Effect of the timing of admission upon patient prognosis in the Intensive Care Unit: On-hours versus off-hours

[Effect on the time of admission to the Intensive Care Unit of the start-up of an Critical Care Outreach Team]

INTRODUCTION

The implementation of the Critical Care Outreach Teams can influence the time of admission of patients to the Intensive Care Unit (ICU).

MATERIAL AND METHODS

Retrospective, descriptive, quasi-experimental "before-after" cohort study. All patients admitted to the unit urgently from Monday to Friday for two periods (between February 1, 2022 and June 30 and between February 1, 2023 and June 30, 2023) are included. The patients were divided into regular shift admissions (08-15h) and on-call (15-08h). The secondary objective was to assess whether there were differences in mortality between the two periods.

RESULTS

During the first period of the study, 239 patients were admitted. 29.29% entered the ordinary shift and 70.71% on duty shift. During the second period, 211 patients were included with 43.13% of admissions in the ordinary shift. The comparison between the two periods observed a significant increase in the percentage of admissions in the morning hours in the second period (P=.0031). Mortality in the first period was 13.80% and in the second period 9.95%. The comparison between the two periods did not reveal significant differences.

CONCLUSIONS

The start-up of the Critical Care Outreach Teams is associated with an increase in the proportion of ICU admissions in the morning period without any observed changes in mortality.

Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study

OBJECTIVES

Diagnostic errors can harm critically ill children. However, we know little about their prevalence in PICUs and factors associated with error. The objective of this pilot study was to determine feasibility of record review to identify patient, provider, and work system factors associated with diagnostic errors during the first 12 hours after PICU admission.

DESIGN

Pilot retrospective cohort study with structured record review using a structured tool (Safer Dx instrument) to identify diagnostic error.

SETTING

Academic tertiary referral PICU.

PATIENTS

Patients 0-17 years old admitted nonelectively to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four of 50 patients (8%) had diagnostic errors in the first 12 hours after admission. The Safer Dx instrument helped identify delayed diagnoses of chronic ear infection, increased intracranial pressure (two cases), and Bartonella encephalitis. We calculated that 610 PICU admissions are needed to achieve 80% power (α = 0.05) to detect significant associations with error.

CONCLUSIONS

Our pilot study found four patients with diagnostic error out of 50 children admitted nonelectively to a PICU. Retrospective record review using a structured tool to identify diagnostic errors is feasible in this population. Pilot data are being used to inform a larger and more definitive multicenter study.

Time of Pediatric Intensive Care Unit Admission and Mortality: A Systematic Review and Meta-Analysis

The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60-0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77-1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57-1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies.

Out-of-hours intensive care unit admission and 90-day mortality: a Danish nationwide cohort study

BACKGROUND

Mortality rates in critically ill adult patients admitted to the intensive care unit (ICU) remains high, and numerous patient- and disease-related adverse prognostic factors have been identified. In recent years, studies in a variety of emergency conditions suggested that outcome is dependent on the time of hospital admission. The importance of out-of-hours admission to the ICU has been sparsely evaluated and with ambiguous findings. We assessed the association between out-of-hours (16:00 to 07:00) and weekend admission to the ICU, respectively, and 90-day mortality in a nationwide cohort.

METHODS

We included all Danish adult patients admitted to the ICU between 1 January 2011 and 30 June 2014, with an ICU stay > 24 h. The crude and adjusted association between out-of-hours and weekend admission and 90-day mortality was assessed (odds ratio (ORs) with 95% confidence intervals (CI)).

RESULTS

A total of 44,797 patients were included, 53.3% were admitted out-of-hours, and 22.6% during weekends. Median age was 67 years (interquartile range (IQR) 55-76), and median SAPS II was 42 (IQR 30-54). Patients admitted in-hours vs. out-of-hours displayed a 90-day mortality rate of 41.0% vs. 44.2%. The adjusted association (OR with 95% CI) between out-of-hours admission and 90-day mortality was 1.07 (1.02-1.11), and the adjusted association (OR with 95% CI) between weekend admission and 90-day mortality was 1.10 (1.05-1.15).

CONCLUSION

This nationwide study suggests that critically ill adult patients admitted to the ICU during weekends and out-of-hours, and with an ICU stay > 24 h are at slightly increased risk of mortality.

Hospitals by day, dispensaries by night: Hourly fluctuations of maternal mortality within Mexican health institutions, 2010-2014

BACKGROUND

Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths.

OBJECTIVE

To analyze the hourly variation of maternal mortality within Mexican health institutions.

METHODS

We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010-2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies.

RESULTS

Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays.

CONCLUSIONS

Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care.

Prognostic impact of the time of admission and discharge from the intensive care unit

Objective

To determine the impact of the day and time of admission and discharge from the intensive care unit on mortality.

Methods

Prospective observational study that included patients admitted to the intensive care unit of the Hospital Maciel in Montevideo between April and November 2014.

Results

We analyzed 325 patients with an average age of 55 (36 - 71) years and a SAPS II value of 43 (29 - 58) points. No differences were found in the mortality of patients in the intensive care unit when time of admission (35% on the weekend versus 31% on weekdays, p = ns) or the hour of entry (35% at night versus 31% in the daytime, p = ns) were compared. The time of discharge was associated with higher hospital mortality rates (57% for weekend discharges versus 14% for weekday discharges, p = 0.000). The factors independently associated with hospital mortality after discharge from the intensive care unit were age > 50 years (OR 2.4, 95%CI, 1.1 - 5.4) and weekend discharge (OR 7.7, 95%CI, 3.8-15.6).

Conclusion

This study identified the time of discharge from the intensive care unit as a factor that was independently associated with hospital mortality.

Are «off hours» intubations a risk factor for complications during intubation? A prospective, observational study

OBJECTIVE

To compare the complications and the difficulty of orotracheal intubation procedures performed in the Intensive Care Unit during the off-hours period and the on-hours period.

DESIGN

A prospective, observational and non-interventional cohort study covering a period of 27 months was carried out. Working days between 8:00 a. m. and 7:59 p. m. were considered «on-hours», while the remaining shifts were regarded as «off-hours».

SCOPE

An 18-bed surgical in a Intensive Care Unit of a third-level hospital.

PATIENTS

All orotracheal intubation patients admitted to the ICU from January 2015 to March 2017 were included. Patients were stratified into 2groups according to whether intubation was performed on-hours or off-hours.

INTERVENTIONS

Non-interventional study.

VARIABLES OF INTEREST

The reason for intubation, time and day on which intubation was performed, degree of intubation difficulty (number of attempts, Cormack-Lehane laryngoscopic vision, need for accessory material) and complications during intubation.

RESULTS

A total of 252 patients were intubated; of these, 132 were included in the on-hours group and 120 patients in the off-hours group. In the off-hours group we observed a greater percentage of urgent and emergent intubations compared to the on-hours group. However, no differences were found between the 2groups in relation to the other variables studied.

CONCLUSIONS

During the off-hours period, orotracheal intubation was not associated to a greater number of complications or to greater difficulty of the technique in our Unit.

Mortality Associated with Night and Weekend Admissions to ICU with On-Site Intensivist Coverage: Results of a Nine-Year Cohort Study (2006-2014)

Background

The association between mortality and time of admission to ICU has been extensively studied but remains controversial. We revaluate the impact of time of admission on ICU mortality by retrospectively investigating a recent (2006–2014) and large ICU cohort with on-site intensivist coverage.

Patients and Methods

All adults (≥ 18 years) admitted to a tertiary care medical ICU were included in the study. Patients' characteristics, medical management, and mortality were prospectively collected. Patients were classified according to their admission time: week working days on- and off-hours, and weekends. ICU mortality was the primary outcome and adjusted Hazard-ratios (HR) of death were analysed by multivariate Cox model.

Results

2,428 patients were included: age 62±18 years; male: 1,515 (62%); and median SAPSII score: 38 (27–52). Overall ICU mortality rate was 13.7%. Admissions to ICU occurred during open-hours in 680 cases (28%), during night-time working days in 1,099 cases (45%) and during weekends in 649 cases (27%). Baseline characteristics of patients were similar between groups except that patients admitted during the second part of night (00:00 to 07:59) have a significantly higher SAPS II score than others. ICU mortality was comparable between patients admitted during different time periods but was significantly higher for those admitted during the second part of the night. Multivariate analysis showed however that admission during weeknights and weekends was not associated with an increased ICU mortality as compared with open-hours admissions.

Conclusion

Time of admission, especially weeknight and weekend (off-hour admissions), did not influence the prognosis of ICU patients. The higher illness severity of patients admitted during the second part of the night (00:00–07:59) may explain the observed increased mortality.

Effects of time and day of admission on the outcome of critically ill patients admitted to ICU

Background

Studies have shown that patients admitted to hospitals on weekends and after-hours experience worse outcome than those admitted on weekdays and daytime hours. Although admissions of patients to intensive care units (ICUs) occur 24 hours a day, not all critical care units maintain the same level of staffing during nighttime, weekends, and holidays. This raises concerns in view of evidence showing that the organizational structure of an ICU influences the outcome of critically ill patients. The objective of this study is to evaluate the effects of day and time of admission to ICU on patients’ outcome.

Methods

A single-center, prospective, observational study was conducted among all consecutive admissions to ICU in a community teaching hospital during a 4-month period.

Results

A total of 282 patients were admitted during the study period. Their mean age was 59.5 years (median 59, range 17–96), and the majority were male (157, 55.7%). Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 18.9 (median 33, range 1–45), and mean ICU length of stay was 3.1 days (median 2, range 1–19). Of the patients, 104 patients (36.9%) were admitted during weekends and 178 (63.1%) during weekdays. A total of 122 patients (43.3%) were admitted after-hours, constituting 68.5% of all admissions during weekdays. Fifty-six patients (19.9%) were admitted during daytime hours, representing 31.5% of all weekday admissions. Forty-five patients (15.9%) died in ICU. Compared to patients admitted on weekends, those admitted on weekdays had increased ICU mortality (operating room (OR)=0.437; 95% confidence interval=0.2054–0.9196; p=0.0293).

Conclusion

Admissions to ICU during weekends were not independently associated with increased mortality. A linear relationship between weekdays and after-hours admissions to ICU with mortality was observed at our institution.