The off-hour effect in severe trauma and the structure of care delivery among Japanese emergency and critical care centers: A retrospective cohort study

Improvement in quality of trauma care at non-tertiary hospitals in Ghana during on-hours and off-hours with a trauma intake form: A stepped-wedge cluster randomized trial

BACKGROUND

We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours.

METHODS

A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression.

RESULTS

Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS).

CONCLUSIONS

At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.

[Indicators to measure the performance of emergency trauma care]

The objective of this paper was to identify the main indicators used to measure the performance in emergency trauma care. A literature review was carried out in the electronic databases: PubMEd, LILACS and Epistemónikos, including publications between January 2011 and December 31, 2021, in Spanish, English and Portuguese. A total of 962 publications were identified. When reviewing the full text, 48 articles were included. The indicators were classified in the dimensions of process and results. 100 different indicators were identified to analyze the performance of emergency trauma care. 71% were process indicators, including service time and triage. In the results dimension 29 indicators were identified; mortality was the indicator most analyzed as well as length of stay. Six indicators on the disability of injured people and 14 indicators related to satisfaction were identified, the most frequent being complaints. Various indicators have been used to assess the performance of emergency trauma care. In the results dimension, the indicators related to satisfaction and disability after injuries have been little explored. Decision-makers and those responsible for emergency care must promote performance evaluation exercises to learn about their current situation using appropriate and sensitive indicators with the available data.

An epidemiological assessment of choking-induced out-of-hospital cardiac arrest: A post hoc analysis of the SOS-KANTO 2012 study

OBJECTIVES

The aim of this study was to reveal the neurological outcomes of choking-induced out-of-hospital cardiac arrest (OHCA) and evaluate the presence of witnesses, cardiopulmonary resuscitation (CPR) performed by a witness (bystander-witnessed CPR), and the proportion of patients with favourable neurological outcomes by the time from CPR by emergency medical services (EMS) to the return of spontaneous circulation (ROSC) (CPR-ROSC time).

METHODS

We retrospectively analysed the SOS-KANTO 2012 database, which included data of 16,452 OHCAs in Japan. We selected choking-induced OHCA patients aged ≥ 20 years. We evaluated the neurological outcomes at 1 month with the Cerebral Performance Category (CPC). We defined favourable neurological outcomes (CPCs: 1-2) and present the outcomes with descriptive statistics.

RESULTS

Of 1,045 choking-induced OHCA patients, 18 (1.7%) had a favourable neurological outcome. Of 1,045 OHCAs, 757 (72.6%) were witnessed, and 375 (36.0%) underwent bystander-witnessed CPR. Of the 18 OHCAs with favourable outcomes, 17 (94.4%) were witnessed, and 11 (61.1%) underwent bystander-witnessed CPR. With a CPR-ROSC time of 0-5 minutes, the proportion of patients with favourable neurological outcomes was 29.7%, ranging from 0% to 6% in the following time groups.

CONCLUSIONS

The neurological outcome of choking-induced OHCA was poor. The neurological outcomes deteriorated rapidly from 5 minutes after the initiation of CPR by EMS. The presence of witnesses and bystander-witnessed CPR may be factors that contribute to improved outcomes, but the effects were not remarkable. As another approach to reduce deaths due to choking, citizen education for the prevention of choking may be effective.

Correlation between surgical mortality for perforated peritonitis and days of the week for operations: A retrospective study using the Japanese National Clinical Database

BACKGROUND

The association between weekend interventions and poor outcomes is termed the "weekend effect." This retrospective study investigated whether the weekend effect exists in the surgical treatment of acute diffuse peritonitis due to gastrointestinal perforation.

METHODS

Patients (n = 16,209) who underwent operation for acute diffuse peritonitis during 2016-2017 were included and grouped depending on the perforation site. Using 23 variables, we performed hierarchical logistic regression analysis and calculated odds ratios for surgical mortality.

RESULTS

Surgical mortality rates were 8.8%, 15.0%, and 14.1% for patients with gastroduodenal, small bowel, and large bowel perforations, respectively. Unadjusted odds ratios for surgical mortality differed significantly on Wednesdays only for patients with large bowel perforation (odds ratio: 0.772, 95% confidence interval: 0.613-0.972, P = 0.03). However, there was no significant difference in adjusted odds ratios.

CONCLUSION

The quality of emergency surgical treatment is uniform in Japan throughout the week in terms of mortality.

Does off-hours endoscopic hemostasis affect outcomes of nonvariceal upper gastrointestinal bleeding?

Aim: Different researches showed controversial results about the 'off-hours effect' in nonvariceal upper gastrointestinal bleeding (NVUGIB). Materials & methods: A total of 301 patients with NVUGIB were divided into regular-hours group and off-hours group based on when they received endoscopic hemostasis, and the relationship of the clinical outcomes with off-hours endoscopic hemostasis was evaluated. Results: Patients who received off-hours endoscopy were sicker and more likely to experience worse clinical outcomes. Off-hours endoscopic hemostasis was a significant predictor of the composite outcome in higher-risk patients (adjusted OR: 4.63; 95% CI: 1.35-15.90). However, it did not associate with the outcomes in lower-risk patients. Conclusion: Off-hours effect may affect outcomes of higher-risk NVUGIB patients receiving endoscopic hemostasis (GBS ≥12).

Association between off-hour admission of critically ill children to intensive care units and mortality in a Japanese registry

Limited information exists regarding the effect of off-hour admission among critically ill children. To evaluate whether children admitted to intensive care units (ICUs) in off-hour have worse outcomes, we conducted a cohort study in 2013–2018 in a multicenter registry in Japan. Pediatric (age < 16 years) unplanned ICU admissions were divided into regular-hour (daytime on business days) or off-hour (others). Mortality and changes in the functional score at discharge from the unit were compared between the two groups. We established multivariate logistic regression models to examine the independent association between off-hour admission and outcomes. Due to the small number of outcomes, two different models were used. There were 2512 admissions, including 757 for regular-hour and 1745 for off-hour. Mortality rates were 2.4% (18/757) and 1.9% (34/1745) in regular-hour and off-hour admissions, respectively. There was no significant association between off-hour admission and mortality both in model 1 adjusting for age, sex, and Pediatric Index of Mortality 2 (adjusted odds ratio [aOR] 0.89, 95% confidence interval [CI] 0.46–1.72) and in model 2 adjusting for propensity score predicting off-hour admission (aOR 1.05, 95% CI 0.57–1.91). In addition, off-hour admission did not show an independent association with deterioration of functional score.