Do weekends or evenings matter in a pediatric intensive care unit?

On-Hours Compared to Off-Hours Pediatric Extracorporeal Life Support Initiation in the United States Between 2009 and 2018-An Analysis of the Extracorporeal Life Support Organization Registry

We aimed to investigate whether there are differences in outcome for pediatric patients when extracorporeal life support (ECLS) is initiated on-hours compared with off-hours.

DESIGN

Retrospective cohort study.

SETTING

Ten-year period (2009-2018) in United States centers, from the Extracorporeal Life Support Organization registry.

PATIENTS

Pediatric (>30 d and <18 yr old) patients undergoing venovenous and venoarterial ECLS.

INTERVENTIONS

The primary predictor was on versus off-hours cannulation. On-hours were defined as 0700-1859 from Monday to Friday. Off-hours were defined as 1900-0659 from Monday to Thursday or 1900 Friday to 0659 Monday or any time during a United States national holiday. The primary outcome was inhospital mortality. The secondary outcomes were complications related to ECLS and length of hospital stay.

MEASUREMENTS AND MAIN RESULTS

In a cohort of 9,400 patients, 4,331 (46.1%) were cannulated on-hours and 5,069 (53.9%) off-hours. In the off-hours group, 2,220/5,069 patients died (44.0%) versus 1,894/4,331 (44.1%) in the on-hours group (p = 0.93). Hemorrhagic complications were lower in the off-hours group versus the on-hours group (hemorrhagic 18.4% vs 21.0%; p = 0.002). After adjusting for patient complexity and other confounders, there were no differences between the groups in mortality (odds ratio [OR], 0.95; 95% CI, 0.85-1.07; p = 0.41) or any complications (OR, 1.02; 95% CI, 0.89-1.17; p = 0.75).

CONCLUSIONS

Survival and complication rates are similar for pediatric patients when ECLS is initiated on-hours compared with off-hours. This finding suggests that, in aggregate, the current pediatric ECLS infrastructure in the United States provides adequate capabilities for the initiation of ECLS across all hours of the day.

Does admission time matter in a paediatric intensive care unit? A prospective cohort study

AIM

Studies assessing the association between admission time to paediatric intensive care unit (PICU) and mortality are sparse with conflicting results. We aimed to evaluate the impact of time of admission on PICU mortality within 48 h after admission.

METHODS

This was a single-centre prospective cohort. We collected data from all consecutive children aged 1 month to 16 years over 10 years.

RESULTS

We included a total of 1368 admissions, with a PICU mortality of 6.6%. Compared with daytime admissions, the overall mortality rate (5.3% vs. 8.5%, P = 0.026) and the mortality within 48 h after admission were higher for those admitted during night-time (2% vs. 4.2%, P = 0.021). There were no differences between mortality rates and the day of admission (weekend admissions vs. weekday admissions). The adjusted odds of death within 48 h after admission was 2.5 (95% confidence interval = 1.22-5.24, P = 0.012) for patients admitted at night-time. A secondary analysis assessing trends in mortality rates during admission showed that the last 5 years of study were more responsible for the chances of death within 48 h (odds ratio = 7.6, 95% confidence interval = 1.91-30.17, P = 0.0039).

CONCLUSION

Admission to the PICU during night shifts was strongly associated with death compared to daytime admissions. A time analysis of the moment of admission is necessary as a metric of quality of care to identify the interruption or improvement in the continuity of care. Further studies are needed to assess the modified contributing factors.

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.

Incidence and predictors of mortality among children admitted to the pediatric intensive care unit at the University of Gondar comprehensive specialised hospital, northwest Ethiopia: a prospective observational cohort study

OBJECTIVE

To determine the incidence and predictors of mortality among children admitted to the paediatric intensive care unit (PICU) at the University of Gondar comprehensive specialised hospital, northwest Ethiopia.

DESIGN

A single-centre prospective observational cohort study.

PARTICIPANTS

A total of 313 children admitted to the ICU of the University of Gondar comprehensive specialised hospital during a one-and-a-half-year period.

MEASUREMENTS

Data were collected using standard case record form, physical examination and patient document review. Clinical characteristics such as systolic blood pressure, pupillary light reflex, oxygen saturation and need for mechanical ventilation (MV) were assessed and documented within the first hour of admission and entered into an electronic application to calculate the modified Pediatric Index of Mortality 2 (PIM 2) Score. We fitted the Cox proportional hazards model to identify predictors of mortality.

RESULT

The median age at admission was 48 months with IQR: 12-122, 28.1% were infants and adolescents accounted for 21.4%. Of the total patients studied, 59.7% were males. The median observation time was 3 days with (IQR: 1-6). One hundred and two (32.6%) children died during the follow-up time, and the incidence of mortality was 6.9 deaths per 100 person-day observation. Weekend admission (adjusted HR (AHR)=1.63, 95% CI: 1.02 to 2.62), critical illness diagnoses (AHR=1.79, 95% CI: 1.13 to 2.85), need for MV (AHR=2.36, 95% CI: 1.39 to 4.01) and modified PIM 2 Score (AHR=1.53, 95% CI: 1.36 to 1.72) were the predictors of mortality.

CONCLUSION

The rate of mortality in the PICU was high, admission over weekends, need for MV, critical illness diagnoses and higher PIM 2 scores were significant and independent predictors of mortality.

Management of children visiting the emergency department during out-of-office hours: an observational study

BACKGROUND

The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.

METHODS

We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.

RESULTS

Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.

CONCLUSIONS

Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS OF DATA SYNTHESIS

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

CONCLUSION

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

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

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

Working-hour phenomenon in obstetrics is an attainable target to improve neonatal outcomes

BACKGROUND

Giving birth in a health care facility does not guarantee high-quality care or favorable outcomes. The working-hour phenomenon describes adverse outcomes of institutional births outside regular working hours.

OBJECTIVES

The objectives of the study were to evaluate whether the time of birth is associated with adverse neonatal outcomes and to identify the riskiest time periods for obstetrical care.

STUDY DESIGN

This nationwide retrospective cohort study analyzed data from 2008 to 2016 from all 82 obstetric departments in Austria. Births at ≥ 23+0 gestational weeks with ≥500 g birthweight were included. Independent variables were categorized by the time of day vs night as core time (morning, day) and off hours (evening, nighttime periods 1-4). The composite primary outcome was adverse neonatal outcome, defined as arterial umbilical cord blood pH <7.2, 5 minute Apgar score <7, and/or admission to the neonatal intensive care unit. Multivariate logistic regression was used to develop a model to predict these adverse neonatal outcomes.

RESULTS

Of 462,947 births, 227,672 (49.2%) occurred during off hours and had a comparable distribution in all maternity units, regardless of volume (<500 births per year: 50.3% during core time vs 49.7% during off hours; ≥500 births per year: 50.7% core time vs 49.3% off hours; perinatal tertiary center: 51.2% core time vs 48.8% off hours). Furthermore, most women (35.8-35.9%) gave birth between 2:00 and 5:59 am (night periods 3 and 4). After adjustment for covariates, we found that adverse neonatal outcomes also occurred more frequently during these night periods 3 and 4, in addition to the early morning period (night 3: odds ratio, 1.05; 95% confidence interval, 1.03-1.08; P < .001; night 4: odds ratio, 1.08; 95% confidence interval, 1.05-1.10; P < .001; early morning period: odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P < .001). The adjusted odds for adverse outcomes were lowest for births between 6:00 and 7:59 pm (odds ratio, 0.96; 95% confidence interval, 0.93-0.99; P = .006).

CONCLUSION

There is an increased risk of adverse neonatal outcomes when giving birth between 2:00 and 7:59 am. The so-called working-hour phenomenon is an attainable target to improve neonatal outcomes. Health care providers should ensure an optimal organizational framework during this time period.

Remote Pediatric Critical Care Telephone Consultations: Quality and Outcomes

There are no studies describing the nature and quality of telephone consultations for critically ill children despite being an important part of pediatric intensive care. We described pediatric telephone consultations to a PICU in Ontario, Canada in 2011 and 2012. Of 203 consultations, 104 patients (51.2%) were admitted to the PICU; this was associated with weekend consultations ( p  = 0.005) and referral hospital location ( p  = 0.036). Frequency of interruptions was 1 in every 3.2 (2.0, 5.7) minutes and not associated with call content. Twenty-one percent of consults had limited discussion of vital signs. Our study described our center's remote critical care consultation program and outcomes.

Do the Care Process and Survival Chances Differ in Patients Arriving to a Level 1 Indian Trauma Center, during-Hours and after-Hours?

Introduction

Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country.

Methodology

Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded.

Results

Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan-Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST.

Conclusions

Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Paediatric outcomes and timing of admission

Studies of adult patients have demonstrated that weekend admissions compared with weekday admissions had a significantly higher hospital mortality rate. We have reviewed the literature to determine if the timing of admission, for example, weekend or weekday, influenced mortality and morbidity in children. Seventeen studies reported the effect of timing of admission on mortality, and only four studies demonstrated an increase in those admitted at the weekend. Meta-analysis of the results of 15 of the studies demonstrated there was no significant weekend effect. There was, however, considerable heterogeneity in the studies. There were two large UK studies: one reported an increased mortality only for planned weekend admissions likely explained by planned admissions for complex conditions and the other showed no significant weekend effect. Two studies, one of which was large (n=2913), reported more surgical complications in infants undergoing weekend oesophageal atresia and trachea-oesophageal repair. Medication errors have also been reported to be more common at weekends. Five studies reported the effect of length of stay, meta-analysis demonstrated a significantly increased length of stay following a weekend admission, the mean difference was approximately 1 day. Those data, however, should be interpreted with the caveat that there was no adjustment in all of the studies for differences in disease severity. We conclude that weekend admission overall does not increase mortality but may be associated with a longer length of stay and, in certain conditions, with greater morbidity.

Off-Hours Admissions and Mortality in PICU Without 24-Hour Onsite Intensivist Coverage

OBJECTIVE

To evaluate whether the off-hours admission has any effect on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (PICU) without 24-hour in-house intensivist coverage.

DESIGN

Prospective cohort study.

SETTING

A 34-bed tertiary PICU.

PATIENTS

All consecutive nonelective patients aged 0 to 14 years admitted from January 2012 to June 2015.

MEASUREMENTS AND MAIN RESULTS

A total of 1254 patients were nonelectively admitted to the PICU. They were categorized according to time of PICU admission as either office hours (07:30 to 16:30 from Sunday to Thursday and whenever an intensivist is present in the ICU) or off-hours (16:30 to 07:30, Friday and Saturday and public holidays). Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Risk of Mortality (PRISM2) score. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the PRISM2. The mortality observed in the office-hours group was 9.4% and in the off-hours group was 8.1%. The PRISM2-based SMR was 0.83 (95% confidence interval [CI]: 0.43-1.47) for the office-hours group and 0.68 (95% CI: 0.34-1.36) for the off-hours group. No significant differences in length of ICU stay or duration of mechanical ventilation were observed between patients admitted during off-hours and those admitted during office hours. In the logistic regression model, off-hours admission was not significantly associated with a higher mortality (odds ratio: 0.85, 95% CI: 0.57-1.27; P = .44).

CONCLUSIONS

The absence of an in-house intensivist during off-hours is not associated with an increase in mortality, length of ICU stay, or duration of mechanical ventilation for patients admitted to our pediatric ICU.

Mortality and other outcomes after paediatric hospital admission on the weekend compared to weekday

Mortality is higher for adults admitted to hospital and for babies born on weekends compared to weekdays. This study compares in-hospital mortality and in children admitted to hospital on weekends and weekdays. Details for all acute medical admissions to hospitals in Scotland for children aged ≤16 years between 1st January 2000 and 31st December 2013 were obtained. Death was linked to day of admission. There were 570,403 acute medical admissions and 334 children died, including 83 who died after an admission on Saturday or Sunday and 251 who died following admission between Monday and Friday. The adjusted odds ratio (aOR) for a child dying after admission on a weekend compared to weekday was 1.03 [95% CI 0.80 to 1.32]. The OR for a child admitted over the weekend requiring intensive care unit (ICU) or high dependency unit (HDU) care was 1.24 [1.16 to 1.32], but the absolute number of admissions to HDU and ICU per day were similar on weekends and weekdays. We see no evidence of increased in-hospital paediatric mortality after admission on a weekend. The increased risk for admission to ITU or HDU with more serious illness over weekends is explained by fewer less serious admissions.

Severe neonatal hyperbilirubinaemia is frequently associated with long hospitalisation for emergency care in Nigeria

AIM

This study investigated the frequency and predictors of a long hospital stay (LHS) for severe neonatal hyperbilirubinaemia in Nigeria.

METHODS

Length of stay (LOS) for severe hyperbilirubinaemia was examined among neonates consecutively admitted to the emergency department of a children's hospital in Lagos from January 2013 to December 2014. The median LOS was used as the cut-off for LHS. Multivariate logistic regression determined the independent predictors of LHS based on demographic and clinical factors significantly associated with the log-transformed LOS in the bivariate analyses.

RESULTS

We enrolled 622 hyperbilirubinaemic infants with a median age of four days (interquartile range 2-6 days) and 276 (44.4%) had LHS based on the median LOS of five days. Regardless of their birth place, infants were significantly more likely to have LHS if they were admitted in the first two days of life (p = 0.008) - especially with birth asphyxia - or had acute bilirubin encephalopathy (p = 0.001) and required one (p = 0.020) or repeat (p = 0.022) exchange transfusions. Infants who required repeat exchange transfusions had the highest odds for LHS (odds ratio 4.98, 95% confidence interval 1.26-19.76).

CONCLUSION

Severe hyperbilirubinaemia was frequently associated with long hospitalisation in Nigeria, especially if neonates had birth asphyxia or required exchange transfusions.

Time of Admission to the PICU and Mortality

OBJECTIVES

To evaluate for any association between time of admission to the PICU and mortality.

DESIGN

Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014.

SETTING

One hundred and twenty-nine PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons.

CONCLUSIONS

Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Survival analysis of weekend emergency medical admissions

BACKGROUND

We previously reported weekend emergency admissions to have a higher mortality; we have now examined the time profile of deaths, by weekday or weekend admission, in all emergency medical patients admitted between 2002 and 2014.

METHODS

We divided admissions by a weekday or weekend (After 17.00 Friday-Sunday) hospital arrival. We examined survival following an admission using Cox proportional hazard models and Kaplan-Meier time to event analysis.

RESULTS

In total 82 368 admissions were recorded in 44, 628 patients. Weekend admissions had an increased mortality of 5.0% (95% CI 4.7, 5.4) compared with weekday admissions of 4.5% (95% CI 4.3, 4.7) ( P = 0.007). The univariate adjusted Odds Ratio (OR) of death for a weekend admission was significantly increased OR = 1.15 (95% CI 1.05, 1.24) ( P = 0.001). Mortality following an admission declined exponentially over time with a long tail, ∼25% of deaths occurred after day 28. Only 11.4% of deaths occurred on the weekend of the admission. Survival curves showed no mortality difference at 28 days ( P = 0.21) but a difference at 90 days ( P = 0.05). The higher mortality for a weekend admission was attributable to late deaths in the cohort with an extended stay; compared with weekday, these weekend admissions were more likely to be older and have greater co-morbidity.

CONCLUSION

Survival rates following a weekend or weekday admission were similar out to 28 days. The higher overall mortality for weekend admissions is due to divergence in survival between 28 and 90 days. Most deaths in weekend admissions occurred when the hospital was fully staffed.

Factors Associated With Mortality in Low-Risk Pediatric Critical Care Patients in The Netherlands

OBJECTIVE

To determine differences between survivors and nonsurvivors and factors associated with mortality in pediatric intensive care patients with low risk of mortality.

DESIGN

Retrospective cohort study.

SETTING

Patients were selected from a national database including all admissions to the PICUs in The Netherlands between 2006 and 2012.

PATIENTS

Patients less than 18 years old admitted to the PICU with a predicted mortality risk lower than 1% according to either the recalibrated Pediatric Risk of Mortality or the Pediatric Index of Mortality 2 were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 16,874 low-risk admissions were included of which 86 patients (0.5%) died. Nonsurvivors had more unplanned admissions (74.4% vs 38.5%; p < 0.001), had more complex chronic conditions (76.7% vs 58.8%; p = 0.001), were more often mechanically ventilated (88.1% vs 34.9%; p < 0.001), and had a longer length of stay (median, 11 [interquartile range, 5-32] d vs median, 3 [interquartile range, 2-5] d; p < 0.001) when compared with survivors. Factors significantly associated with mortality were complex chronic conditions (odds ratio, 3.29; 95% CI, 1.97-5.50), unplanned admissions (odds ratio, 5.78; 95% CI, 3.40-9.81), and admissions in spring/summer (odds ratio, 1.67; 95% CI, 1.08-2.58).

CONCLUSIONS

Nonsurvivors in the PICU with a low predicted mortality risk have recognizable risk factors including complex chronic condition and unplanned admissions.

Cost-Effective Recruitment need for 24x7 Paediatricians in the State General Hospitals in Relation to the Reduction of Infant Mortality

INTRODUCTION

According to World Health Organisation (WHO), improvement of hospital based care can have an impact of upto 30% in reducing Infant Mortality Rate (IMR), whereas, strengthening universal outreach and family-community based care is known to have a greater impact. The study intends to assess how far gaps in the public health facilities contribute towards infant mortality, as 2/3^rd of infant mortality is due to suboptimum care seeking and weak health system.

AIM

To identify cost-effectiveness of employment of additional paediatric manpower to provide round the clock skilled service to reduce IMR in the present state health facilities at the district general hospitals.

MATERIALS AND METHODS

A cross-sectional observational study was conducted in a tertiary teaching hospital and district hospitals of 2 districts (Hooghly and Howrah in West Bengal). Factors affecting infant mortality and shift wise analysis of proportion of infant deaths were analysed in both tertiary and district level hospitals. Information was gathered in a predesigned proforma for one year period by verifying hospital records and by personal interview with service personnel in the health establishment. SPSS software version 17 (Chicago, IL) was used. The p-value was calculated by Fischer exact t-test.

RESULTS

Available hospital beds per 1000 population were 1.1. Percentage of paediatric beds available in comparison to total hospital bed was disproportionately lower (10%). Dearth of skilled medical care provider at odd hours in district hospitals resulted in significantly greater infant death (p < 0.0001), but was not seen in tertiary hospital. The investment for appointing four additional paediatricians for round the clock stay duty was found to be cost-effective.

CONCLUSION

Provision of round the clock availability of skilled medical care may reduce hospital based infant mortality and it is cost-effective.

Interhospital transfer of pediatric neurosurgical patients

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

PURPOSE

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

METHODS

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

RESULTS

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

CONCLUSION

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

Weekday vs. weekend repair of esophageal atresia and tracheoesophageal fistula

PURPOSE

We hypothesize that weekend esophageal atresia and tracheoesophageal fistula (EA/TEF) repair has worse outcomes compared to procedures performed on weekdays.

METHODS

Kids' Inpatient Database (1997-2009) was searched for EA/TEF in infants admitted at <8days of life. Cases were limited to patients who underwent repair during their hospitalization. Risk-adjusted multivariate analysis (MVA) compared complications, mortality, and resource utilization (length of stay [LOS] total charges [TC]) between weekday and weekend procedures.

RESULTS

Overall, 861 EA/TEF cases with known day of repair were identified. Cohort survival was 96%. On risk-adjusted MVA, complication rates were higher with EA/TEF repair on a weekend (OR: 2.2) compared to a weekday. Additionally, complications (OR: 6.5) and LOS (OR: 9.3) were found to be higher among African American children compared to Caucasians. LOS was higher in patients with Medicaid (OR: 2.4) and repairs performed at non-teaching hospitals (OR: 3.2). Weekend vs. weekday procedure had no significant effect on mortality or resource utilization.

CONCLUSION

By risk-adjusted MVA, increased complication rates for EA/TEF are seen in patients undergoing repair on weekends compared to weekdays. Additionally, African American children experienced higher complication rates compared to Caucasians. LOS after repair varies according to race, payer status, and hospital characteristics.

The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients

OBJECT

Several studies have indicated that the 30-day morbidity and mortality risks are higher among pediatric and adult patients who are admitted on the weekends. This "weekend effect" has been observed among patients admitted with and for a variety of diagnoses and procedures, including myocardial infarction, pulmonary embolism, ruptured abdominal aortic aneurysm, stroke, peptic ulcer disease, and pediatric surgery. In this study, morbidity and mortality outcomes for emergency pediatric neurosurgical procedures carried out on the weekend or after hours are compared with emergency surgical procedures performed during regular weekday business hours.

METHODS

A retrospective analysis of operative data was conducted. Between December 1, 2011, and August 20, 2014, a total of 710 urgent or emergency neurosurgical procedures were performed at Texas Children's Hospital in children younger than than 18 years of age. These procedures were then stratified into 3 groups: weekday regular hours, weekday after hours, and weekend hours. By cross-referencing these events with a prospectively collected morbidity and mortality database, the impact of the day and time on complication incidence was examined. Outcome metrics were compared using logistic regression models.

RESULTS

The weekday regular hours and after-hours (weekday after hours and weekends) surgery groups consisted of 341 and 239 patients and 434 and 276 procedures, respectively. There were no significant differences in the types of cases performed (p = 0.629) or baseline preoperative health status as determined by American Society of Anesthesiologists classifications (p = 0.220) between the 2 cohorts. After multivariate adjustment and regression, children undergoing emergency neurosurgical procedures during weekday after hours or weekends were more likely to experience complications (p = 0.0227).

CONCLUSIONS

Weekday after-hours and weekend emergency pediatric neurosurgical procedures are associated with significantly increased 30-day morbidity and mortality risk compared with procedures performed during weekday regular hours.

The effect of surgical timing on the outcome of patients with neck of femur fracture

AIMS

To investigate the effect of surgical timing (in hours versus after hours and weekdays versus weekends) on the outcome of patients with neck of femur fracture.

METHODS

Patients who were admitted to a single tertiary referral hospital for surgical management of femoral neck fractures over a continuous period from 1/11/2002 to 12/7/2012 were identified from medical records and the operating theatre database.

RESULTS

A consecutive series of 2334 patients were included in the study. Of the patients who underwent surgery during the weekday and during usual hours, 18% (207/1135) experienced an adverse event, compared to 16% (193/1199) outside of these times. The difference between the two groups was not significant (p = 0.17). The same conclusion was made for the comparison between those who had surgery during the week with those who had surgery on the weekend (17%, 267/1546 and 17%, 133/788, respectively, p > 0.05). The proportion of patients who underwent surgery during hours that experienced an adverse event was significantly higher than those undergoing surgery out of hours (18%, 327/1789 and 13%, 73/545, respectively, p = 0.0081). When adjusted for age, ASA score and pre-operative stay, there was no statistical difference between those different sub-groups.

CONCLUSIONS

There was no difference in the rates of adverse events between patients who had surgery during hours and weekdays with those who had surgery after hours or weekends. The careful selection of patients with appropriate hospital staff, resources and adequate theatre access, surgery during after hours and weekends may be safely considered to prevent a delay in surgical treatment for patient with neck of femur fracture.

Pediatric weekend admission and increased unplanned readmission rates

Outcomes for patients hospitalized on weekends are often worse for adults-the so-called "weekend effect." Less is known about the weekend effect for children. We examined 55,383 hospitalizations at a tertiary care children's hospital. We used logistic regression to examine the associations of weekend admission and weekend discharge with unplanned 30-day readmission. We adjusted analyses for patient and hospitalization characteristics including number of complex chronic conditions, technology dependency, and length of stay. The 30-day unplanned readmission rate was 10.3%. Children admitted on the weekend had significantly higher odds of unplanned readmission compared to children admitted on weekdays (adjusted odds ratio = 1.09 [95% confidence interval: 1.004-1.18]). In contrast, being discharged on the weekend was not associated with readmission. In conclusion, children admitted on the weekend have higher rates of 30-day unplanned readmission than children admitted during the week, suggesting care differences on the weekend related to initial clinical management rather than discharge planning.

Associations Between Day of Admission and Day of Surgery on Outcome and Resource Utilization in Infants With Hypoplastic Left Heart Syndrome Who Underwent Stage I Palliation (from the Single Ventricle Reconstruction Trial)

Newborns with hypoplastic left heart syndrome and other single right ventricular variants require substantial health care resources. Weekend acute care has been associated with worse outcomes and increased resource use in other populations but has not been studied in patients with single ventricle. Subjects of the Single Ventricle Reconstruction trial were classified by whether they had a weekend admission and by day of the week of Norwood procedure. The primary outcome was hospital length of stay (LOS); secondary outcomes included transplant-free survival, intensive care unit (ICU) LOS, and days of mechanical ventilation. The Student's t test with log transformation and the Wilcoxon rank-sum test were used to analyze associations. Admission day was categorized for 533 of 549 subjects (13% weekend). The day of the Norwood was Thursday/Friday in 39%. There was no difference in median hospital LOS, transplant-free survival, ICU LOS, or days ventilated for weekend versus non-weekend admissions. Day of the Norwood procedure was not associated with a difference in hospital LOS, transplant-free survival, ICU LOS, or days ventilated. Prenatally diagnosed infants born on the weekend had lower mean birth weight, younger gestational age, and were more likely to be intubated but did not have a difference in measured outcomes. In conclusion, in this cohort of patients with single right ventricle, neither weekend admission nor end-of-the-week Norwood procedure was associated with increased use of hospital resources or poorer outcomes. We speculate that the complex postoperative course following the Norwood procedure outweighs any impact that day of admission or operation may have on these outcomes.

Off-hours admission to pediatric intensive care and mortality

BACKGROUND

Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs.

METHODS

A retrospective cohort study of admissions of patients <18 years of age to PICUs was performed using the Virtual PICU Systems (VPS, LLC) database. "Off-hours" was defined as nighttime (7:00 pm to 6:59 am) or weekend (Saturday or Sunday any time). Mixed-effects multivariable regression was performed by using Pediatric Index of Mortality 2 (PIM2) to adjust for severity of illness. Primary outcome was death in the pediatric ICU.

RESULTS

Data from 234,192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85-0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16-1.39; P < .0001).

CONCLUSIONS

Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.

The "weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend

BACKGROUND

For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures.

METHODS

Using the Nationwide Inpatient Sample and the Kids' Inpatient Database, we identified 439,457 pediatric (<18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed.

RESULTS

Patient characteristics of those admitted on the weekend (n=112,064) and weekday (n=327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21-2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01-1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14-1.74).

CONCLUSION

Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.

Evaluation of endocrine function in children admitted to pediatric intensive care unit

BACKGROUND

Although studied widely in adulthood, little is known about endocrinological disorders during critical illnesses in childhood. The aims of this study were to define the endocrinological changes in patients admitted to pediatric intensive care unit (PICU) and to identify their effects on prognosis.

METHODS

Forty patients with a mean age of 5.1 years admitted to PICU were enrolled in the study. Blood samples were taken at admission and at 24 and 48 h to measure cortisol, adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), GH binding protein (GHBP), insulin-like growth factor-binding protein-3 (IGFBP-3) and interleukin-6 (IL-6). The severity of the patient's condition was assessed using pediatric risk of mortality (PRISM) and pediatric logistic organ dysfunction (PELOD) scores.

RESULTS

PRISM and PELOD scores were significantly higher in non-survivors. Cortisol, ACTH, prolactin, GH, GHBP, IGFBP-3 and IL-6 were not significantly different between the survivors and non-survivors. There was a negative correlation between baseline IGFBP-3 and PRISM scores. A positive correlation was seen between cortisol level at 24 h and PRISM score. On multivariate linear regression analysis, PRISM score was best explained by ACTH and cortisol at 24 h. A positive weak correlation was detected between IL-6 at 24 h and PELOD scores.

CONCLUSIONS

Although there was no difference between survivors and non-survivors regarding the studied endocrine parameters, there were associations between cortisol, ACTH, IL-6 and IGFBP-3 and risk assessment scores, and, given that these scores correlated with mortality, these parameters might be useful as prognostic factors.

Perceptions of 24/7 in-hospital intensivist coverage on pediatric housestaff education

BACKGROUND

In recent years, the focus on patient safety and housestaff supervision has led to a steady increase in institutions providing 24/7 in-hospital (also known as in-house, henceforth referred to as IH) coverage by pediatric intensivists. Effects of this increased attending physician presence on education of pediatric housestaff have not been studied. We hypothesized that IH coverage would decrease perceived autonomy of housestaff and negatively affect their preparedness to be independent attending physicians on completion of training.

METHODS

A secure, anonymous, Web-based survey was sent to pediatric intensivists in the United States and Canada, and pediatric critical care fellows and pediatric residents at academic centers across the United States. Questions focused on perceptions of IH coverage and housestaff educational experience.

RESULTS

We report 1323 responses from 147 institutions (center response rate 74%). Although 96% of respondents stated that the PICU provides "a good educational experience," only 50% of pediatric intensivists and 67% of housestaff feel that housestaff are prepared for independent practice after training in an IH model. Compared with those training in home-call models, respondents currently working in IH models have more favorable perceptions of the effects of IH coverage on housestaff autonomy (P < .0001), supervision (P < .0001), and preparation for independent practice (P < .0001).

CONCLUSIONS

Pediatric intensivists and housestaff express concern regarding the preparation of housestaff training in a 24/7 IH attending model. An important priority for institutions using or considering a 24/7 IH attending coverage model is the balance between adequate housestaff supervision and autonomy.

Effects of out-of-hours and winter admissions and number of patients per unit on mortality in pediatric intensive care

OBJECTIVE

To investigate the effect of out-of-hours and winter admissions, and unit size on risk adjusted mortality in pediatric intensive care.

STUDY DESIGN

A national pediatric intensive care clinical audit provided data on over 86000 admissions to 29 pediatric intensive care units (2006-2011). Multivariate logistic regression modeled risk adjusted mortality prior to discharge with out-of-hours (night, weekend, public holiday) admissions, admissions per unit, winter admission, and potential confounders, overall and separately for emergency and planned admissions.

RESULTS

Nearly one-half (47.1%) of admissions were out-of-hours (n = 40948) and 79.2% of those were emergencies. Mortality for all out-of-hours admissions was raised (OR 1.1; 95% CI 1.02-1.2; P = .013), accounted for by planned admissions (OR 1.99; 95% CI 1.67-2.37; P < .001) compared with a reduced risk for emergency admissions (OR 0.93; 95% CI 0.86-1.1; P = .07). Winter admissions were associated with increased risk. Unit size did not affect mortality.

CONCLUSIONS

A child admitted to pediatric intensive care as an out-of-hours emergency is not at increased risk of dying compared with a weekday daytime admission, indicating pediatric intensive care units provide consistent quality of care around the clock. Excess mortality in planned out-of-hours admissions may be explained by admissions following complex operations where risk-adjustment models underestimate the true probability of mortality. In winter, a time of seasonally high bed occupancy, there was an increased mortality risk, an effect which requires further investigation. Despite the different characteristics of small units, the absence of any effect of unit size on mortality suggests that number of admissions per unit does not influence standards of care.

Monitoring the pulse of hospital activity: electronic health record utilization as a measure of care intensity

BACKGROUND

Hospital care on weekends has been associated with reduced quality and poor clinical outcomes, suggesting that decreases in overall intensity of care may have important clinical effects. We describe a new measure of hospital intensity of care based on utilization of the electronic health record (EHR).

METHODS

We measured global intensity of care at our academic medical center by monitoring the use of the EHR in 2011. Our primary measure, termed EHR interactions, was the number of accessions of a patient's electronic record by a clinician, adjusted for hospital census, per unit of time. Our secondary measure was percent of total available central processing unit (CPU) power used to access EHR servers at a given time.

RESULTS

EHR interactions were lower on weekend days as compared to weekdays at every hour (P < 0.0001), and the daytime peak in intensity noted each weekday was blunted on weekends. The relative rate and 95% confidence interval (CI) of census-adjusted record accessions per patient on weekdays compared with weekends were: 1.76 (95% CI: 1.74-1.77), 1.52 (95% CI: 1.50-1.55), and 1.14 (95% CI: 1.12-1.17) for day, morning/evening, and night hours, respectively. Percent CPU usage correlated closely with EHR interactions (r = 0.90).

CONCLUSIONS

EHR usage is a valid and easily reproducible measure of intensity of care in the hospital. Using this measure we identified large, hour-specific differences between weekend and weekday intensity. EHR interactions may serve as a useful measure for tracking and improving temporal variations in care that are common, and potentially deleterious, in hospital systems.

The evolving model of pediatric critical care delivery in North America

The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.

Acute variceal hemorrhage in patients with liver cirrhosis: weekend versus weekday admissions

PURPOSE

Little is known about the impact of weekend admission on acute variceal hemorrhage (AVH). Thus, we investigated whether day of admission due to AVH influenced in-hospital mortality.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 294 patients with cirrhosis admitted between January 2005 and February 2009 for the management of AVH. Clinical characteristics were compared between patients with weekend and weekday admission, and independent risk factors for in-hospital mortality were determined by multivariate binary logistic regression analysis.

RESULTS

No demographic differences were observed between patients according to admission day or in the clinical course during hospitalization. Seventeen (23.0%) of 74 patients with weekend admission and 48 (21.8%) of 220 with weekday admission died during hospitalization (p=0.872). Univariate and subsequent multivariate analysis showed that initial presentation with hematochezia [p=0.042; hazard ratio (HR), 2.605; 95% confidence interval (CI), 1.038-6.541], in-patient status at the time of bleeding (p=0.003; HR, 4.084; 95% CI, 1.598-10.435), Child-Pugh score (p<0.001; HR, 1.877; 95% CI, 1.516-2.324), and number of endoscopy sessions for complete hemostasis (p=0.001; HR, 3.864; 95% CI, 1.802-8.288) were independent predictors for in-hospital mortality.

CONCLUSION

Weekend admission did not influence in-hospital mortality in patients with cirrhosis who presented AVH.

Physician staffing pattern in intensive care units: Have we cracked the code?

Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.

Physician staffing pattern in intensive care units: Have we cracked the code?

Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a “turf” war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.

"Weekend effects" in patients with intracerebral hemorrhage

Studies have shown that weekend admissions are associated with outcomes of patients with different diseases. Our aim is to evaluate the weekend effects in patients with intracerebral hemorrhage (ICH) in our hospital. A retrospective analysis of patients with ICH was performed. Weekend admission was defined as the period from Friday, 6:01 p.m., to Monday, 7:59 a.m. The ICH score was used to evaluate severity on admission. The chi-square goodness-of-fit test was applied to analyze weekly distribution. The rank sum test was conducted to calculate the functional outcomes (modified Rankin scale, MRS), and the mortality was compared by binary logistic regression. Between 2008 and 2009, 313 patients with ICH were included, of which 30% (95/313) were admitted on the weekend. Patients with ICH were equally distributed on weekdays and weekends (P=0.7123). Weekend admission was not a statistically significant predictive factor for in-hospital mortality (P=0.315) and functional outcomes (P=0.128) in patients with ICH. However, a significant correlation was found between the ICH score and the mortality (OR=6.819, 95%CI: 4.323-10.757; P=0.009). Our results suggest that compared with weekday admission, weekend admission is not significantly associated with increased short-term mortality and poorer functional outcome among patients hospitalized with ICH.

Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit

OBJECTIVE

Mortality rates from critical illness in children have declined over the past several decades, now averaging between 2% and 5% in most pediatric intensive care units. Although these rates, and mortality rates from specific disorders, are widely understood, the impact of acute neurologic injuries in such children who die and the role of these injuries in the cause of death are not well understood. We hypothesized that neurologic injuries are an important cause of death in children.

DESIGN

Retrospective review.

SETTING

Pediatric intensive care unit at Children's Hospital of Pittsburgh, an academic tertiary care center.

PATIENTS

Seventy-eight children who died within the pediatric intensive care unit from April 2006 to February 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding admission diagnosis, presence of chronic illness, diagnosis of brain injury, and cause of death were collected. Mortality was attributed to brain injury in 65.4% (51 of 78) of deaths. Ninety-six percent (28 of 29) of previously healthy children died with brain injuries compared with 46.9% (23 of 49) of chronically ill children (p < .05). The diagnosed brain injury was the proximate cause of death in 89.3% of previously healthy children and 91.3% with chronic illnesses. Pediatric intensive care unit and hospital length of stay was longer in those with chronic illnesses (38.8 ± 7.0 days vs. 8.9 ± 3.7 days and 49.2 ± 8.3 days vs. 9.0 ± 3.8 days, p < .05 and p < .001, respectively).

CONCLUSION

Brain injury was exceedingly common in children who died in our pediatric intensive care unit and was the proximate cause of death in a large majority of cases. Neuroprotective measures for a wide variety of admission diagnoses and initiatives directed to prevention or treatment of brain injury are likely to attain further improvements in mortality in previously healthy children in the modern pediatric intensive care unit.

Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis

OBJECTIVE

To study variation in mortality associated with time and day of admission to the intensive care unit (ICU).

DESIGN

Retrospective cohort analysis using the Australian and New Zealand Intensive Care Society Adult Patient Database.

SETTING AND PARTICIPANTS

245,057 admissions to 41 Australian ICUs from January 2000 to December 2008.

MAIN OUTCOME MEASURES

Observed mortality and standardised mortality ratio (SMR) based on Acute Physiology and Chronic Health Evaluation III, 10th iteration (APACHE III-j) scores. Subgroup analysis was performed on the basis of elective surgical or emergency admission to ICU.

RESULTS

48% of patients were admitted after hours (18:00-05:59) and 20% of patients were admitted on weekends (Saturday and Sunday). Patients admitted after hours had a 17% hospital mortality rate compared with 14% of patients admitted in hours (P < 0.001); and SMRs of 0.92 (95% CI, 0.91-0.93) and 0.83 (95% CI, 0.83-0.84), respectively. Weekend admissions had a 20% hospital mortality rate compared with 14% on weekdays (P < 0.001), with SMRs of 0.95 (95% CI, 0.94-0.97) and 0.92 (95% CI, 0.92-0.93), respectively. Variation in outcome with time of admission to ICU was accounted for predominantly by elective surgical patients.

CONCLUSIONS

Patients admitted to ICUs in Australia after hours and on weekends have a higher observed and risk-adjusted mortality than patients admitted at other times. Further research is required to determine the causes and relationship to resource availability and staffing.

Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit

OBJECTIVE

To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit.

DESIGN

Retrospective, observational study.

SETTING

Medical intensive care unit of a tertiary care, academic medical center.

PATIENTS

A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008.

INTERVENTIONS

A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team.

MEASUREMENTS AND MAIN RESULTS

Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61-0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62-0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0-25 vs. 22, interquartile range 0-26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1-5.2 vs. 2.7, interquartile range 1.3-5.9), p = .009) but not hospital (8.3, interquartile range 4.1-17.0 vs. 8.2, interquartile range 4.0-16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention.

CONCLUSIONS

A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.

No effect of time of day at presentation to the emergency department on the outcome of patients who are admitted to the intensive care unit

OBJECTIVES

To determine if an association exists between the time of day when a patient presents to ED and their outcome for those admitted directly to the ICU.

METHODS

We performed a retrospective cohort study on all patients admitted to the ICU directly from the ED from 1 July 2006 to 30 June 2008, using data from the ED and ICU databases in a single institution. Comparisons of mortality, length of stay in the ED, ICU, hospital and time on a ventilator were made based on the time of presentation.

RESULTS

A total of 400 patients were admitted to ICU from the ED. There was no evidence of a difference in mortality between those presenting between midnight and 8 am, 8 am and 4 pm or 4 pm and midnight (23.2%, 22.8%, 19.5%, respectively, P= 0.71), or for those presenting during office hours (8 am-4 pm Monday to Friday) or outside office hours (26.1% and 20.2%, respectively, P= 0.23). There were no differences in time on a ventilator, or length of stay in ED, intensive care and hospital.

CONCLUSIONS

The time of day patients arrive at the ED has no association with length of stay in ED, intensive care or hospital, time on the ventilator, or mortality for those who are admitted to the ICU.

The relationship between workload and medical staffing levels in a paediatric cardiac intensive care unit

OBJECTIVE

To evaluate the matching between workload in a paediatric cardiac intensive care unit (ICU) and the corresponding medical staffing levels over a 24-h period.

DESIGN

A review of workload measured by: (a) admissions, (b) severity of illness in admissions using case-mix descriptors and mortality as a proxy, (c) cardiac arrests (CA) and (d) extracorporeal membrane oxygenation (ECMO) cannulations. An evaluation of matching between workload and medical staff schedules.

SETTING

A tertiary paediatric cardiac ICU.

PATIENTS

2,799 admissions over a 49-month period.

RESULTS

New admissions peaked in the evening, and the ratio of doctors' hours to admissions was lowest between 1359 and 2000 h. Although only 515 (17.3%) cases were admitted between 2000 and 0759 h, these were more likely to be emergencies, to have higher Paediatric Index of Mortality 2 (PIM2) scores and to die (p < 0.001). There was an increased adjusted risk of death in admissions between 2000 and 0159 h (p = 0.021). There was no difference in the occurrence of either CA (p = 0.41) or ECMO (p = 0.95) between day and night. The ratio of doctors' hours to CAs and ECMOs was lowest from 2000 to 0800 h. The conventional medical staffing roster generated the greatest concentration of staff in the morning, reducing to the lowest level between 0200 and 0759 h.

CONCLUSIONS

Workload was most intense for the in-house team at night, in terms of sicker admissions, ECMOs and cardiac arrests. Conventional roster patterns may not offer ideal matching between staffing and workload. Data analysis of variable and urgent workload may be used to inform medical rosters.

Off-hours admission and mortality in two pediatric intensive care units without 24-h in-house senior staff attendance

PURPOSE

To compare risk-adjusted mortality of children non-electively admitted during off-hours with risk-adjusted mortality of children admitted during office hours to two pediatric intensive care units (PICUs) without 24-h in-house attendance of senior staff.

DESIGN

Prospective observational study, performed between January 2003 and December 2007, in two PICUs without 24-h in-house attendance of senior staff, located in tertiary referral children's hospitals in the Netherlands.

METHODS

Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Index of Mortality (PIM1) and Pediatric Risk of Mortality (PRISM2) scores. Office hours were defined as week days between 8:00 a.m. and 6:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 6:00 p.m. and 8:00 a.m., Saturdays, Sundays and public holidays, with one resident covering the PICU and senior staff directly available on-call.

RESULTS

Of 3,212 non-elective patients admitted to the PICUs, 2,122 (66%) were admitted during off-hours. SMRs calculated according to PIM1 and PRISM2 did not show a significant difference with those of patients admitted during office hours. There was no significant effect of admission time on mortality in multivariate logistic regression with odds ratios of death in off-hours of 0.95 (PIM1, 95% CI 0.71-1.27, p = 0.73) and 1.03 (PRISM2, 95% CI 0.76-1.39, p = 0.82).

CONCLUSION

Off-hours admission to our PICUs without 24-h in-house attendance of senior staff was not associated with higher SMRs than admission during office hours when senior staff were available in-house.