Do hospitals provide lower quality care on weekends?

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.

Weekend / holiday effect on stroke mortality in regional Australia: A ten-year retrospective study

BACKGROUND

There is a deficiency in the evidence from rural and regional centres in Australia on the weekend effect following presentation with acute stroke.

OBJECTIVE

To estimate the association between admission over a weekend/holiday and all-cause mortality 3-day, 7-day, 14-day, 1-month, 3-month, 6-month, and 12-month following acute stroke.

METHODS

The records of stroke patients admitted to a main regional hospital in Australia from 2010 to 2020 were linked with the National Death Index. Time to death following ischaemic, haemorrhagic, and total stroke at different time points was modelled using Weibull, Exponential, or Gompertz regression based on best model fit determined by Akaike's information criterion.

RESULTS

Of 1669 patients, 1273 (76.3%) were admitted on a weekday, and 396 (23.7%) on a weekend/ or holiday. After adjusting for age, sex, and Charlson Comorbidity Index, stroke type and country of birth, admissions over a weekend/holiday following total stroke were significantly associated with an increased risk of dying within three days from admission [hazard ratio (HR): 1.59, 95% confidence interval: 1.01-2.50]. In haemorrhagic stroke, increased risk of death was significantly higher at three days (HR: 2.19, 95% confidence interval: 1.17-4.08), 14 days (HR: 1.73, 95% confidence interval: 1.02-2.93), and 1 month (HR: 1.82, 95% confidence interval: 1.09-3.03) following admission on the weekend/ or holiday compared to those admitted during the weekdays.

CONCLUSIONS

This study reports a short-term adverse weekend/holiday effect following admission for haemorrhagic stroke or total stroke. No significant weekend/holiday effect was found in ischaemic stroke.

Analysis of the Weekend Effect on Mortality, Diagnostic Coronary Angiography, and Percutaneous Coronary Intervention in Acute Myocardial Infarction Across Rural US Hospitals

BACKGROUND

Rural hospitals face several unique challenges in delivering healthcare to an underserved population. Achieving time-sensitive goals in a resource-scarce facility is often a difficult task without the right team at hand. Resources are further depleted on the weekends, exposing understaffed hospitals to poorer outcomes. Acute myocardial infarction (AMI) mortality depends on timely diagnosis and intervention. It is unknown to what extent resource shortages impact rural hospitals during weekends and how they affect AMI mortality.

METHODS

This cross-sectional study was performed on patients admitted on weekends with AMI using the National Inpatient Sample (NIS) 2019. Patients with type II non-ST-elevation myocardial infarction (NSTEMI) and missing information were excluded. The rates and timing of in-hospital diagnostic coronary angiograms, PCIs (percutaneous coronary interventions), and in-hospital mortality were studied. Regression models were used for data analyses.

RESULTS

A total of 161,625 patients met the inclusion criteria (58,690 females (36%), 114,830 Caucasians (71%), 17,910 African American (11%), 13,920 Hispanic (8.6%); mean (SD) age, 66.5 (0.5) years), including 47,665 (29.5%) ST-elevation myocardial infarction (STEMI) and 113,960 (70.5%) NSTEMI. Patients admitted to rural hospitals were less likely to undergo diagnostic coronary angiogram (adjusted odds ratio (aOR), 0.69; CI, 0.57-0.83; p<0.001) and PCI (aOR, 0.83; CI, 0.72-0.96; p 0.012). Rural hospitals had lesser odds of early diagnostic angiograms (aOR, 0.79; CI, 0.67-0.95; p<0.05) and PCI (aOR, 0.78; CI, 0.66-0.92; p<0.05) within 24 hours. The mortality difference between rural and urban hospitals was not significant (aOR, 1.08; CI, 0.85-1.4; p 0.52).

CONCLUSIONS

Diagnostic coronary angiograms and PCI are performed at a lesser rate in rural hospitals during weekends. This trend did not affect rural AMI mortality.

Weekend admissions and outcomes in patients with pneumonia: a systematic review and meta-analysis

Background

To document pooled evidence on the association between weekend hospital admissions and the potential risks of mortality, intensive care requirements, and readmission among patients with pneumonia.

Methods

We performed a systematic search across the PubMed, EMBASE, and Scopus databases. We collected observational studies exploring the association between weekend admissions and outcomes of interest in patients with pneumonia. To analyze the data, we used a random effects model and expressed the effect sizes as pooled odds ratios (ORs) accompanied by their respective 95% confidence intervals (CIs).

Results

The analysis comprised data from 13 retrospective studies. Compared to patients admitted on weekdays, those admitted during the weekend had a non-statistically significant marginally higher risk of in-hospital mortality (OR, 1.02; 95% CI, 1.00, 1.04) but similar 30-day mortality after admission (OR, 1.03; 95% CI, 0.97, 1.10), and similar risks of admission to intensive care unit (OR, 1.04; 95% CI, 0.98, 1.11) and re-admission (OR, 0.85; 95% CI, 0.65-1.12).

Conclusion

Our findings do not support the presence of a "weekend effect" in patients with pneumonia.

Systematic review registration

PROSPERO, identifier CRD42023425802, https://www.crd.york.ac.uk/prospero/.

The dose-response effect of time between emergency admission and inpatient care on mortality

To analyse mortality associated to emergency admissions on weekends, differentiating whether the patients were admitted to the Internal Medicine department or to the hospital as a whole. Retrospective follow-up study of patients discharged between 2015 and 2019 in: (a) the Internal Medicine department (n = 7656) and (b) the hospital as a whole (n = 83,146). Logistic regression models were fitted to analyse the risk of death, adjusting for age, sex, severity, Charlson index, sepsis, pneumonia, heart failure and day of admission. Cox models were also adjusted for the time from admission until normal inpatient care. There was a significant increase in mortality for patients admitted in weekends with short stays in Internal Medicine (48, 72 and 96 h: OR = 2.50, 1.89 and 1.62, respectively), and hospital-wide (OR = 2.02, 1.41 and 1.13, respectively). The highest risk in weekends occurred on Fridays (stays ≤ 48 h: OR = 3.92 [95% CI 2.06-7.48]), being no significative on Sundays. The risk increased with the time elapsed from admission until the inpatient department took over care (OR = 5.51 [95% CI 1.42-21.40] when this time reached 4 days). In Cox models patients reached HR = 2.74 (1.00-7.54) when the delay was 4 days. Whether it was Internal Medicine or hospital-wide patients, the risk of death associated with emergency admission in WE increased with the time between admission and transfer of care to the inpatient department; consequently, Friday was the day with the highest risk while Sunday lacked a weekend effect. Healthcare systems should correct this serious problem.

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.

From Ties to Events in the Analysis of Interorganizational Exchange Relations

Relational event models expand the analytical possibilities of existing statistical models for interorganizational networks by: (i) making efficient use of information contained in the sequential ordering of observed events connecting sending and receiving units; (ii) accounting for the intensity of the relation between exchange partners, and (iii) distinguishing between short- and long-term network effects. We introduce a recently developed relational event model (REM) for the analysis of continuously observed interorganizational exchange relations. The combination of efficient sampling algorithms and sender-based stratification makes the models that we present particularly useful for the analysis of very large samples of relational event data generated by interaction among heterogeneous actors. We demonstrate the empirical value of event-oriented network models in two different settings for interorganizational exchange relations-that is, high-frequency overnight transactions among European banks and patient-sharing relations within a community of Italian hospitals. We focus on patterns of direct and generalized reciprocity while accounting for more complex forms of dependence present in the data. Empirical results suggest that distinguishing between degree- and intensity-based network effects, and between short- and long-term effects is crucial to our understanding of the dynamics of interorganizational dependence and exchange relations. We discuss the general implications of these results for the analysis of social interaction data routinely collected in organizational research to examine the evolutionary dynamics of social networks within and between organizations.

Playing defense? Health care in the era of Covid

Health workers have to balance their own welfare vs. that of their patients particularly when patients have a readily transmissible disease. These risks become more consequential during an outbreak, and especially so when the chance of severe illness or mortality is non-negligible. One way to reduce risk is by reducing contact with patients. Such changes could be along the intensive or extensive margins. Using data on primary care outpatient encounters during the early months of the Covid-19 pandemic, I document important changes in the intensity of provider-patient interactions. Significantly, I find that adherence to clinical guidelines, the probability that routine procedures such as physical examinations were completed, and even the quality of information given by health providers, all declined sharply. I present evidence that these effects likely reflect risk mitigation behavior by health providers.

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.

The weekend effect in stroke mortality: evidence from Austrian acute care hospitals

Many studies provide evidence for the so-called weekend effect by demonstrating that patients admitted to hospital during weekends show less favourable outcomes such as increased mortality, compared with similar patients admitted during weekdays. The underlying causes for this phenomenon are still discussed controversially. We analysed factors influencing weekend effects in inpatient care for acute stroke in Austria. The study analysed secondary datasets from all 130 public acute care hospitals in Austria between 2010 and 2014 (Austrian DRG Data). The study cohort included 86,399 patient cases admitted with acute ischaemic stroke. By applying multivariate regression analysis, we tested whether patient, treatment or hospital characteristics drove in-hospital mortality on weekends and national holidays. We found that the risk to die after an admission at weekend was significantly higher compared to weekdays, while the number of admissions following stroke was significantly lower. Adjustment for patient, treatment and hospital characteristics substantially reduced the weekend effect in mortality but did not eliminate it. We conclude that the observed weekend effect could be explained either by lower quality of health care or higher severity of stroke admissions at the weekend. In depth analyses supported the hypothesis of higher stroke severity in weekend patients as seen in other studies. While DRG data is useful to analyse stroke treatment and outcomes, adjustment for case mix and severity is essential.

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).

Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect

(1) Purpose: Undesirable health care outcomes could conceivably increase as a result of the entry of new, less experienced health care personnel into patient care during the month of July (the July effect) or as a result of the less balanced allocation of health care resources on weekends (the weekend effect). Whether these two effects were present in Taiwan’s National Health Insurance (NHI) system was investigated. (2) Methods: The current study data were acquired from the NHI Research Database. The research sample comprised ≥18-year-old patients diagnosed as having a stroke for the first time from 1 January 2006 to 30 September 2012. The mortality rate within 30 days after hospitalization and readmission rate within 14 days after hospital discharge were used as health care quality indicators, whereas health care utilization indicators were the total length and cost of initial hospitalization. (3) Results: The results revealed no sample-wide July effect with regard to the four indicators among patients with stroke. However, an unexpected July effect was present among in-patients in regional and public hospitals, in which the total lengths and costs of initial hospitalization for non-July admissions were higher than those for July admissions. Furthermore, the total hospitalization length for weekend admissions was 1.06–1.07 times higher than that for non-weekend admissions; the total hospitalization length for weekend admissions was also higher than that for weekday admissions during non-July months. Thus, weekend admission did not affect the health care quality of patients with stroke but extended their total hospitalization length. (4) Conclusions: Consistent with the NHI’s general effectiveness in ensuring fair, universally accessible, and high-quality health care services in Taiwan, the health care quality of patients examined in this study did not vary significantly overall between July and non-July months. However, a longer hospitalization length was observed for weekend admissions, possibly due to limitations in personnel and resource allocations during weekends. These results highlight the health care efficiency of hospitals during weekends as an area for further improvement.

Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals

BACKGROUND

Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay.

METHODS

We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay.

RESULTS

We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001).

CONCLUSION

Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.

Brain Imaging in Patients With Dementia Visiting U.S. Emergency Departments

OBJECTIVE. This article aimed to assess changing use of brain imaging tests among patients with Alzheimer disease and vascular dementia who visited U.S. emergency departments (EDs) between 2006 and 2014. MATERIALS AND METHODS. Using the largest publicly available all-payer ED database, the Nationwide Emergency Department Sample, we identified a weighted cohort of 427,705 individuals with Alzheimer disease and 33,743 individuals with vascular dementia who visited U.S. EDs between 2006 and 2014. Logistic regression analyses were performed to identify factors associated with use. RESULTS. Between 2006 and 2014, ED visits among patients with Alzheimer disease and vascular dementia declined by 24.7% and 20.3%, respectively. However, there was a significant increase in utilization rates of head CT (from 4.4% to 11.1% in patients with Alzheimer disease and from 1.5% to 2.9% in patients with vascular dementia) and brain MRI (from 0.04% to 0.5% in patients with Alzheimer disease and 0.0% to 0.1% in those with vascular dementia) in the same time period. Among patients with Alzheimer disease, age, median income in patient ZIP code, day of the week of the ED visit, hospital teaching status, and hospital geographic region were significant predictors of imaging use. Among patients with vascular dementia, insurance type and hospital classification (urban vs rural) were significant predictors of imaging use. CONCLUSION. Despite declining ED visits, ED brain imaging in patients with Alzheimer disease and vascular dementia has increased. Various patient-specific and hospital-specific factors contribute to differential utilization rates.

Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday

INTRODUCTION

Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively.

MATERIALS AND METHODS

Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables.

RESULTS

2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score (P < .0001) and large hospital size (P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income (P = .0022) and weekend admission (P = .048).

DISCUSSION

There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.

Association Between Off-hour Presentations and In-hospital Mortality for Patients with Acute ST-Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Objectives

This study aimed to assess the effect of the admission time (on-hours versus off-hours) on in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) in a region without STEMI network.

Methods

We analysed in-hospital the mortality among 300 consecutive ST-segment elevation myocardial infarction (STEMI) patients treated with PPCI between March 2012 and February 2017. Patients were divided according to admission time into on-hours admission (08:00 AM until 08:00 PM on weekdays) versus off-hours admission (08:00 PM until 08:00 AM on weekdays and 24 h on weekends and holidays). Demographic and clinical data as well as in-hospital mortality were compared between the two groups.

Results

One hundred and seventy eight (59.3%) patients were admitted during on-hours, and 122 (40.7%) patients were presented in off-hours. The mean door-to-balloon time was 42.3 min in the off-hours group and 34.2 min in the on-hours group with no statistically significant difference (p = 0.39). The mortality rate was 3.9% at on-hours presentation versus 4.09% in off-hours admission (p = 0.58). Multivariate logistic regression analysis showed that off-hours presentation was not associated with in-hospital mortality. [odds ratio (OR) 0.74; 95% CI, 0.21–2.61, p = 0.64].

Conclusion

Despite no efficient STEMI network in present study, off-hour presentation had no significant impact on in-hospital prognosis in patients with STEMI treated with PPCI. Larger studies are warranted in order to determine the prognostic role of off-hour presentation in patients with STEMI undergoing PPCI.

Holiday and weekend effects on mortality for acute myocardial infarction in Shanxi, China: a cross-sectional study

OBJECTIVES

To examine the effects of holiday and weekend admission on in-hospital mortality for patients with acute myocardial infarction (AMI) in China.

METHODS

Patients with AMI in 31 tertiary hospitals in Shanxi, China from 2014 to 2017 were included (N = 54,968). Multivariable logistic regression models were used to examine the effects of holiday and weekend admission on in-hospital mortality.

RESULTS

Compared to non-holiday and weekday admissions, holiday and weekend admissions, respectively, were associated with increases in risk-adjusted mortality rates. Chinese National Day was associated with an additional 10 deaths per 1000 admissions (95% confidence interval (CI): (0, 20))-a relative increase from baseline mortality of 64% (95% CI: (1%, 128%)). Sunday was associated with an additional 4 deaths per 1000 admissions (95% CI: (0, 7))-a relative increase from baseline mortality of 23% (95% CI: (3%, 45%)). We found no evidence of gender differences in holiday or weekend effects on mortality.

CONCLUSIONS

Holiday and weekend admissions were associated with in-hospital AMI mortality. The admissions on Chinese National Day and Sunday contributed to the observed "holiday effect" and "weekend effect," respectively.

Does the "Weekend Effect" Extend to Friday Admissions? An Analysis of Ischemic Stroke Hospitalizations in South Carolina

Background: Weekend admission has been found to be associated with higher hospital mortality and longer hospital stay among patients with acute cardiovascular conditions. Whether those admitted on Fridays face similar risk as those admitted on Sundays and Saturdays remain uncertain.

Methods: This study used 2012–2013 data from hospital records for nonfatal patients with ischemic stroke in the state of South Carolina. The database contained the records of all hospitalizations in South Carolina except military and federal institutions. Multilevel logistic, negative binomial, and log-linear regression models were performed to explore the temporal pattern by hospital admission on specific day of a week for three outcomes: discharge to hospice care (vs. other alive discharges), length of stay, and total charge, respectively. Each model controlled for the patient age, gender, race/ethnicity, year of hospital admission, season of admission, payer, and Charlson Comorbidity Index.

Results: A total of 19,346 nonfatal ischemic stroke hospitalizations were identified. Multilevel logistic regression shows that patients admitted on non-Friday weekdays had a significantly lower odds of being discharged to hospice care as compared with those admitted on Fridays [odds ratio = 0.80, 95% confidence interval (CI) = 0.65–0.99] where there was no significant difference between Friday admissions and weekend admissions. The length of hospital stay for admission on non-Friday weekdays was significantly shorter than that of Friday admissions [incident rate ratio (IRR) = 0.87, 95% CI = 0.84–0.90], whereas longer length of hospital stay was found on weekend admission (IRR = 1.06, 95% CI = 1.02–1.11). Friday admissions were not associated with higher charges as compared with non-Friday weekday admissions.

Conclusions: Some hospitalization outcomes admitted on Fridays seemed to have the “weekend effects” too. Further studies are warranted to investigate underlying mechanism for such a difference in outcomes between Friday and other weekdays. Interventions to close the weekend–weekday gap of patient outcomes need to consider the elevated risk on Friday admission.

Weekend readmissions associated with mortality following pancreatic resection for cancer

BACKGROUND

The weekend effect is associated with an increased risk of adverse events, with complex patient populations especially susceptible to its impact. The objective of this study was to determine if outcomes for patients readmitted following pancreas resection differed on the weekend compared to weekdays.

METHODS

The Healthcare Cost and Utilization State Inpatient Database for Florida was used to identify patients undergoing pancreas resection for cancer who were readmitted within 30 days of discharge following surgery. Measured outcomes (for readmission encounters) included inpatient morbidity and mortality.

RESULTS

Patients with weekend readmissions had an increased odds of inpatient mortality (aOR 2.7, 95% C.I.: 1.1-6.6) compared to those with weekday readmissions despite having similar index lengths of stay (15.9 vs. 15.5 days, P = .73), incidence of postoperative inpatient complications (22.4% vs. 22.3%, P = .98), reasons for readmission, and baseline comorbidity.

DISCUSSION

Weekend readmissions following pancreatic resection are associated with increased risk of mortality. This is not explained by measured patient factors or clinical characteristics of the index hospital stay. Developing strategies to overcome the weekend effect can result in improved care for patients readmitted on the weekend.

Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome?

Objective

The study aimed to evaluate the effect of a single after-hours rapid response team (RRT) calls on patient outcome.

Design

A retrospective cohort study of RRT-call data over a 3-year period.

Setting

A 600-bedded, tertiary referral, public university hospital.

Participants

All adult patients who had a single RRT-call during their hospital stay.

Intervention

None.

Main outcomes measures

The primary outcome was to compare all-cause in-hospital mortality. The secondary outcomes were to study the hourly variation of RRT-calls and the mortality rate.

Results

Of the total 5,108 RRT-calls recorded, 1,916 patients had a single RRT-call. Eight hundred and sixty-one RRT-calls occurred during work-hours (08:00-17:59 hours) and 1,055 during after-hours (18:00-7:59). The all-cause in-hospital mortality was higher (15.07% vs 9.75%, OR 1.64, 95% CI 1.24-2.17, p value 0.001) in patients who had an after-hours RRT-call. This difference remained statistically significant after multivariate regression analysis (OR 1.50, 95% CI 1.11-2.01, p value 0.001). We noted a lower frequency of hourly RRT-calls after-hours but were associated with higher hourly mortality rates. There was no difference in outcomes for patients who were admitted to ICU post-RRT-call.

Conclusion

Patients having an after-hour RRT-call appear to have a higher risk for hospital mortality. No causal mechanism could be identified other than a decrease in hourly RRT usage during after-hours.

How to cite this article

Singh MY, Vegunta R, Karpe K, Rai S. Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome? Indian J Crit Care Med 2020;24(1):38-43.

Day of the Week of Surgery Affects Time to Discharge for Patients With Adolescent Idiopathic Scoliosis

Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P=.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days (P=.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days (P<.001). There was no longer a significant difference in length of stay between the "early" and the "late" groups (P=.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [Orthopedics. 2020; 43(1);8-12.].

The 'morning dip' in antimicrobial appropriateness: circumstances determining appropriateness of antimicrobial prescribing

Objectives

Quality of care has been shown to vary depending on the time of day or day of the week and depending on caregivers' gender and experience. We aimed to study how these factors influence quality of antimicrobial prescribing.

Methods

Prospective point-prevalence surveys were performed to determine the association between the above-mentioned prescription factors and antimicrobial appropriateness. Surveys included cases of patients admitted to a tertiary care hospital with a prescribed systemic antimicrobial drug and its prescribers. The main outcome was appropriateness of antimicrobial prescriptions. A post hoc qualitative survey among hospital physicians asked physicians to reflect on the results.

Results

The study included 351 antimicrobial prescriptions by 150 physicians prescribed for 276 patients. Appropriateness of antimicrobial prescribing in the morning was significantly lower compared with the afternoon and evening/night [43% versus 68% versus 70%, crude OR afternoon versus morning = 3.00 (95% CI = 1.60-5.48), crude OR evening/night versus morning = 3.40 (95% CI = 1.64-6.69)]. First-year residents performed significantly worse than their more experienced colleagues [51% versus 69%, crude OR = 2.09 (95% CI = 1.26-3.38)]. Infectious disease expert consultation improved appropriateness [54% versus 81%, crude OR = 3.71 (95% CI = 2.05-6.23)]. No significant effects for gender or office hours versus non-office hours were found. Post hoc survey results suggest creating room to improve prescribing circumstances during mornings and for inexperienced physicians.

Conclusions

Antimicrobial prescribing was less appropriate in the mornings and when prescribed by inexperienced physicians. Appropriateness may be increased by improving prescribing circumstances.

Mortality for emergency laparotomy is not affected by the weekend effect: a multicentre study

INTRODUCTION

The 'weekend effect' describes variation in outcomes of patients treated over the weekend compared with those treated during weekdays. This study examines whether a weekend effect exists for patients who undergo emergency laparotomy.

MATERIALS AND METHODS

Data entered into the National Emergency Laparotomy Audit between 2014 and 2017 at four NHS trusts in England and Wales were analysed. Patients were grouped into those admitted on weekdays and those on weekends (Friday 5pm to Monday 8am). Patient factors, markers of quality of care and patient outcomes were compared. Secondary analysis was performed according to the day of surgery.

RESULTS

After exclusion of patients who underwent laparotomy more than one week after admission to hospital, a total of 1717 patients (1138 patients admitted on weekdays and 579 admitted on weekends) were analysed. Age, preoperative lactate and P-POSSUM scores were not significantly different between the two groups. Time from admission to consultant review, decision to operate, commencement of antibiotics and theatre were not significantly different. Grades of operating surgeon were also similar in both groups. Inpatient 60-day mortality was 12.5% on weekdays and 12.8% on weekends (P = 0.878). Median length of postoperative stay was 12 days in both groups. When analysed according to day of surgery, only number of hours from admission to antibiotics (12.8 weekday vs 9.4 weekend, P = 0.046) and number of hours to theatre (26.5 weekday vs 24.1 hours weekend, P = 0.020) were significantly different.

DISCUSSION

Quality of care and clinical outcomes for patients undergoing emergency laparotomy during the weekend are not significantly different to those carried out during weekdays.

Variations in the number of births by day of the week, and morbidity and mortality in very-low-birth-weight infants

OBJECTIVE

To know the distribution of births of very low birth weight infants by day of the week, and whether this distribution affects the morbidity and mortality in this group of patients.

METHODS

This was a retrospective analysis of data collected prospectively in the Spanish SEN1500 network (2002-2011). Outborn infants, patients with major congenital anomalies, and those who died in the delivery room were excluded. Births were grouped into "weekdays" and "weekends." A multivariate logistic regression analysis was conducted to evaluate the independent effect of the birth moment on outcomes, and Cox regression for survival.

RESULTS

Out of a total of 27,205 very low birth weight infants born at and/or admitted to the participating centers, 22,961 (84.4%) met inclusion criteria. A reduction of 24% in the number of births was observed during the "weekends" compared with "weekdays". In the raw analysis, patients born on weekends exhibited higher morbidity and mortality (mortality rate: 14.2% vs. 16.5%, p<0.001), but differences were no longer significant after adjusting for confounding factors.

CONCLUSIONS

The present results suggest that current care practices reduce the proportion of births during the weekends and tend to cluster some high-risk births during this period, increasing crude morbidity and mortality. However, after adjusting for confounding factors, the differences disappear, suggesting that overall care coverage in these centers is appropriate.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis

BACKGROUND

The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis.

METHODS

We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost.

RESULTS

A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality.

CONCLUSIONS

Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

Impact of Weekend Presentation on Short-Term Outcomes and Choice of Clipping vs Coiling in Subarachnoid Hemorrhage

BACKGROUND

Presentation on a weekend is commonly associated with higher mortality and a decreased likelihood of receiving invasive procedures.

OBJECTIVE

To determine whether weekend presentation influences mortality, discharge destination, or type of treatment received (clip vs coil) in subarachnoid hemorrhage (SAH).

METHODS

We performed a serial cross-sectional retrospective study using the Nationwide Inpatient Sample. All adult discharges with a primary diagnosis of SAH (ICD-9-CM 435) from 2005 to 2010 were included, and records with trauma or arteriovenous malformation were excluded. Unadjusted and adjusted associations between weekend presentation and 3 outcomes (in-hospital mortality, discharge destination, and treatment with clip vs coil) were estimated using chi-square tests and multilevel logistic regression.

RESULTS

A total of 46 093 admissions for nontraumatic SAH were included in the sample; 24.6% presented on a weekend, 68.9% on a weekday, and 6.5% had unknown day of presentation. Weekend admission was not a significant predictor of inpatient mortality (25.4% weekend vs 24.9% weekday; P = .44), or a combined poor outcome measure of mortality or discharge to long-term acute care or hospice (30.3% weekend vs 29.4% weekday; P = .23). Among those treated for aneurysm obliteration, the proportion of clipped vs coiled did not change with weekend vs weekday presentation (21.5% clipped with weekend presentation vs 21.6% weekday, P = .95; 21.5% coiled with weekend presentation vs 22.4% weekday, P = .19).

CONCLUSION

Presentation with nontraumatic SAH on a weekend did not influence mortality, discharge destination, or type of treatment received (clip vs coil) compared with weekday presentation.

Variables affecting hospital length of stay: a scoping review

Purpose

Tertiary hospitals have registered an incremental rise in expenditure mostly because of the increasing demands by ageing populations. Reducing the length of stay (LOS) of patients within tertiary hospitals is one of the strategies, which has been used in the last decades to ensure health care systems’ sustainability. Furthermore, LOS is one of the key performance indicators, which is widely used to assess hospital efficiency. Hence, it is crucial that policy makers use evidence-based practices in health care to aim for optimal LOS. The purpose of this paper is to identify and summarize empirical research that brings together studies on the various variables that directly or indirectly impact on LOS within tertiary hospitals so as to develop a LOS causal systems model.

Design/methodology/approach

This scoping review was guided by the following research question: “What is affecting the LOS of patients within tertiary-level health care?” and by the guidelines specified by Arksey and O’Malley (2005), and by Armstrong et al. (2011). Relevant current literature was retrieved by searching various electronic databases. The PRISMA model provided the process guidelines to identify and select eligible studies.

Findings

An extensive literature search yielded a total of 30,350 references of which 46 were included in the final analysis. These articles yielded variables, which directly/indirectly are linked to LOS. These were then organized according to the Donabedian model – structure, processes and outcomes. The resultant LOS causal model reflects its complexity and confirms the consideration by scholars in the field that hospitals are complex adaptive systems, and that hospital managers must respond to LOS challenges holistically.

Originality/value

This paper illustrates a complex LOS causal model that emerged from the scoping review and may be of value for future research. It also highlighted the complexity of the construct under study.

"Weekend Effect" in Patients With Upper Gastrointestinal Hemorrhage: A Systematic Review and Meta-analysis

OBJECTIVES

"Weekend effect" refers to worse outcomes among patients presenting to the hospital on weekends or holidays. We performed a systematic review and meta-analysis of observational studies assessing the impact of the "weekend effect" in patients with upper gastrointestinal hemorrhage (UGIH).

METHODS

We searched key bibliographic databases using keywords and MeSH terms related to gastrointestinal hemorrhage and "weekend effect". Our primary analysis evaluated mortality in patients with UGIH who were hospitalized on the weekend or after-hours compared with a weekday. Secondary outcomes included need for definitive therapy and length of hospital stay. Relevant data were extracted and meta-analyses were performed using random effects model. Subgroup sensitivity analyses were also performed to assess the effects of key variables.

RESULTS

A total of 21 of 224 identified studies met inclusion criteria. Overall, there was no association between weekend admission and mortality among patients with UGIH (Odds Ratio (OR): 1.06; 95% confidence interval (CI): 0.99-1.14). However, meta-analysis using only the nine studies that did not report having a weekend rounder showed a significant increase in mortality (OR: 1.12; 95% CI: 1.07-1.17). There was no effect of weekend admission on any of our secondary outcomes.

CONCLUSIONS

Current evidence suggests that weekend admission is associated with significant increase in mortality in patients with non-variceal UGIH but no difference in mortality was noted in patients with variceal UGIH. Our findings are relevant to policymakers, practitioners and providers who should ensure the creation of consistent quality and access to care throughout the week.

Higher mortality rate in patients hospitalised for acute pulmonary embolism during weekends

The management of acute pulmonary embolism (PE) is often challenging and requires specific medical expertise, diagnostic techniques and therapeutic options that may not be available in all hospitals throughout the entire week. The aim of our study was to evaluate whether or not an association exists between weekday or weekend admission and mortality for patients hospitalised with acute PE. Using routinely collected hospital administrative data, we examined patients discharged with a diagnosis of PE from the hospitals of the Emilia- Romagna Region in Italy (January 1999-December 2009). The risk of inhospital death was calculated for admissions at the weekend and compared to weekday admissions. Of a total of 26,560 PEs, 6,788 (25.6%) had been admitted during weekends. PE admissions were most frequent on Mondays (15.8%) and less frequent on Saturdays and Sun- days/holidays (12.8%) (p<0.001). Weekend admissions were associated with significantly higher rates of in-hospital mortality than weekday admissions (28% vs. 24.8%) (p<0.001). The risk of weekend admission and in-hospital mortality was higher after adjusting for sender, hospital characteristics, and the Charlson co-morbidity index. In conclusion, hospitalisation for PE on weekends seems to be associated with a significantly higher mortality rate than on weekdays. Further research is needed to investigate the reasons for this observed difference in mortality in order to try and implement future strategies that ensure an adequate level of care throughout the entire week.

[Mortality and medical care of patients hospitalized during weekends]

BACKGROUND AND OBJECTIVES

It has been shown that patients admitted to hospital during the weekends tend to have less favourable outcomes, including higher mortality rates, compared with those admitted during weekdays. The main objective of this study is to evaluate the impact of on the health outcomes of patients admitted during the weekend.

MATERIAL AND METHODS

A retrospective observational study was conducted on all patients admitted to Montilla Hospital (Córdoba).. All hospitalised patients were attended to daily, including weekends and holidays. An analysis was performed on the epidemiological variables and health outcomes (total mortality).

RESULTS

The study included a total of 2,565 hospital admissions, of whom 653 (25.6%) were discharged during the weekend. Patients discharged during the weekend were significantly younger [53 (27) versus 56 (27) years, P<.002], had fewer diagnoses on discharge [6.2 (3.7) versus 6.7 (3.9), P<.003], and had fewer procedures performed [(3 (1.9) versus 3.2 (1.8), P<.005]. The mean length of stay was shorter for weekend discharges than the weekday discharges [3 (2.6) days versus 3.7 (3.9) days, P<.001). The total mortality was 4%, and there were no differences between weekday and weekend admissions (4.3% versus 3.7%). Home discharges on the weekend were related to a reduction in the mean length of stay by 0.3 days (from 3.6 to 3.9 days, P<.001).

CONCLUSIONS

Hospitalised patient care has led to the disappearance of increased mortality during weekends.

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.

Operating room scheduling is not associated with early outcome following elective anatomic lung resections: a propensity score case-matched analysis

Objectives

To investigate the effect of operating room scheduling on the outcome of patients undergoing elective lung resection.

Methods

In total, 420 patients submitted to anatomical pulmonary resections (363 lobectomies, 35 pneumonectomies, 22 segmentectomies) (April 2014-November 2015) were analysed. Ninety-two patients (22%) were operated on during weekends (Friday or Saturday) and 161 patients (38%) in the afternoon. Propensity score matching was performed to account for possible selection bias between the groups. The matched groups (weekdays versus weekends; morning versus afternoon) were compared in terms of cardiopulmonary complications, in-hospital mortality and length of stay (LOS).

Results

In total, 102 (24%) patients developed cardiopulmonary complications and 56 (13%) patients developed major complications. In-hospital mortality was 3.1% (13 patients). The case-matched comparison between patients operated on during the week versus those operated on during weekends (92 pairs) showed no differences of cardiopulmonary morbidity (22 vs 24, P  = 0.8), major complications (14 in both groups), mortality (2 vs 4, P  = 0.7) and LOS (7 vs 7.5 days, P  = 0.6). The case-matched comparison between patients operated on in the morning versus those operated on in the afternoon (161 pairs) showed no differences of cardiopulmonary morbidity (32 vs 33, P  = 0.9), major morbidity (17 vs 19, P  = 1), mortality (7 vs 4, P  = 0.5) and LOS (7.2 vs 5.9 days, P  = 0.2).

Conclusions

In our setting, operating room scheduling did not affect early outcome following elective lung resections, confirming the appropriate structural and procedural characteristics of a dedicated Thoracic Unit.

Time patterns in mortality after an emergency medical admission; relationship to weekday or weekend admission

BACKGROUND

The aim of this study was to detail the time profile and frequency distribution of mortality following an emergency admission and to compare these for weekday and weekend admissions.

METHODS

We profiled in-hospital deaths following emergency medical admission between 2002 and 2014. We determined the frequency distribution, time pattern, causality and influence of day of admission on mortality out to 120days. We utilized a multivariable regression model (logistic for in-hospital mortality and truncated Poisson for count data) to adjust for major predictor variables.

RESULTS

There were 82,368 admissions in 44,628 patients with 4587 in-hospital deaths. The 30-day in-hospital mortality declined from 8.2% in 2002 to 3.7% in 2014. The mortality pattern showed an exponential decay over time; the time to death was best described by the three-parameter Weibull model. The calculated time to death for the 5th, 10th, 25th, 50th, 75th, and 90th centiles were 0.5, 1.2, 3.8, 11.1, 26.3 and 49.3days. Acute Illness Severity Score, Chronic Disabling Disease Score, Charlson Co-Morbidity Index and Sepsis status were associated with mortality. The risk of death was initially high, lower by day 3, and showed a cumulative increase over time. The mortality pattern was very similar between a weekday or weekend admission; however, the risk of death was greater at all time points between 0 and 120days for patients admitted at a weekend OR 1.08 (95% CI 1.01-1.15).

CONCLUSION

We have demonstrated the pattern of mortality following an emergency admission. The underlying pattern is similar between weekday and weekend admissions.

Is weekend surgery a risk factor for post-tonsillectomy haemorrhage?

Background:

Tonsillectomy is a common, low-risk procedure. Post-tonsillectomy haemorrhage remains the most serious complication. Recent nationwide studies in the UK have identified an increased morbidity and mortality for both high-risk and low-risk elective general surgery performed at the weekend.

Methods:

Data for tonsillectomies performed at a district general hospital over a three-year period were retrospectively reviewed. The same group of surgeons performed elective tonsillectomies on both weekends and weekdays. All patients who developed a post-tonsillectomy haemorrhage were identified and the day of original operation was noted.

Results:

Between 2010 and 2013, 2208 (94.00 per cent) elective tonsillectomies were performed on a weekday and 141 (6.00 per cent) were performed on the weekend. Post-tonsillectomy haemorrhages occurred in 104 patients (4.71 per cent) who underwent their procedure on a weekday and in 10 patients (7.09 per cent) who had their surgery at the weekend (p = 0.20).

Conclusion:

There is no difference in the rate of post-tonsillectomy haemorrhage for procedures performed on a weekday or weekend.

Readmission after spinal cord injury: analysis of an institutional cohort of 795 patients

BACKGROUND

Recent studies in other fields have suggested that healthcare on the weekend may have worse outcomes. In particular, patients with stroke and acute cardiovascular events have shown worse outcomes with weekend treatment. It is unclear whether this extends to patients with spinal cord injury. This study was designed to evaluate factors for readmission after index hospitalization for spinal cord injury.

METHODS

A total of 795 consecutive patients over an 11-year period were analyzed. After excluding patients with chronic spinal cord injury and surgical care at an outside hospital, 745 patients remained. The primary outcome measure evaluated was 30-day readmission. Secondary measures include perioperative complications, readmission rate when discharged on the weekend, and the effect of race and insurance status on readmission rate. Univariate and multivariate analysis were utilized to evaluate the covariates collected. The χ2 test, Fisher's exact test, and linear and logistic regression methods were utilized for statistical analysis.

RESULTS

A total of 745 patients were analyzed after exclusions. Payer status did not affect length of stay, ICU length of stay, or perioperative complications. Neither weekend admission nor weekend operation affected length of stay, ICU length of stay, or readmission by 30 days. Patients undergoing weekend surgical treatment had lower perioperative complication rates (2.2% vs. 6.5% on weekday, P<0.01). Discharge on the weekend was associated with a significantly lower rate of readmission by 30 days (OR=0.07, 95% CI: 0.009-0.525, P<0.005). Payer status was associated with 30-day readmission (P<0.005). Patients with Medicare (20.8%) and Medicaid (20.1%) showed higher rates of readmission than patients with other payers. 21.1% of African-American patients were readmitted, versus 10.2% of other patients (Odds ratio: 2.2, 95% confidence interval 1.36-3.27, P<0.001). Correcting for payer status lessened but did not eliminate the effect of race on readmission.

CONCLUSIONS

Weekend admission did not increase perioperative complications or hospital length of stay. After discharge, patients with Medicaid and Medicare show higher rates of 30-day readmission, as do African-American patients. The effect of race on readmission is multifactorial, and may partially explained by the increased rate of Medicaid coverage in African-Americans in our institutions catchment area.

Impact of weekend admission on in-hospital mortality in severe community-acquired pneumonia patients in Japan

BACKGROUND AND OBJECTIVE

Little is known about the consequences of weekend admission on the quality of care in patients with severe community-acquired pneumonia. We compared the outcomes of weekend versus weekdays' admission for these patients on risk-adjusted mortality.

METHODS

Using a large nationwide administrative database, we analysed patients with severe pneumonia who had been hospitalized in 1044 acute care hospitals between 2012 and 2013. We compared risk-adjusted in-hospital mortality of guideline-concordant care between patients admitted weekdays and patients admitted on weekends.

RESULTS

The study sample comprised 17 342 patients admitted on weekdays and 6190 patients admitted on weekends. The mortality rate of the weekend admission group was significantly higher than that of the weekday admission group (23.7% vs 20.5%; P < 0.001). Even after adjusting for baseline patient severity and need for urgent care, weekend admissions were associated with higher mortality (odds ratio: 1.10; 95% confidence interval: 1.02-1.19). The implementation rates of guideline-concordant microbiological tests (including sputum cultures and urine antigen tests) were significantly lower in the weekend admission group. These tests were found to be associated with lower in-hospital mortality.

CONCLUSION

Our findings showed that weekend admission was associated with increased mortality in patients with severe community-acquired pneumonia in Japan. This may have been influenced by lower implementation of microbiological testing.

Population-based approaches to treatment and readmission after spinal cord injury

BACKGROUND

Recent studies in surgical and non-surgical specialties have suggested that patients admitted on the weekend may have worse outcomes. In particular, patients with stroke and acute cardiovascular events have shown worse outcomes with weekend treatment. It is unclear whether this extends to patients with spinal cord injury (SCI). This study was designed to evaluate factors for readmission after index hospitalization for spinal cord injury.

METHODS

This cohort was constructed from the State Inpatient Databases of California, New York, and Florida. For this study 14,396 patients with SCI were identified. The primary outcome measure evaluated was 30-day readmission. Secondary measures include in-hospital complications. Univariate and multivariate analysis were utilized to evaluate covariates. c2, Fisher's exact, and linear, logistic, and modified Poisson regression methods were utilized for statistical analysis. Propensity score methods were used with matched pairs analysis performed by the McNemar's Test.

RESULTS

Weekend admission was not associated with increased 30- day readmission rates in multivariate analysis. Race and discharge to a facility (RR 1.60 [1.43-1.79]) or home with home care (RR 1.23 [1.07-1.42]), were statistically significant risk factors for readmission. Payor status did not affect rates of readmission. In propensity score matched pairs analysis, weekend admission was not associated with increased odds of 30-day readmission (OR 1.04 [0.89-1.21]). Patients admitted to high volume centers had significantly lower risk of readmission when compared with patients admitted to low volume centers.

CONCLUSIONS

Our results suggest that the weekend effect, described previously in other patient populations, may not play as important a role in patients with SCI.

Effect of Weekend Admissions on the Treatment Process and Outcomes of Internal Medicine Patients: A Nationwide Cross-Sectional Study

Many studies address the effect of weekend admission on patient outcomes. This population-based study aimed to evaluate the relationship between weekend admission and the treatment process and outcomes of general internal medicine patients in Taiwan.A total of 82,340 patients (16,657 weekend and 65,683 weekday admissions) aged ≥20 years and admitted to the internal medicine departments of 17 medical centers between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. A generalized estimating equation (GEE) analysis was used to compare patients admitted on weekends and those admitted on weekdays.Patients who were admitted on weekends were more likely to undergo intubation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.16-1.39; P < 0.001) and/or mechanical ventilation (OR, 1.25; 95% CI, 1.15-1.35; P < 0.001), cardio-pulmonary resuscitation (OR: 1.45; 95% CI: 1.05-2.01; P = 0.026), and be transferred to the intensive care unit (ICU) (OR: 1.16; 95% CI: 1.03-1.30; P = 0.015) compared with those admitted on weekdays. Weekend-admitted patients also had higher odds of in-hospital mortality (OR: 1.19; 95% CI: 1.09-1.30; P < 0.001) and hospital treatment cost (OR: 1.04; 95% CI: 1.01-1.06; P = 0.008) than weekday-admitted patients.General internal medicine patients who were admitted on weekends experienced more intensive care procedures and higher ICU admission, in-hospital mortality, and treatment cost. Intensive care utilization may serve as early indicator of poorer outcomes and a potential entry point to offer preventive intervention before proceeding to intensive treatment.

Impact of an Intervention to Improve Weekend Hospital Care at an Academic Medical Center: An Observational Study

BACKGROUND

Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes.

OBJECTIVE

The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends.

DESIGN AND PATIENTS

This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders.

MAIN MEASURES

The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate.

KEY RESULTS

The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period.

CONCLUSIONS

The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.

Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients--A Retrospective Cohort Study

Study objective

To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old).

Methods

A retrospective cohort study of internal medicine patients visiting the emergency department between September 1^st 2010 and August 31^st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75^th percentile of ED-LOS in the study population, which was 208 minutes.

Results

Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients.

Conclusion

Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.

Insights into temporal patterns of hospital patient safety from routinely collected electronic data

BACKGROUND

The last two decades have seen an unprecedented growth in initiatives aimed to improve patient safety. For the most part, however, evidence of their impact remains controversial. At the same time, the healthcare industry has experienced an also unprecedented growth in the amount and variety of available electronic data.

METHODS

In this paper, we provide a review of the use of routinely collected electronic data in the identification, analysis and surveillance of temporal patterns of patient safety.

RESULTS

Two important temporal patterns of the safety of hospitalised patients were identified and discussed: long-term trends related to changes in clinical practice and healthcare policy; and shorter term patterns related to variations in workforce and resources. We found that consistency in reporting is intrinsically related to availability of large-scale, fit-for-purpose data. Consistent reported trends of patient harms included an increase in the incidence of post-operative sepsis and a decrease in central-line associated bloodstream infections. Improvement in the treatment of specific diseases, such as cardiac conditions, has also been demonstrated. Linkage of hospital data with other datasets provides essential temporal information about errors, as well as information about unsuspected system deficiencies. It has played an important role in the measurement and analysis of the effects of off-hours hospital operation.

CONCLUSIONS

Measuring temporal patterns of patient safety is still inadequate with electronic health records not yet playing an important role. Patient safety interventions should not be implemented without a strategy for continuous monitoring of their effect.

Similar outcomes among general medicine patients discharged on weekends

BACKGROUND

Hospitals reduce staffing levels and services on weekends. This raises the question of whether weekend discharges may be inadequately prepared and thus at higher risk for adverse events postdischarge.

OBJECTIVE

To compare death or nonelective readmission rates 30 days after weekend versus weekday discharge.

DESIGN

Retrospective cohort.

SETTING

All teaching hospitals in Alberta, Canada.

PATIENTS

General internal medicine (GIM) discharges (only 1 per patient).

MEASUREMENTS

Analyses were adjusted for demographics, comorbidity, and length of stay based on a previously validated index.

RESULTS

Of 7991 patients (mean age, 62.1 years; 51.9% male; mean Charlson 2.56; 57.5% LACE ≥10) discharged from 7 teaching hospitals, 1146 (14.3%) were discharged on a weekend. Although they had substantially shorter lengths of stay (5.64 days, 95% confidence interval [CI]: 5.35-5.93 vs 7.86 days, 95% CI: 7.71-8.00, adjusted P value < 0.0001) and were less likely to be discharged with homecare support (10.9% vs 19.3%) or to long-term care facilities (3.1% vs 7.8%), patients discharged on weekends exhibited similar rates of death or readmission at 30 days compared to those discharged on weekdays (10.6% vs 13.2%, adjusted odds ratio [aOR]: 0.94, 95% CI: 0.77-1.16), even among the 4591 patients deemed to be at high risk for postdischarge events based on LACE (length of hospital stay, acuity of admission, comorbidity burden quantified using the Charlson Comorbidity Index, and emergency department visits in the 6 months prior to admission) score ≥10 (16.8% vs 16.5% for weekday discharges, aOR: 1.09 [95% CI: 0.85-1.41]).

CONCLUSIONS

GIM patients discharged from teaching hospitals on weekends have shorter lengths of stay and exhibit similar postdischarge outcomes as patients discharged on weekdays.