekends. Over 90% had 1st and 5th minutes Apgar scores ≥7. There was statistical difference in NICU admission between morning and evening hours (p = 0.009) but not between morning and night hours (p = 0.795). ENND during evening was twice higher (1.2%) than morning (0.5%); p = 0.047 and night hours (0.6%); p = 0.623.There was no difference in the risk of fresh stillbirths between morning and evening (p = 0.560), as well as morning and night hours (p = 0.75), there was also no difference in fresh stillbirths between week days and weekends (p = 0.895). There was no difference in low Apgar scores at 1st minute between morning and evening (p = 0.053) and night (p = 0.221), and between weekdays and weekends (p = 0.524). Similarly, there was no difference in low 5th minute Apgar scores between morning and evening (p = 0.165) and night (p = 0.944), as well as between week days and weekends (p = 0.529). However, ENND was twice (p = 0.085) and 1.3 times higher (p = 0.526) for evening and night hours respectively, while there was no difference between weekends and week days (p = 0.652).

CONCLUSION

NICU admission and ENND were commoner during evening hours. However, work hours did not affect the rate of stillbirth and low Apgar scores during weekdays and weekends. It is pertinent for each obstetric unit to identify and modify factors responsible for unfavourable outcomes during various shifts, with the aim of improving perinatal health.

The weekend effect in status epilepticus: a national cohort study

Higher mortality following admission to hospital at the weekend has been reported for several conditions. It is unclear whether this variation is due to differences in patients or their care. Status epilepticus mandates hospital admission and usually critical care: its study might provide new insights into the nature of any weekend effect. We studied 20,922 adults admitted to UK critical care with status epilepticus from 2010 to 2015. We used multiple logistic regression to evaluate the association between weekend admission and in-hospital mortality, comparing university hospitals with other hospitals. There were 2462 in-hospital deaths (12%). There was no difference in mortality after weekend admission to university hospitals, adjusted odds ratio (95%CI) 0.99 (0.84-1.16), p = 0.89. Mortality was less after weekend admission than after admissions Monday to Friday in hospitals not associated with a university, adjusted odds ratio (95%CI) 0.74 (0.64-0.87), p = 0.0001. There is no evidence that adults admitted to UK critical care at the weekend in status epilepticus are more likely to die than similar patients admitted during the week.

Foetal Morbidity Depending on the Day and Time of Delivery

Introduction It is known that perinatal mortality is increased with births at night and at the weekend. The aim of the study was to investigate whether there is also an association between the time of delivery (weekday, night, weekend) and perinatal morbidity. Material and Methods All births at Hannover Medical College between 2000 and 2014 were included in a retrospective data analysis. Multiple births, primary sections, severe foetal malformations and intrauterine deaths were not included. A 5-minute Apgar score ≤ 5 and cord arterial pH < 7.10 were defined as perinatal morbidity. Besides the time of delivery, different variables that are regarded as risk factors for increased perinatal morbidity were studied. Univariate logistical regression analysis was performed, followed by multivariate analysis. Results 18 394 deliveries were included in the study. Pathological prepartum Doppler, medical induction of labour and delivery at night and/or at the weekend significantly increased the probability of an Apgar score ≤ 5 after 5 minutes. The probability that a child will have cord arterial pH < 7.1 post partum is significantly increased with a BMI > 25 before pregnancy, primiparity, medical induction of labour, peripartum administration of oxytocic agents, when the delivery took place at night and weekend combined, but also when the delivery took place at night or at the weekend/on a public holiday. Multivariate regression analysis showed that a time of delivery at night and/or at the weekend or on a public holiday is not a prognostic factor for a 5-minute Apgar score ≤ 5 (p = 0.2377) but is a prognostic factor for cord arterial pH < 7.1 (p = 0.0252). Conclusion The time of delivery at night or at the weekend/on a public holiday increases the risk for cord arterial pH < 7.1 by ~ 30% compared with delivery on a weekday. However, the time of delivery at night or at the weekend/on a public holiday does not increase the risk for the baby of having a 5-minute Apgar score ≤ 5.

The effect of senior obstetric presence on maternal and neonatal outcomes in UK NHS maternity units: a systematic review and meta-analysis

BACKGROUND

There is little consensus regarding the hypothesised link between obstetric consultant presence and maternal and neonatal outcomes.

OBJECTIVES

To pool existing data on the impact of consultant presence on the outcomes of women who have given birth in UK National Health Service (NHS) maternity units.

SEARCH STRATEGY

Twelve databases, grey literature, and reference lists were searched.

SELECTION CRITERIA

Studies conducted in UK NHS maternity units comparing outcomes during lesser consultant presence versus increased consultant presence that reported mode of delivery and adverse maternal or neonatal outcomes.

DATA COLLECTION AND ANALYSIS

Studies were divided into three groups by type of comparison: (1) hours of rostered consultant presence during the weekend versus hours of rostered consultant presence during the week; (2) hours per week of rostered consultant presence pre-increase versus hours per week of rostered consultant presence post-increase; and (3) no rostered consultant presence versus rostered consultant presence. A random-effects meta-analysis was performed.

MAIN RESULTS

Fifteen studies fulfilled the inclusion criteria, presenting data from 125 856 births. Overall, there was no significant difference between lesser and increased consultant presence for any outcome. When data were stratified by comparison type, the likelihood of emergency caesarean section was significantly lower (odds ratio, OR 0.91; 95% confidence interval, 95% CI 0.86-0.96) and the likelihood of non-instrumental vaginal delivery was significantly higher (OR 1.07; 95% CI 1.02-1.12) when the rostered hours of consultant presence per week were increased.

CONCLUSIONS

Increased consultant presence has some effect on mode of delivery, but no evidence for a benefit for adverse outcomes was found.

TWEETABLE ABSTRACT

Increasing hours of NHS obstetric consultant presence may increase chance of non-instrumental vaginal delivery.

The influence of hours worked prior to delivery on maternal and neonatal outcomes: a retrospective cohort study

BACKGROUND

Long continuous periods of working contribute to fatigue, which is an established risk factor for adverse patient outcomes in many clinical specialties. The total number of hours worked by delivering clinicians before delivery therefore may be an important predictor of adverse maternal and neonatal outcomes.

OBJECTIVE

We aimed to examine how rates of adverse delivery outcomes vary with the number of hours worked by the delivering clinician before delivery during both day and night shifts.

STUDY DESIGN

We conducted a retrospective cohort study of 24,506 unscheduled deliveries at an obstetrics center in the United Kingdom from 2008-2013. We compared adverse outcomes between day shifts and night shifts using random-effects logistic regression to account for interoperator variability. Adverse outcomes were estimated blood loss of ≥1.5 L, arterial cord pH of ≤7.1, failed instrumental delivery, delayed neonatal respiration, severe perineal trauma, and any critical incident. Additive dynamic regression was used to examine the association between hours worked before delivery (up to 12 hours) and risk of adverse outcomes. Models were controlled for maternal age, maternal body mass index, parity, birthweight, gestation, obstetrician experience, and delivery type.

RESULTS

We found no difference in the risk of any adverse outcome that was studied between day vs night shifts. Yet, risk of estimated blood loss of ≥1.5 L and arterial cord pH of ≤7.1 both varied by 30-40% within 12-hour shifts (P<.05). The highest risk of adverse outcomes occurred after 9-10 hours from the beginning of the shift for both day and night shifts. The risk of other adverse outcomes did not vary significantly by hours worked or by day vs night shift.

CONCLUSION

Number of hours already worked before undertaking unscheduled deliveries significantly influences the risk of certain adverse outcomes. Our findings suggest that fatigue may play a role in increasing the risk of adverse delivery outcomes later in shifts and that obstetric work patterns could be better designed to minimize the risk of adverse delivery outcomes.