Weekend versus weekday admission and mortality from myocardial infarction

Impact of day of admission on patients admitted with complete heart block: Analyzing the weekend effect

BACKGROUND

Complete heart block (CHB) is a conduction disorder that can be fatal if not treated promptly. Admission on a week or weekend day may influence the outcomes of cardiac emergencies, such as CHB.

OBJECTIVES

The purpose of this study was to determine the effects of weekday vs. weekend admissions in terms of CHB outcomes.

METHODS

A retrospective cohort study was conducted using the National Inpatient Sample database to study the outcomes of adult patients admitted with complete heart block. Outcomes were compared between the patients admitted on weekends (midnight Friday to midnight Sunday) and weekdays.

RESULTS

Thirty-four thousand three hundred ninety-five patients were included, of which 7350 (21.37 %) were admitted on weekends. Mean age for included patients was 75.69 years, with 43.23 % females. Compared to those admitted on weekdays, participants admitted on weekends had similar mortality (aOR 0.73; 95 % CI 0.46-1.16), longer length of stay (mean increase 0.74 days; P < 0.01) and higher hospital charges (mean increase $10,540.82; P < 0.01). Weekend admissions were associated with higher rates of cardiac arrest (adjusted OR 1.40; 95 % CI 1.07-1.84; P = 0.02) and higher rates of cardiogenic shock (adjusted OR 1.40; 95 % CI 1.07-1.83; P = 0.01) and similar rates of permanent pacemaker implantation (adjusted OR 0.88; 95 % CI 0.77-1.01; P = 0.06), but had longer delay to permanent pacemaker (mean increase 0.46 days; P < 0.01).

CONCLUSION

Hospital and administrative-level strategies are needed to address the differences between the weekend and weekday CHB admissions.

Reduced 30-day in-hospital but increased long-term mortality for weekend vs weekday acute medical admission

BACKGROUND

Acute medical admission at the weekend has been reported to be associated with increased mortality. We aimed to assess 30-day in-hospital mortality and subsequent follow-up of all community deaths following discharge for acute medical admission to our institution over 21 years.

METHODS

We employed a database of all acute medical admissions to our institution over 21 years (2002-2023). We compared 30-day in-hospital mortality by weekend (Saturday/Sunday) or weekday (Tuesday/Wednesday) admission. Outcome post-discharge was determined from the National Death Register to December 2021. Predictors of 30-day in-hospital and long-term mortality were analysed by logistic regression or Cox proportional hazards models.

RESULTS

The study population consisted of 109,232 admissions in 57,059 patients. A weekend admission was associated with a reduced 30-day in-hospital mortality, odds ratio (OR) 0.70 (95%CI 0.65, 0.76). Major predictors of 30-day in-hospital mortality were acute illness severity score (AISS) OR 6.9 (95%CI 5.5, 8.6) and comorbidity score OR 2.4 (95%CI 1.2, 4.6). At a median follow-up of 5.9 years post-discharge, 19.0% had died. The strongest long-term predictor of mortality was admission AISS OR 6.7 (95%CI 4.6, 9.9). The overall survival half-life after hospital discharge was 16.6 years. Survival was significantly worse for weekend admissions at 20.8 years compared to weekday admissions at 13.3 years.

CONCLUSION

Weekend admission of acute medical patients is associated with reduced 30-day in-hospital mortality but reduced long-term survival.

Impact of off-hours admissions in STEMI-related cardiogenic shock managed with microaxial flow pump - insights from J-PVAD

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (STEMI-CS) is associated with high mortality rates. Patients admitted during off-hours, specifically on weekends and at night, show higher mortality rates, which is called the "off-hours effect". The off-hours effect in patients with STEMI-CS treated with mechanical circulatory support, especially Impella, has not been fully evaluated.

AIMS

We aimed to investigate whether off-hours admissions were associated with higher mortality rates in this population.

METHODS

We used large-scale Japanese registry data for consecutive patients treated with Impella between February 2020 and December 2021 and compared on- and off-hours admissions. On- and off-hours were defined as the time between 8:00 and 19:59 on weekdays and the remaining time, respectively. The Cox proportional hazards model was used to calculate the adjusted hazard ratios (aHRs) for 30-day mortality.

RESULTS

Of the 1,207 STEMI patients, 566 (46.9%) patients (mean age: 69 years; 107 females) with STEMI-CS treated with Impella were included. Of these, 300 (53.0%) were admitted during on-hours. During the follow-up period (median 22 days [interquartile range 13-38 days]), 112 (42.1%) and 91 (30.3%) deaths were observed among patients admitted during off- and on-hours, respectively. Off-hours admissions were independently associated with a higher risk of 30-day mortality than on-hours admissions (aHR 1.60, 95% confidence interval: 1.07-2.39; p=0.02).

CONCLUSIONS

Our findings indicated the persistence of the "off-hours effect" in STEMI-CS patients treated with Impella. Healthcare professionals should continue to address the disparities in cardiovascular care by improving the timely provision of evidence-based treatments and enhancing off-hours medical services.

Are heart attacks deadlier on weekends? Evidence of weekend effect in Brazil

This article aims to examine the effects of weekend admission on in-hospital mortality for patients with acute myocardial infarction (AMI) in Brazil. Information from the Hospital Information System of the Unified Health System (SIH/SUS) of urgently admitted patients diagnosed with acute myocardial infarction (AMI) between 2008 and 2018 was used, made available through the Hospital Admission Authorization (AIH). Multivariable logistic regression models, controlling for observable patient characteristics, hospital characteristics and year and hospital-fixed effects, were used. The results were consistent with the existence of the weekend effect. For the model adjusted with the inclusion of all controls, the chance of death observed for individuals hospitalized on the weekend is 14% higher. Our results indicated that there is probably an important variation in the quality of hospital care depending on the day the patient is hospitalized. Weekend admissions were associated with in-hospital AMI mortality in Brazil. Future research should analyze the possible channels behind the weekend effect to support public policies that can effectively make healthcare equitable.

Outcomes of Weekday Versus Weekend Admissions for Heart Block Requiring De Novo Intracardiac Device Implantation

Even with comparable healthcare structure and staffing, patients presenting on weekends often face poorer outcomes, including longer wait times in the emergency department, extended hospital stays, and delays in major procedures. This discrepancy prompts questions about whether life-saving cardiac procedures, such as permanent pacemaker (PPM) implantation for atrioventricular block, also experience similar delays and differences in outcomes. We researched over 200,000 patients from the National Inpatient Sample (NIS) database to help study whether patients admitted on the weekend truly had worse outcomes than patients admitted on the weekday. Using the International Classification of Diseases, Tenth Revision (ICD-10) using STATA software (StataCorp LLC, College Station, TX), we found that 79.6% of patients were admitted on weekdays. Among these weekday admissions, 56.2% were males, with an average age of 75.8 years. Weekend admissions included 54.4% male patients, with an average age of 76.4 years. Key variables influencing outcomes were renal failure history, non-ST elevation myocardial infarction, diabetes mellitus, and percutaneous coronary intervention. Of the total patients, 1,315 died during hospitalization, with no significant difference in mortality between weekday and weekend admissions. However, weekend admissions had a higher rate of cardiac arrest, a greater likelihood of delayed pacer implantation, and longer hospital stays. Weekend admissions were linked to delays in PPM placement, longer hospital stays, and higher hospitalization costs. Mortality rates did not increase for patients admitted on weekends. Further research is needed to explore this issue in greater depth and to identify the specific factors contributing to the discrepancy between weekend and weekday admissions, which resulted in worse outcomes for weekend patients.

The "Weekend Effect" in Extracorporeal Cardiopulmonary Resuscitation

Background

The phenomenon known as the "weekend effect" impacts various medical disciplines. We compared outcomes between regular hours and off hours to investigate the presence of the weekend effect in extracorporeal cardiopulmonary resuscitation (ECPR).

Methods

Between January 2018 and December 2020, 159 patients at our center were treated with veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiac arrest. We assessed the time required for ECMO preparation, the rate of successful weaning, and the rate of in-hospital mortality. These factors were compared among regular hours ("daytime": weekdays from 7:00 AM-7:00 PM), off hours on weekdays ("nighttime": weekdays from 7:00 PM-7:00 AM), and off hours on weekends and holidays ("weekend": Fridays at 7:00 PM to Mondays at 7:00 AM).

Results

The time from the recognition of cardiac arrest to the arrival of the ECMO team was shortest for the daytime group and longest for those treated over the weekend (daytime, 10.0 minutes; nighttime, 12.5 minutes; weekend, 15.0 minutes; p=0.064). The time from the ECMO team's arrival to ECMO initiation was shortest for the daytime and longest for the nighttime group (daytime, 13.0 minutes; nighttime, 18.5 minutes; weekend, 14.0 minutes; p=0.028). No significant difference was observed in the rate of successful ECMO weaning (daytime, 48.3%; nighttime, 39.5%; weekend, 36.1%; p=0.375).

Conclusion

In situations involving CPR, the time to arrival of the ECMO team was longer during off hours. Furthermore, ECMO insertion required more time at night than during the other periods. These findings warrant specific training in decision-making and emergent ECMO insertion.

Impact of Off-Hour Admission on In-Hospital Outcomes for Patients With Stroke Receiving Reperfusion Therapy in China

BACKGROUND

The structure and staffing of hospitals greatly impact patient outcomes, with frequent changes occurring during nights and weekends. This retrospective cohort study assessed the impact of admission timing on in-hospital management and outcomes for patients with stroke receiving reperfusion therapy in China using data from a nationwide registry.

METHODS

Data from patients receiving reperfusion therapy were extracted from the Chinese Stroke Center Alliance. Hospital admission time was categorized according to day/evening versus night and weekday versus weekend. Primary outcomes were in-hospital death or discharge against medical advice, hemorrhage transformation, early neurological deterioration, and major adverse cardiovascular events. Logistic regression was performed to compare in-hospital management performance and outcomes based on admission time categories.

RESULTS

Overall, 42 381 patients received recombinant tissue-type plasminogen activator (r-tPA) therapy, and 5224 underwent endovascular treatment (EVT). Patients admitted during nighttime had a higher probability of receiving r-tPA therapy within 4.5 hours from onset or undergoing EVT within 6 hours from onset compared with those admitted during day/evening hours (adjusted odds ratio, 1.04 [95% CI, 1.01-1.08]; P=0.021; adjusted odds ratio, 1.72 [95% CI, 1.59-1.86]; P<0.001, respectively). However, no significant difference was observed between weekend and weekday admissions for either treatment. No notable differences were noted between weekends and weekdays or nighttime and daytime periods in door-to-needle time for r-tPA or door-to-puncture time for EVT initiation. Furthermore, weekend or nighttime admission did not have a significant effect on the primary outcomes of r-tPA therapy or EVT. Nevertheless, in patients undergoing EVT, a higher incidence of pneumonia was observed among those admitted at night compared with those admitted during day/evening hours (adjusted odds ratio, 1.22 [95% CI, 1.05-1.42]; P=0.011).

CONCLUSIONS

Patients admitted at nighttime were more likely to receive r-tPA therapy or EVT within the time window recommended in the guidelines. However, patients receiving EVT admitted at night had an increased risk of pneumonia.

Association between holiday and weekend admissions and mortality outcomes among patients with acute myocardial infarction receiving percutaneous coronary intervention in Taiwan

There is a lack of studies that concurrently differentiate the effect of the holiday season from the weekend effect on mortality risk in patients with acute myocardial infarction (AMI). We evaluated the mortality risk among patients admitted with AMI who underwent percutaneous coronary intervention, using data from the Taiwan National Health Insurance Research Database. Adult AMI patients admitted during January and February between 2013 and 2020 were enrolled and classified into the holiday season (using the Chinese New Year holiday seasons as an indicator) (n = 1729), weekend (n = 4725), and weekday (n = 14,583) groups according to the first day of admission. A multivariable logistic regression model was used to assess the risk. With the weekday group or the weekend group as the reference, the holiday season group did not have increased risks of in-hospital mortality (adjusted odds ratio [aOR] 1.15; 95% confidence intervals [CI] 0.93-1.42 or aOR 1.23; 95% CI 0.96-1.56) and 7-day mortality (aOR 1.20; 95% CI 0.90-1.58 or aOR 1.24; 95% CI 0.90-1.70). Stratified and subgroup analyses showed similar trends. We conclude that holiday season-initiated admissions were not associated with higher mortality risks in AMI admission cases than weekday or weekend admissions.

Was there a weekend effect on mortality rates for hospitalized patients with COVID-19 and acute myocardial infarction? Insights from the National Inpatient Sample, 2020

Our study aimed to assess the effect of weekend versus weekday hospital admissions on all-cause mortality in patients with acute myocardial infarction (AMI) and COVID-19 during the COVID-19 pandemic. We analyzed data from the National Inpatient Sample (NIS) 2020, identifying patients with co-existing AMI and COVID-19 admitted on weekdays and weekends. Baseline demographics, comorbidities, and outcomes were assessed. A multivariable regression analysis was conducted, adjusting for confounders to determine the odds of all-cause mortality. Among 74,820 patients, 55,145 (73.7%) were admitted on weekdays, while 19,675 (26.3%) were admitted on weekends. Weekend admissions showed slightly higher proportions of men (61.3% vs. 60%) and whites (56.3% vs. 54.9%) with a median age of 73 years (range: 62-82). The overall all-cause mortality had an odds ratio (OR) of 1.00 (95% CI, 0.92-1.09; P = 0.934). After adjusting for covariates, there was no significant associations between mortality and hospital type (rural: OR = 1.04; 95% CI, 0.78-1.39; P = 0.789; urban teaching: OR = 1.04; 95% CI, 0.94-1.14; P = 0.450) or geographic region (Northeast: OR = 1.16; 95% CI, 0.96-1.39; P = 0.12; Midwest: OR = 0.99; 95% CI, 0.83-1.17; P = 0.871; South: OR = 0.97; 95% CI, 0.85-1.12; P = 0.697; West: OR = 0.94; 95% CI, 0.77-1.15; P = 0.554). There was no significant difference in the rate of all-cause mortality among patients admitted for AMI and COVID-19 between weekdays and weekends.

Urban-rural disparities in the association of nitrogen dioxide exposure with cardiovascular disease risk in China: effect size and economic burden

BACKGROUND

Together with rapid urbanization, ambient nitrogen dioxide (NO2) exposure has become a growing health threat. However, little is known about the urban-rural disparities in the health implications of short-term NO2 exposure. This study aimed to compare the association between short-term NO2 exposure and hospitalization for cardiovascular disease (CVD) among urban and rural residents in Shandong Province, China. Then, this study further explored the urban-rural disparities in the economic burden attributed to NO2 and the explanation for the disparities.

METHODS

Daily hospitalization data were obtained from an electronic medical records dataset covering a population of 5 million. In total, 303,217 hospital admissions for CVD were analyzed. A three-stage time-series analytic approach was used to estimate the county-level association and the attributed economic burden.

RESULTS

For every 10-μg/m3 increase in NO2 concentrations, this study observed a significant percentage increase in hospital admissions on the day of exposure of 1.42% (95% CI 0.92 to 1.92%) for CVD. The effect size was slightly higher in urban areas, while the urban-rural difference was not significant. However, a more pronounced displacement phenomenon was found in rural areas, and the economic burden attributed to NO2 was significantly higher in urban areas. At an annual average NO2 concentration of 10 μg/m3, total hospital days and expenses in urban areas were reduced by 81,801 (44,831 to 118,191) days and 60,121 (33,002 to 86,729) thousand CNY, respectively, almost twice as much as in rural areas. Due to disadvantages in socioeconomic status and medical resources, despite similar air pollution levels in the urban and rural areas of our sample sites, the rural population tended to spend less on hospitalization services.

CONCLUSIONS

Short-term exposure to ambient NO2 could lead to considerable health impacts in either urban or rural areas of Shandong Province, China. Moreover, urban-rural differences in socioeconomic status and medical resources contributed to the urban-rural disparities in the economic burden attributed to NO2 exposure. The health implications of NO2 exposure are a social problem in addition to an environmental problem. Thus, this study suggests a coordinated intervention system that targets environmental and social inequality factors simultaneously.

Higher 1-year mortality on rest days in patients with acute coronary syndromes and decompensated heart failure-A SPUM-ACS sub-study

BACKGROUND

Acute coronary syndromes (ACS) occurring on rest days have been associated with higher mortality, but the current literature remains inconsistent in this regard. This study included ACS patients presenting with acute decompensated heart failure (ADHF) investigating the relationship between time of coronary catheterization and outcomes.

METHODS

Analyses were performed from the prospective, multicentric Special Program University Medicine Acute Coronary Syndromes and Inflammation (SPUM-ACS) Cohort. Patients were divided into two groups according to time of coronary catheterization on either workdays (Monday, 00:00 to Friday, 23:59) or rest days (Saturday, 00:00 to Sunday, 23:59 and public holidays). ADHF was defined by Killip Class III or IV upon presentation. Patients were followed over 1 year.

RESULTS

Out of 4787 ACS patients enrolled in the SPUM-ACS Cohort, 207 (4.3%) presented with ADHF. 52 (25.1%) and 155 (74.9%) patients underwent coronary angiography on rest days or workdays, respectively. Baseline characteristics were similar among these groups. ACS patients with ADHF showed increased 1-year mortality on rest days (34.6% vs. 17.4%, p-value = 0.009). After correction for baseline characteristics, including the GRACE 2.0 Score, rest day presentation remained a significant predictor for 1-year mortality (adjusted hazard ratio = 2.42 [95% confidence interval: 1.14-5.17], p-value = 0.022).

CONCLUSIONS

One-year all-cause mortality was high in ACS patients with ADHF and doubled for patients admitted on rest days. The present data support the association of a rest day effect and long-term patient survival and indicate a need for further investigations.

Impact of day of admission on in-hospital outcomes of cardiogenic shock

BACKGROUND

The management of cardiogenic shock (CS) requires attentiveness to details and in some cases, invasive interventions. In the past, studies have shown relationships between the day of admission and cardiovascular outcomes. We aim to analyze the trends and in-hospital outcomes of patients admitted with CS over the weekends compared to weekdays.

METHOD

We identified all patients with CS from the National Inpatient Sample (NIS) database between 2016 and 2020. Using multivariate logistic regression analysis, baseline demographics and in-hospital outcomes were obtained and compared by weekend or weekday admission.

RESULTS

Out of 854,684 CS admissions, 199,255 (23.6%) occurred on weekends. Patients admitted over the weekend had worse outcomes, including higher rates of mortality (aOR 1.09 CI 1.05 - 1.11, p<0.001), cardiac arrest (aOR 1.09 CI 1.04 -1.14, p<0.001), and respiratory failure. We also noted higher percutaneous coronary intervention (PCI) rates (aOR 1.2 CI 1.16 - 1.25, p<0.001) but lower rates of pulmonary artery catheterization (PAC) and post-procedure pneumothorax. Weekend admissions had shorter hospital lengths of stay, and they incurred lower charges ($223,222 vs. $247,908). Between 2016 and 2020, we observed a consistent downward trend in the mortality rates of the weekend and weekday CS admissions, with consistently higher weekend than weekday admissions.

CONCLUSION

Weekend admissions for CS are associated with worse outcomes, which have persisted for years. This now begs the question of whether physician dissatisfaction, understaffing, or burn-out are responsible for this finding.

Impact of off-hour admission on the MACEs of patients with acute myocardial infarction

BACKGROUND

In China, on more than 100 weekends or holidays, only on-duty cardiologists are available during admissions. This study aimed to analyze the impact of admission time on major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction (AMI).

METHODS

This prospective observational study enrolled patients with AMI between October 2018 and July 2019. The patients were assorted into off-hour (admitted on weekends or national holidays) and on-hour groups. The outcome was MACEs at admission and 1 year after discharge.

RESULTS

A total of 485 patients with AMI were enrolled in this study. The occurrence of MACEs was significantly higher in the off-hour group compared with the on-hour group (P < .05). Multivariate regression analysis showed that age (HR = 1.047, 95% CI: 1.021-1.073), blood glucose level (HR = 1.029, 95% CI: 1.009-1.050), multivessel disease (HR = 1.904, 95% CI: 1.074-3.375), and off-hour hospital admission (HR = 1.849, 95% CI: 1.125-3.039) were all independent risk factors for in-hospital MACEs, while percutaneous coronary intervention (HR = 0.210, 95% CI: 0.147-0.300) and on-hour admission (HR = 0.723, 95% CI: 0.532-0.984) were protective factors for MACEs 1 year after discharge.

CONCLUSION

The "off-hour effect" still existed in patients with AMI, and the risk of MACEs in the hospital and 1 year after discharge was higher for off-hour admission.

The association of self-reported awake bruxism and sleep bruxism with temporomandibular pain and dysfunction in adult patients with temporomandibular disorders

OBJECTIVE

To investigate the association of the severity of temporomandibular disorders (TMD) pain and dysfunction with the frequency of self-reported awake bruxism (AB), sleep bruxism (SB), and stress in an adult TMD-patient population.

MATERIALS AND METHODS

This cross-sectional study included 237 TMD patients based on the Diagnostic Criteria for TMD. Age, sex, frequency of self-reported AB and SB, and stress were included as independent variables. TMD pain and TMD dysfunction were included as dependent variables in regression analyses. Univariate and multivariable linear regression analyses were used to predict TMD pain and TMD dysfunction in two separate models. Finally, network analysis was performed to investigate the associations between all variables.

RESULTS

In the univariate analyses, TMD pain was significantly associated with self-reported AB-frequent (unstandardized coefficient (B) = 3.196, 95%CI 1.198-5.195, p = 0.002). TMD dysfunction was significantly associated with AB-frequent (B = 2.208, 95%CI 0.177-4.238, p = 0.033) and SB-sometimes (B = 1.698, 95%CI 0.001-3.394, p = 0.050). In the multivariable analyses, TMD pain was significantly associated with TMD dysfunction (B = 0.370, p < 0.001), stress (B=0.102, p < 0.001). TMD dysfunction was significantly associated with TMD pain (B = 0.410, p < 0.001) only. Network analysis showed that TMD pain is a bridge factor between AB, stress, and TMD dysfunction.

CONCLUSIONS

TMD pain is directly associated with AB, stress, and TMD dysfunction, while TMD dysfunction is only associated with TMD pain.

CLINICAL RELEVANCE

Reducing pain may improve pain-related dysfunction, and the management of AB and stress may improve TMD pain and dysfunction, and vice versa.

Association of Hospital Mortality With Initiation of Mechanical Ventilation on a Weekend: A Retrospective Cohort Study

RATIONALE

Increased mortality in patients admitted to hospitals on weekends is a well-described phenomenon labeled the "weekend effect." Studies evaluating the weekend effect in intensive care units (ICUs) have arrived at conflicting results. Identifying a weekend effect for critically-ill patients may inform clinical care pathways and resource allocation.

OBJECTIVES

Determine the association of initiation of mechanical ventilation (MV) upon admission on a weekend versus weekday with hospital mortality.

METHODS

We conducted a retrospective cohort study of non-surgical adult patients using the California Patient Discharge Database from 2018 to 2019. We identified MV initiated on the day of admission and diagnoses using discharge billing codes. The primary exposure was admission and initiation of MV on a weekend versus weekday and the primary outcome was hospital mortality. Hierarchical logistic regression was used to determine the association between hospital mortality and MV initiation timing, adjusting for case-mix.

RESULTS

Among 90 288 admissions in 2018 and 2019 meeting inclusion criteria, 24 771 (27.5%) had MV initiated on weekends, while 65 517 (72.6%) had MV initiated on weekdays. Patient demographics and comorbidities were similar between groups. Chronic alcohol and substance use disorders, and acute intoxications and traumas were more prevalent among patients with MV initiated on weekends. No difference in hospital mortality was observed with initiation of MV on weekends versus weekdays (23.1% vs 22.8%, ARD = 0.3%, aOR = 1.02, 95% CI 0.98, 1.07).

CONCLUSIONS

Contrary to prior studies, no increased mortality was observed among newly admitted patients initiated on MV on weekends compared to weekdays. While weekend effects may exist in other settings, newly admitted patients likely have MV initiated in the emergency department or ICU, which tend to have more consistent staffing levels. Further research is needed to determine if care patterns in these units could be used as a model for units where weekend effects continue to impact outcomes.

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.

Weekend Effect on Clinical Outcomes of Acute Lower Gastrointestinal Bleeding: A Large Multicenter Cohort Study in Japan

INTRODUCTION

Weekend admissions showed increased mortality in several medical conditions. This study aimed to examine the weekend effect on acute lower gastrointestinal bleeding (ALGIB) and its mortality and other outcomes.

METHODS

This retrospective cohort study (CODE BLUE-J Study) was conducted at 49 Japanese hospitals between January 2010 and December 2019. In total, 8,120 outpatients with acute hematochezia were enrolled and divided into weekend admissions and weekday admissions groups. Multiple imputation (MI) was used to handle missing values, followed by propensity score matching (PSM) to compare outcomes. The primary outcome was mortality; the secondary outcomes were rebleeding, length of stay (LOS), blood transfusion, thromboembolism, endoscopic treatment, the need for interventional radiology, and the need for surgery. Colonoscopy and computed tomography (CT) management were also evaluated.

RESULTS

Before PSM, there was no significant difference in mortality (1.3% vs. 0.9%, p = 0.133) between weekend and weekday admissions. After PSM with MI, 1,976 cases were matched for each admission. Mortality was not significantly different for weekend admissions compared with weekday admissions (odds ratio [OR] 1.437, 95% confidence interval [CI] 0.785-2.630; p = 0.340). No significant difference was found with other secondary outcomes in weekend admissions except for blood transfusion (OR 1.239, 95% CI 1.084-1.417; p = 0.006). Weekend admission had a negative effect on early colonoscopy (OR 0.536, 95% CI 0.471-0.609; p < 0.001). Meanwhile, urgent CT remained significantly higher in weekend admissions (OR 1.466, 95% CI 1.295-1.660; p < 0.001).

CONCLUSION

Weekend admissions decrease early colonoscopy and increase urgent CT but do not affect mortality or other outcomes except transfusion.

Effect of weekend versus weekday admission on the mortality of acute ischemic stroke patients in China: an analysis of data from the Chinese acute ischemic stroke treatment outcome registry

Background

Due to disparities in medical resources in rural and urban areas as well as in different geographic regions in China, the effect of weekend versus weekday admission on the outcomes of acute ischemic stroke (AIS) patients is unknown. Our aim was to investigate whether the outcomes of AIS patients differ according to the day of admission in China.

Methods

The data were extracted from the Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR), a multicenter prospective study database of patients diagnosed with AIS. The chi-square test (χ²) and logistic regression were used to assess mortality for weekday and weekend admissions among AIS patients stratified by rural or urban status and geographic region (including the eastern, northeastern, central, and western regions).

Results

In total, 9,256 patients were included in this study. Of these patients, 57.2% were classified as urban, and 42.8% were classified as rural. A total of 6,760 (73%) patients were admitted on weekdays, and 2,496 (27%) were admitted on weekends. There was no significant difference in the mortality rate among patients admitted on weekends compared with those admitted on weekdays in urban (7.5% versus 7.4%) or rural areas (8.8% versus 8.1%; p > 0.05). The mortality rate was the highest among patients admitted on weekends and weekdays (11.6% versus 10.3%) in the northeastern area, without statistical significance before and after adjusting for the patients' background characteristics (p > 0.05). In addition, regression analysis revealed that the mortality of patients admitted on weekdays was more likely to be influenced by regional subgroup, hospital level and intravenous thrombolysis than that of patients admitted on weekends.

Conclusion

The weekend effect was not observed in the mortality of patients with AIS regardless of rural-urban status or geographic region in China.

Weekend effect in emergency laparotomy: a propensity score-matched analysis

BACKGROUND

The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients.

METHODS

A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics.

RESULTS

Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464).

CONCLUSIONS

These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

An analysis of temporal dimensions in maltreatment reporting and child protection responses

BACKGROUND

The health services literature indicates that the day and time of a medical encounter is often significant factor in patient outcomes, yet little is known about the role of temporal dimensions in child maltreatment reporting or substantiation.

OBJECTIVE

We examined time-specific dynamics of screened-in reports of alleged maltreatment from different reporter sources, including their relationship to the likelihood of substantiation.

PARTICIPANTS AND SETTING

We used a population-based dataset of administrative records for 119,758 child protection investigations involving 193,300 unique children in Los Angeles County, California, between 2016 and 2017.

METHODS

For each report, we coded three categorical temporal dimensions of the maltreatment report: season, day of the week, and time of day. We descriptively examined how temporal characteristics varied by reporting source. Finally, we ran generalized linear models to estimate the likelihood of substantiation.

RESULTS

We observed variability overall and by reporter type for all three measures of time. Reports were less likely during summer months (22.2 %), during the weekend (13.6 %), and after midnight (10.4 %). Counts of reports from law enforcement were more common after midnight and contributed to a greater proportion of substantiations over the weekend than other reporter types. Weekend and morning reports were nearly 10 % more likely than weekday and afternoon to be substantiated, respectively. Reporter type was the most prominent factor for substantiation regardless of temporal dimensions.

CONCLUSIONS

Screened-in reports varied by season and other classifications of time, but temporal dimensions exhibited only a modest influence on the likelihood of substantiation.

Developing and Validating a Prediction Model For Death or Critical Illness in Hospitalized Adults, an Opportunity for Human-Computer Collaboration

Hospital early warning systems that use machine learning (ML) to predict clinical deterioration are increasingly being used to aid clinical decision-making. However, it is not known how ML predictions complement physician and nurse judgment. Our objective was to train and validate a ML model to predict patient deterioration and compare model predictions with real-world physician and nurse predictions.

DESIGN

Retrospective and prospective cohort study.

SETTING

Academic tertiary care hospital.

PATIENTS

Adult general internal medicine hospitalizations.

MEASUREMENTS AND MAIN RESULTS

We developed and validated a neural network model to predict in-hospital death and ICU admission in 23,528 hospitalizations between April 2011 and April 2019. We then compared model predictions with 3,374 prospectively collected predictions from nurses, residents, and attending physicians about their own patients in 960 hospitalizations between April 30, and August 28, 2019. ML model predictions achieved clinician-level accuracy for predicting ICU admission or death (ML median F1 score 0.32 [interquartile range (IQR) 0.30-0.34], AUC 0.77 [IQ 0.76-0.78]; clinicians median F1-score 0.33 [IQR 0.30-0.35], AUC 0.64 [IQR 0.63-0.66]). ML predictions were more accurate than clinicians for ICU admission. Of all ICU admissions and deaths, 36% occurred in hospitalizations where the model and clinicians disagreed. Combining human and model predictions detected 49% of clinical deterioration events, improving sensitivity by 16% compared with clinicians alone and 24% compared with the model alone while maintaining a positive predictive value of 33%, thus keeping false alarms at a clinically acceptable level.

CONCLUSIONS

ML models can complement clinician judgment to predict clinical deterioration in hospital. These findings demonstrate important opportunities for human-computer collaboration to improve prognostication and personalized medicine in hospital.

Variation in Health Care Processes, Quality and Outcomes According to Day and Time of Chest Pain Presentation via Ambulance

BACKGROUND

Previous studies examining temporal variations in cardiovascular care have largely been limited to assessing weekend and after-hours effects. We aimed to determine whether more complex temporal variation patterns might exist in chest pain care.

METHODS

This was a population-based study of consecutive adult patients attended by emergency medical services (EMS) for non-traumatic chest pain without ST elevation in Victoria, Australia between 1 January 2015 and 30 June 2019. Multivariable models were used to assess whether time of day and week stratified into 168 hourly time periods was associated with care processes and outcomes.

RESULTS

There were 196,365 EMS chest pain attendances; mean age 62.4 years (standard deviation [SD] 18.3) and 51% females. Presentations demonstrated a diurnal pattern, a Monday-Sunday gradient (Monday peak) and a reverse weekend effect (lower rates on weekends). Five temporal patterns were observed for care quality and process measures, including a diurnal pattern (longer emergency department [ED] length of stay), an after-hours pattern (lower angiography or transfer for myocardial infarction, pre-hospital aspirin administration), a weekend effect (shorter ED clinician review, shorter EMS off-load time), an afternoon/evening peak period pattern (longer ED clinician review, longer EMS off-load time) and a Monday-Sunday gradient (ED clinician review, EMS offload time). Risk of 30-day mortality was associated with weekend presentation (Odds ratio [OR] 1.15, p=0.001) and morning presentation (OR 1.17, p<0.001) while risk of 30-day EMS reattendance was associated with peak period (OR 1.16, p<0.001) and weekend presentation (OR 1.07, p<0.001).

CONCLUSIONS

Chest pain care demonstrates complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs to improve care across all days and times of the week.

Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia

BACKGROUND

We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020.

METHODS

We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am-8:59 pm) and nighttime (9:00 pm-7:59 am). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated.

RESULTS

We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020-2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680-1.163]; P _interaction=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548-1.072]; nighttime, acOR, 1.785 [95% CI, 1.024-3.112] ; P _interaction<0.01); no heterogeneity was observed for other stroke subtypes (P _interaction>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers.

CONCLUSIONS

Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02795962.

ST elevation myocardial infarction - national trend analysis with mortality differences in outcomes based on day of hospitalization

BACKGROUND

Patientswho present with acute ST elevation myocardial infarction (STEMI) need emergent revascularization. Our study aims to investigate the outcomes in patients with STEMI admitted during weekends versus weekdays.

METHODS

We conducted a retrospective analysis of the nationwide inpatient sample database. Patients with an admitting diagnosis of STEMI identified by the International Classification of Disease code for the year 2016 were analyzed. A weighted descriptive analysis was performed to generate national estimates. Patients admitted over the weekend were compared to those admitted over the weekday. Patients were stratified by demographic and clinical factors including the Elixhauser comorbidity index. The primary outcome was in-hospital mortality and secondary outcomes were percutaneous coronary intervention (PCI) utilization rate, rate of transfer-out, length of stay (LOS), and total hospital charges. Statistical analysis including linear and logistic regression was performed using STATA.

RESULTS

A total of 163 715 adult patients were admitted with STEMI, of which 27.9% (45 635) were admitted over the weekend. There were 76.2% Caucasians, 9.3% African Americans, and 8.0% Hispanics. Mean age of the patients was 63.2 years (95% CI, 62.9-63.5) for the weekend group and 63.7 years (95% CI, 63.5-63.9) for weekday admissions. The majority of the patients in both groups had Medicare (43.7% and 45.8% on weekends and weekdays, respectively; P = 0.0047). After adjusting for age, sex, race, income, Elixhauser comorbidity index, PCI use, hospital location, teaching status, and bed size, mortality was not significantly different in weekend versus weekday admissions (odds ratios 1.04; P = 0.498; 95% CI, 0.93-1.16). There was no significant difference in mean total charge per admission during the weekend versus weekday admissions ($107 093 versus $106 869; P = 0.99.) Mean LOS was 4.1 days for both groups (P = 0.81).

CONCLUSIONS

There were no significant differences in mortality, LOS, or total hospital charge in STEMI patients being admitted during the weekend versus weekdays.

Analysis of the Weekend Effect at a High-Volume Center for the Treatment of Intracranial Aneurysms

OBJECTIVE

The "weekend effect" is the negative effect on disease course and treatment resulting from being admitted to the hospital during a weekend. Whether the weekend effect is associated with worse outcomes for patients treated for aneurysmal subarachnoid hemorrhage (aSAH) is unknown. We assessed neurologic outcomes of patients with aSAH admitted during the weekend versus during the week.

METHODS

A retrospective database was reviewed to identify all patients with aSAH who received open or endovascular treatment from August 1, 2007, to July 31, 2019, at a quaternary center. The primary outcome was a poor neurologic outcome (modified Rankin Scale score >2). Propensity adjustment included age, sex, treatment type, Hunt and Hess grade, and Charlson Comorbidity Index.

RESULTS

A total of 1014 patients (women, 703 [69.3%]; men, 311 [30.7%]; mean age, 56 [standard deviation, 14]) met inclusion criteria; 726 (71.6%) had weekday admissions, and 288 (28.4%) had weekend admissions. There was no significant difference between patients with a weekday versus a weekend admission in mean (standard deviation) time to treatment (0.85 [1.29] vs. 0.93 [1.30] days, P = 0.10) or length of stay (19 [9] vs. 19 [9] days, P = 0.04). Total cost and rates of delayed cerebral ischemia and vasospasm were similar between the admission groups, both overall and within the open and endovascular treatment cohorts. After propensity adjustment, weekend admission was not a significant predictor of a modified Rankin Scale score greater than 2 (odds ratio [95% confidence interval]; 1.12 [0.85-1.49]; P = 0.4).

CONCLUSION

No difference in neurologic outcomes was associated with weekend admission among this cohort of patients with aSAH.

Weekend Effect on Mortality, Access to Renal Replacement Therapy, and Other Outcomes Among Patients With End-Stage Renal Disease: A Retrospective Analysis of the Nationwide Inpatient Sample

BACKGROUND

A large body of research has been conducted on the "weekend effect," which is the reportedly increased risk of adverse outcomes for patients admitted to the hospital on weekends versus those admitted on weekdays. This effect has been researched in numerous patient populations, including sub-populations of end-stage renal disease (ESRD) patients, with varying conclusions.

OBJECTIVES

To assess whether differences in in-hospital mortality, access to renal replacement therapy (RRT), time to RRT, and other important outcomes exist in patients with ESRD or patients on RRT admitted on the weekend versus weekdays.

DESIGN AND SETTING

A retrospective cohort study was conducted using the 2018 Nationwide Inpatient Sample. Patients were included if they were adults with a principal or secondary diagnosis of ESRD or if they were admitted with a diagnosis related to initiation, maintenance, or complications of RRT. Patients admitted between midnight Friday and midnight Sunday were classified as weekend admissions. Primary outcome measurements included in-hospital mortality, in-hospital dialysis (peritoneal dialysis, hemodialysis, and continuous RRT), and renal transplantation (TP). Secondary outcomes included length of hospital stay (LOS) and total hospitalization charges.

RESULTS

The study included 1,144,385 patients who satisfied the inclusion criteria. Compared with patients admitted on weekdays, patients with ESRD admitted on weekends had 8% higher adjusted odds of in-hospital mortality (OR: 1.08; 95% CI: 1.03-1.13; p = 0.002), 9% lower adjusted OR of any RRT over the weekend than on weekdays (OR: 0.91; 95% CI: 0.89-0.93; p = 0.000), lower RRT rates (within 24 hours) (adjusted OR: 0.71; 95% CI: 0.70-0.73; p = 0.000), higher odds of renal TP (adjusted OR: 1.32; 95% CI: 1.20-1.45; p = 0.000), and higher hospitalization charges (mean adjusted increase: $1451; p = 0.07).

LIMITATIONS

The limitations of the study include the use of retrospective data and an administrative database.

CONCLUSION

Compared with weekday admissions, patients with ESRD admitted on weekends had higher odds of mortality, higher mean hospitalization charges, and higher odds of renal TP. They had lower overall RRT rates, and a longer time to first RRT. However, the average LOS was similar for both weekend and weekday admissions.

Is there a weekend effect on mortality rate and outcome for moderate and severe traumatic brain injury? A population-based, observational cohort study

Purpose

The aim of the study was to analyse patient and injury characteristics and the effects of weekend admissions on mortality rate and outcome after moderate and severe traumatic brain injuries.

Methods

This is an observational cohort study based on data from a prospectively maintained regional trauma registry in South Western Norway. Patients with moderate and severe traumatic brain injury admitted between January 1st, 2004 and December 31st, 2019 were included in this study.

Results

During the study period 688 patients were included in the study with similar distribution between moderate (n ​= ​318) and severe (n ​= ​370) traumatic brain injury. Mortality rate was 46% in severe and 13% in moderate traumatic brain injury. Two hundred and thirty-one (34%) patients were admitted during weekends. Patients admitted during weekends were significantly younger (median age (IQR) 32.0 (25.5-67.0) vs 47.0 (20.0-55.0), p ​< ​0.001). Pre-injury ASA 1 was significantly more common in patients admitted during weekends (n ​= ​146, 64%, p ​= ​0.001) while ASA 3 showed significance during weekdays compared to weekends (n ​= ​101, 22%, p ​= ​0.013). On binominal logistic regression analysis mortality rate was significantly higher with older age (OR 1.03, 95% CI for OR 1.02-1.04, p ​< ​0.001) and increasing TBI severity (OR 7.08, 95% CI for OR 4.67-10.73, p ​< ​0.001).

Conclusions

Mortality rate and poor clinical outcome remain high in severe traumatic brain injury. While a higher number of patients are admitted during the weekend, mortality rate does not differ from weekday admissions.

Does Weekends Effect Exist in Asia? Analysis of Endovascular Thrombectomy for Acute Ischemic Stroke in A Medical Center

BACKGROUND

Discussing the quality measurements based on interrupted time series in ischemic stroke, delays are often attributed to weekends effect. This study compared the metrics and outcomes of emergent endovascular thrombectomy (EST) during working hours versus non-working hours in the emergency department of an Asian medical center.

METHODS

A total of 297 patients who underwent EST between January 2015 and December 2018 were retrospectively included, with 52.5% of patients presenting during working hours and 47.5% presenting during nights, weekends, or holidays.

RESULTS

Patients with diabetes were more in non-working hours than in working hours (53.9% vs. 41.0%; p=0.026). It took longer during nonworking hours than working hours in door-to -image times (13 min vs. 12 min; p=0.04) and door-to-groin puncture times (median: 112 min vs. 104 min; p=0.042). Significant statistical differences were not observed between the two groups in neurological outcomes, including successful reperfusion and complications such as intracranial hemorrhage and mortality. However, the change in National Institute of Health Stroke Scale (NIHSS) scores in 24 hours was better in the working-hour group than in the nonworking-hour group (4 vs. 2; p=0.058).

CONCLUSION

This study revealed that nonworking-hour effects truly exist in patients who received EST. Although delays in door-to-groin puncture times were noticed during nonworking hours, significant differences in neurological functions and mortality were not observed between working and non-working hours. Nevertheless, methods to improve the process during non-working hours should be explored in the future.

The Management and Outcome of Stroke Patients Admitted on Weekdays Compared to Weekends at the King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background and Purpose

Stroke is an unexpected medical emergency that can result in significant disability. The weekend effect suggests that individuals with acute medical problems are not treated the same way on weekends as they are on weekdays. There is no previous published study about weekend effect on stroke patients from Saudi Arabia.

Methods

This was an IRB approved, retrospective, cohort study. All stroke patients admitted between January 2017 and December 2018 were included. Ten standards of care were chosen to assess compliance with standardized care. Seven measures were chosen for acute management of stroke.

Results

A total of 731 patients were included, 68.5% were males; 493 (67%) were admitted during weekdays and 238 (33%) on weekends. There was no difference for age (P = .32), gender (P = .32), nationality (P = .62), stroke subtype (P = .27) and stroke severity (P = .69) on weekday or weekend admission. In two-third patients, more than 70% of stroke orders were utilized, with no difference in thrombolysis rate (P = .81). There was no difference in recurrent stroke (P = .86), mortality or discharge disposition (P = .34) between the patients. The patients admitted during weekdays had less complications (38 vs 46%; P = .04).

Conclusions

There was no difference in the quality of care provided to stroke patients admitted during weekdays or weekends. There was no difference in the use of acute intervention on weekends and weekdays. Patients had similar outcomes and discharge disposition whether admitted on weekdays or weekends, except that those admitted on weekends had a significantly greater overall number of complications.

The association between out of hours burn centre admission and in-hospital outcomes in patients with severe burns

INTRODUCTION

Patients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context.

METHODS

Data were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest.

RESULTS

We found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27]).

DISCUSSION

In this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest.

CONCLUSION

These findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems.

The liver transplant surgeon Mondays blues: an Italian perspective

Poor data exist on the influence of holidays and weekdays on the number and the results of liver transplantation (LT) in Italy. The study's main objective is to investigate the impact of holidays and the different days of the week on the LT number and early graft survival rates in a multi-centric Italian series. We performed a retrospective analysis on 1,026 adult patients undergoing first deceased-donor transplantation between January 2004 and December 2018 in the three university centers in Rome. During the 4,504 workdays, 881 LTs were performed (85.9%; one every 5.1 days on average). On the opposite, 145 LTs were done during the 975 holidays (14.1%; one every 7.1 days on average). Fewer LTs were performed on holidays (P = 0.004). There were no substantial differences in donor-, recipient- and transplant-related characteristics in LTs performed on weekdays or holidays. On Monday, fewer transplants were performed (vs. other weekdays: P < 0.0001; vs. Sunday: P = 0.03). At multivariable Cox regression analysis, LTs performed during the holiday or during the different days of the week were not found to be independent risk factors for the risk of 3- and 12-month graft loss. At three-month survival curves, no differences were observed among the transplants performed during the holidays versus the workdays (86.2 vs. 85.0%; P-0.70). The range of graft survival rates based on the day of the week was 81.6-86.9%, without showing any significant differences (P = 0.57). Fewer transplants are performed on holidays and Mondays. Survivals are not affected by holidays or the day the transplant is performed.

The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes

GOALS

The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH).

BACKGROUND

The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear.

STUDY

Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates.

RESULTS

Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P <0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P =0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients.

CONCLUSIONS

Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.

Relationship Between Work Mode, Time of Admission, and Mortality in St-Segment Elevation Myocardial Infarction: Results From the TURKMI Registry

Treatment of acute myocardial infarction has evolved steadily. However, limited studies exist regarding the effect of all innovations on mortality. We aimed to investigate the effect of time of admission and work mode on 1-year outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). Based on the TURKMI registry, we analyzed 735 STEMI patients recruited consecutively and prospectively from 50 PCI-capable cardiology clinics within a prespecified two-week period. Centers were categorized as "on-call" and "on-duty" according to their work mode. At 1-year follow-up, all-cause mortality and cardiovascular mortality were the primary outcomes. The secondary outcome was a composite of coronary revascularization, re-infarction/stroke, and recurrent angina. One-fifth of the participants (19.5%) were treated in the on-call group. All-cause mortality (7.9 vs 10.5%, aHR: 1.16, P = .650) and cardiovascular mortality rates (6.1 vs 9.1%, aHR: 1.35, P = .413) were similar between centers' modes of work. Likewise, both groups were equally likely to undergo coronary revascularization (P = .278), re-MI/stroke (P = .280), recurrent angina (P = .175), and the composite outcome of these components (P = .482). No significant difference was observed in primary outcomes between weekend and weekday admissions. In conclusion, we observed similar outcomes between the on-call and on-duty groups among STEMI patients.

Measuring empiric antibiotic spectrum—A journey through space and time

Objectives:

The typical 5-day work week affects healthcare outcomes. Structured work hours have also been implicated in antimicrobial prescribing choice. We developed a visualization tool to aid in evaluating breadth of antibiotic use in various time (day of week and hour of day) and space (patient location) combinations.

Methods:

We evaluated antibiotic administration data from a tertiary-care academic medical center between July 1, 2018, and July 1, 2020. We calculated a cumulative empiric antibiotic spectrum score by adapting a previously validated antibiotic spectrum index (ASI) and applying that score to empiric antibiotic use. We visualized these data as a heat map based on various day-of-week–time combinations and then compared the distribution of scores between weekday nights, weekend days, and weekend nights to the typical workweek hours (weekday days, weekday days) using the Mann-Whitney U nonparametric test with a Bonferroni correction.

Results:

The analysis included 76,535 antibiotic starts across 53,900 unique patient admissions over 2 years. The mean cumulative ASI was higher in all 3 night and weekend combinations (weekday nights, 7.3; weekend days, 7.6; weekend nights, 7.5) compared to the weekday daytime hours (weekday days, 7.1) and the distribution of scores was different in all groups compared to the weekday daytime reference. The cumulative ASI was also higher in intensive care units.

Conclusions:

Empiric antibiotic prescribing patterns differed across space and time; broader antibiotic choices occurred in the intensive care units and on nights and weekends. Visualization of these patterns aids in antimicrobial prescribing pattern recognition and may assist in finding opportunities for additional antimicrobial stewardship interventions.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery

INTRODUCTION

Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.

METHODS

All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.

RESULTS

Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday.

CONCLUSION

With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

In-Hospital Mortality of Patients With Acute Type A Aortic Dissection Hospitalized on Weekends Versus Weekdays

BACKGROUND

In acute aortic dissection, weekend admissions are reported to be associated with increased mortality compared with weekday admissions.

OBJECTIVE

This study aimed to determine whether patients with acute type A aortic dissection (ATAAD) admitted on weekends had higher in-hospital mortality than those admitted on weekdays in the Tokyo metropolitan area, where we developed a patient-transfer system for aortic dissection.

METHODS

Data were collected during the first year after our transfer system began (cohort I) and in the subsequent years from 2013 to 2015 (cohort II).

RESULTS

We studied 2,339 patients (500 in cohort I; 1,839 in cohort II) with ATAAD. Patients with weekend admissions had higher in-hospital mortality than those with weekday admissions in cohort I. In association with increased interfacility transfer during weekends and reduced mortality at non-high-volume centers, the in-hospital mortality in the weekend group improved from 37.2% in cohort I to 22.2% in cohort II (P < 0.001). After inverse probability weighting adjustment, weekend admission was associated with higher in-hospital mortality in cohort I (odds ratio: 2.28; 95% confidence interval: 1.48 to 3.52; P < 0.001), but not in cohort II (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.22; P = 0.731). On multivariable analyses, weekend admission was associated with higher in-hospital mortality in combined cohort I+II; the associations between weekend admission and mortality were not significant in cohort II.

CONCLUSIONS

We found a significant reduction in in-hospital mortality in patients with weekend admissions for ATAAD. No mortality difference between weekend and weekday admissions was observed in the later years of the study.

[What about the weekend effect? Impact of the day of admission on in-hospital mortality, length of stay and cost of hospitalization]

INTRODUCTION

There is no agreement on the existence of the weekend effect in healthcare or, if it exists, on its possible causes. The objective of the study was to evaluate the differences in healthcare outcomes between patients admitted on weekdays or weekends in a high-complexity hospital.

METHODS

Observational and retrospective study of patients admitted between 2016 and 2019 in a public hospital with more than 1300 beds. Hospitalization episodes were classified according to whether admission took place between Friday at 3:00 p.m. and the following Monday at 8:00 a.m. (weekend admission) or not (admission on weekdays). Mortality, length of stay and associated costs were compared, applying their respective risk-adjustment models.

RESULTS

Of the total 169,495 hospitalization episodes analyzed, 48,201 (28.44%) corresponded to the weekend, presenting an older age (54.9 years vs. 53.9; P<.001), a higher crude mortality rate (5.22% vs. 4.59%; P<0.001), and a longer average length of stay (7.42 days vs. 6.74; P<.001), than those admitted on weekdays. The median crude cost of stay was lower (€731.25 vs. €850.88; P<0.001). No significant differences were found when applying the adjustment models, with a risk-adjusted mortality ratio of 1.03 (0.99-1.08) vs. 0.98 (0.95-1.01), risk-adjusted length of stay of 1.002 (0.98-1.005) vs. 0.999 (0.997-1.002) and risk-adjusted cost of stay of 0.928 (0.865-0.994) vs. 0.901 (0.843-0.962).

CONCLUSION

The results of the study reveal that the assistance provided during the weekends does not imply worse health outcomes or increased costs. Comparing the impact between hospitals will require a future homogenization of temporal criteria and risk adjustment models.

Off-hour presentation and outcomes for percutaneous coronary intervention in acute myocardial infarction with Killip III-IV

BACKGROUND/AIMS

Acute myocardial infarction (AMI) is conventionally recognized as an urgent medical condition requiring timely and effective reperfusion therapy. However, the results of studies on the clinical outcomes in AMI according to hospital visit timings are inconclusive. To explore the difference in long-term outcomes between off- and on-hour percutaneous coronary interventions (PCI) in patients with AMI of Killip functional classification III-IV (Killip III-IV AMI).

METHODS

Data on the characteristics and clinical outcomes of 1,751 patients with Killip III-IV AMI between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health registry were analyzed. All participants were allocated into two groups: off-hour (weekdays from 6:00 PM to 8:00 AM, weekends, and legal holidays) and on-hour (weekdays from 8:00 AM to 6:00 PM) groups. The incidence of major adverse cardiac and cerebrovascular events, defined as a composite of all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis, was the primary endpoint.

RESULTS

Among the 1,751 patients, 572 (39.1%) underwent PCI during on-hours and 892 (60.9%) during off-hours. At the 3-year follow-up, no significant difference was found in the clinical outcomes between the two groups in both the unadjusted and propensity-score weighing-adjusted analyses.

CONCLUSION

The outcomes of patients with Killip III-IV AMI admitted during off- and on-hours were similar.

Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time

BACKGROUND/AIMS

Rapid percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-elevation myocardial infarction (STEMI). However, there have been conflicting results regarding the differences in clinical outcomes between on-hours and off-hours presentation in STEMI patients. We aimed to examine the difference in long-term outcomes between off-hours and on-hours PCI in patients with STEMI.

METHODS

The characteristics and clinical outcomes of 5,364 STEMI patients between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry were analyzed. Patients were divided into two groups: the off-hours group (weekdays from 6:01 PM to 7:59 AM, weekends, and legal holidays) and the on-hours group (weekdays from 8:00 AM to 6:00 PM). Major adverse cardiac and cerebrovascular events (MACCEs) were defined as a composite of allcause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. The primary endpoint was the occurrence of MACCEs, and all other clinical outcomes were analyzed.

RESULTS

A total of 3,119 patients (58.1%) underwent primary PCI due to STEMI during off-hours and 2,245 patients (41.9%) during on-hours. At 36 months, the clinical outcomes of the off-hours group were similar to those of the on-hours group in both the unadjusted and propensity score weighting-adjusted analyses.

CONCLUSION

Our analysis revealed that the long-term outcomes in STEMI patients admitted to hospitals during off-hours were similar to outcomes of those admitted during on-hours.

No evidence of "weekend effect" in upper gastrointestinal bleeding in Italy: data from a nationwide prospective registry

OBJECTIVES

The literature offers conflicting information about 'weekend effect' in acute upper gastrointestinal bleeding (AUGIB). Aim of our study was to compare clinical outcomes of patients admitted for AUGIB during the weekend or on weekdays in Italy.

METHODS

We analyzed data from a prospective registry of AUGIB (either nonvariceal, NV-AUGIB or variceal, V-AUGIB) from 50 Italian hospitals from January 2014 to December 2015. Mortality, rebleeding, need for salvage procedures and length of hospitalization were compared among patients admitted during the weekend or on weekdays.

RESULTS

In total 2599 patients (mean age 67.4 ± 15.0 years, 69.2% males) were included, 2119 (81.5%) with NV-AUGIB and 480 (18.5%) with V-AUGIB. Totally 494 patients with NV-AUGIB (23.3%) and 129 patients with V-AUGIB (20.7%) were admitted during the weekend. The two study groups were similar in terms of physical status (American Society of Anesthesiologists score, comorbidities) and bleeding-specific prognostic scores. We did not find differences in terms of mortality (5.6 vs. 4.9%; P = 0.48), rebleeding (5.9 vs. 5.1%; P = 0.39), need for salvage procedures (4.0 vs. 3.6%; P = 0.67) or duration of hospitalization (8.5 ± 6.9 vs. 8.3 ± 7.2 days; P = 0.58) between patients admitted during weekend or weekdays. Considering separately NV-AUGIB and V-AUGIB, the only difference found in clinical outcomes was a higher rebleeding risk in patients with V-AUGIB admitted during the weekend (13.2 vs. 7.4%; P = 0.05).

CONCLUSIONS

Data from our large, prospective multicenter registry shows that in Italy there is no significant 'weekend effect' for either NV- or V-AUGIB. Our results show that the Italian hospital network is efficient and able to provide adequate care and an effective therapeutic endoscopy even during the weekend.

How Can Patient's Risk Dictate the Timing of Endoscopy in Upper Gastrointestinal Bleeding?

INTRODUCTION

Although upper gastrointestinal bleeding (UGIB) management has improved substantially in the last decades, there is still much controversy regarding the optimal timing for performance of endoscopy. Recent guidelines suggest performing an early endoscopy within 24 h of nonvariceal UGIB (NVUGIB) presentation, although its impact on patients with different bleeding risks remains unclear.

AIM

To evaluate the impact of performing endoscopy within 24 h on NVUGIB outcomes and to compare it in patients with lower-risk vs. higher-risk bleeding.

METHODS

This is a retrospective cohort study including consecutive patients undergoing upper endoscopy for suspected NVUGIB over 4 years. Demographic, clinical, biochemical, endoscopic, and outcome data were collected. Lower-risk bleeding was defined as a Glasgow-Blatchford score (GBS) <12 and higher-risk bleeding was defined as a GBS ≥12.

RESULTS

A total of 298 patients with suspected NVUGIB were included, 55% of whom had higher-risk bleeding. Endoscopy was performed within 24 h in 62.1% of the patients. In lower-risk bleeding patients, performance of endoscopy within 24 h was associated with a higher need for endoscopic treatment (OR = 2.6; 95% CI 1.2-5.7; p = 0.004), a lower 30-day mortality (OR = 0.41; 95% CI 0.27-0.63; p = 0.03), and a lower need for transfusion (OR = 0.58; 95% CI 0.36-0.92; p = 0.02). In higher-risk bleeding patients, there were no statistically significant differences in NVUGIB outcomes in performing endoscopy within 24 h.

CONCLUSION

Endoscopy within 24 h of presentation was associated with a lower need for transfusion, a higher need for endoscopic treatment, and a lower 30-day mortality in lower-risk NVUGIB patients. Thus, performing endoscopy within the first 24 h of presentation can have a positive impact on NVUGIB outcomes even in lower-risk bleeding.

Weekend Mortality in an Italian Hospital: Immediate versus Delayed Bedside Critical Care Treatment

Background: a number of studies highlighted increased mortality associated with hospital admissions during weekends and holidays, the so–call “weekend effect”. In this retrospective study of mortality in an acute care public hospital in Italy between 2009 and 2015, we compared inpatient mortality before and after a major organizational change in 2012. The new model (Model 2) implied that the intensivist was available on call from outside the hospital during nighttime, weekends, and holidays. The previous model (Model 1) ensured the presence of the intensivist coordinating a Medical Emergency Team (MET) inside the hospital 24 h a day, 7 days a week. Methods: life status at discharge after 9298 and 8223 hospital admissions that occurred during two consecutive periods of 1185 days each (organizational Model 1 and 2), respectively, were classified into “discharged alive”, “deceased during nighttime–weekends–holidays” and “deceased during daytime-weekdays”. We estimated Relative Risk Ratios (RRR) for the associations between the organizational model and life status at discharge using multinomial logistic regression models adjusted for demographic and case-mix indicators, and timing of admission (nighttime–weekends–holidays vs. daytime-weekdays). Results: there were 802 and 840 deaths under Models 1 and 2, respectively. Total mortality was higher for hospital admissions under Model 2 compared to Model 1. Model 2 was associated with a significantly higher risk of death during nighttime–weekends–holidays (IRR: 1.38, 95% CI 1.20–1.59) compared to daytime–weekdays (RRR: 1.12, 95% CI 0.97–1.31) (p = 0.04). Respiratory diagnoses, in particular, acute and chronic respiratory failure (ICD 9 codes 510–519) were the leading causes of the mortality excess under Model 2. Conclusions: our data suggest that the immediate availability of an intensivist coordinating a MET 24 h, 7 days a week can result in a better prognosis of in-hospital emergencies compared to delayed consultation.

Association Between Out-of-Hour Admission and Short- and Long-Term Mortality in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Objectives: Out-of-hour admission (on weekends, holidays, and weekday nights) has been associated with higher mortality in patients with acute myocardial infarction (AMI). We conducted a meta-analysis to verify the association between out-of-hour admission and mortality (both short- and long-term) in AMI patients.

Design: This Systematic review and meta-analysis of cohort studies.

Data Sources: PubMed and EMBASE were searched from inception to 27 May 2021.

Eligibility Criteria for Selected Studies: Studies of any design examined the potential association between out-of-hour admission and mortality in AMI.

Data Extraction and Synthesis: In total, 2 investigators extracted the data and evaluated the risk of bias. Analysis was conducted using a random-effects model. The results are shown as odds ratios [ORs] with 95% confidence intervals (CIs). I² value was used to estimate heterogeneity. Grading of Recommendations Assessment, Development, and Evaluation was used to assess the certainty of the evidence.

Results: The final analysis included 45 articles and 15,346,544 patients. Short-term mortality (defined as either in-hospital or 30-day mortality) was reported in 42 articles (15,340,220 patients). Out-of-hour admission was associated with higher short-term mortality (OR 1.04; 95%CI 1.02–1.05; I² = 69.2%) but there was a significant statistical indication for publication bias (modified Macaskill's test P < 0.001). One-year mortality was reported in 10 articles (1,386,837 patients). Out-of-hour admission was also associated with significantly increased long-term mortality (OR 1.03; 95%CI 1.01–1.04; I² = 66.6%), with no statistical indication of publication bias (p = 0.207). In the exploratory subgroup analysis, the intervention effect for short-term mortality was pronounced among patients in different regions (p = 0.04 for interaction) and socio-economic levels (p = 0.007 for interaction) and long-term mortality was pronounced among patients with different type of AMI (p = 0.0008 for interaction) or on different types of out-to-hour admission (p = 0.006 for interaction).

Conclusion: Out-of-hour admission may be associated with an increased risk of both short- and long-term mortality in AMI patients.

Trial Registration: PROSPERO (CRD42020182364).

Contemporary impact of circadian symptom-onset patterns of acute ST-Segment elevation myocardial infarction on long-term outcomes after primary percutaneous coronary intervention

BACKGROUND

Daytime variation with regard to onset time of ST-elevation myocardial infarction (STEMI) symptoms has been observed. Nevertheless, with the advanced medical therapy, it is not uncertainty if a similar circadian pattern of STEMI symptom onset occurs, as well as its possible impact on clinical outcomes. Few long-term data are available. We assess the impact of circadian symptom-onset patterns of STEMI on major adverse cardiovascular events (MACE) in more contemporary patients treated with primary percutaneous coronary intervention (PPCI).

METHODS AND RESULTS

A total of 1099 consecutive STEMI patients undergoing PPCI ≤12h from symptom onset during 2013 to 2019 were classified into 4 groups by 6-h intervals according to time-of-day at symptom onset: night (0:00-5:59), morning (6:00-11:59), afternoon (12:00-17:59), and evening (18:00-23:59). Incidence of MACE including cardiovascular death and nonfatal MI during a median follow-up of 48 months was compared among the 4 groups. A morning peak of symptom onset of STEMI was detected during the period 06:00-11:59 (p < .001). Compared with other three 6-h intervals, the incidence of long-term MACE during night onset-time (18.8%, 10.1%, 10.7% and 12.4%, p = .020) was significant higher that was driven by more mortality (13.1%, 6.5%, 7.1%and 7.7%, p = .044). Night symptom-onset STEMI was independently associated with subsequent MACE (hazard ratio = 1.57, 95%CI: 1.09-2.27, p = .017) even after multivariable adjustment.

CONCLUSIONS

Circadian variation of STEMI symptom-onset with morning predominance still exists in contemporary practice. Night symptom-onset STEMI was independently associated with increased risk of MACE in Chinese patients treated with PPCI.