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Loughlin E, Gabr A, Galvin R, McCormack J, Brych O, O'Donnell MJ, Collins R, Thornton J, Harbison J, O'Connor M. The impact of hospital presentation time on stroke outcomes: A nationally representative Irish cohort study. PLoS One 2024; 19:e0304536. [PMID: 38995918 PMCID: PMC11244793 DOI: 10.1371/journal.pone.0304536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 05/14/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery. MATERIALS AND METHODS A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times). RESULTS Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001). CONCLUSION More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes.
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Affiliation(s)
- Elaine Loughlin
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Ahmed Gabr
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Ageing Research Centre, University of Limerick, Limerick, Ireland
| | | | - Olga Brych
- National Office of Clinical Audit, Ireland
| | | | - Rónán Collins
- Clinical Lead, National Stroke Programme, Royal College of Physicians of Ireland and Health Service Executive, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Joseph Harbison
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
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Küçükceran K, Ayrancı MK, Girişgin AS, Koçak S, Dündar ZD, Koç O. The Effect of Out-of-Hours Admission on Mortality in Patients Who Underwent Thrombectomy Due to Ischemic Stroke. J Acute Med 2024; 14:20-27. [PMID: 38487760 PMCID: PMC10933590 DOI: 10.6705/j.jacme.202403_14(1).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 03/17/2024]
Abstract
Background It is important to investigate the factors that may delay the diagnosis and treatment process of ischemic stroke. The aim of this study was to investigate whether in-hospital mortality increased in patients who presented to the emergency department out-of-hours and underwent thrombectomy. Methods A total of 59 patients who applied to the emergency department between January 1, 2018 and November 1, 2021 and underwent thrombectomy due to ischemic stroke were included in the study. Patient age, gender, thrombectomy success (successful recanalization), in-hospital mortality status, intracranial hemorrhage status after thrombectomy, and out-of-hours admission status were recorded and compared according to out-of-hours admission status. Results Twenty-seven (45.8%) patients were male, and the median age was 74 (61-81) years. Forty-two (71.2%) patients applied to the emergency department out-of-hours. In-hospital mortality occurred in 27 (45.8%) patients. There was no statistically significant difference in out-of-hours admission status between the non-survivor group and the survivor group (non-survivor: 24 [75%]; survivor: 18 [66.7%], p = 0.481). Nor was a statistically significant difference found in the intracranial hemorrhage complication rate of the patients admitted out-of-hours compared to the patients admitted during working hours (out-of-hours: 17 [40.5%]; during working hours: 6 [35.3%], p = 0.712). Conclusion No statistically significant difference was found in the rate of in-hospital mortality and intracranial bleeding complications in patients who underwent thrombectomy out of working hours compared to during working hours.
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Affiliation(s)
- Kadir Küçükceran
- Necmettin Erbakan University Emergency Department Faculty of Medicine, Konya Turkey
| | | | | | - Sedat Koçak
- Necmettin Erbakan University Emergency Department Faculty of Medicine, Konya Turkey
| | - Zerrin Defne Dündar
- Necmettin Erbakan University Emergency Department Faculty of Medicine, Konya Turkey
| | - Osman Koç
- Necmettin Erbakan University Neuroradiology Faculty of Medicine, Konya Turkey
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Omura N, Kakita H, Fukuo Y, Shimizu F. Differences in mechanical thrombectomy for acute ischemic stroke on weekdays versus nights/ weekends in a Japanese primary stroke core center. J Cerebrovasc Endovasc Neurosurg 2023; 25:297-305. [PMID: 37433465 PMCID: PMC10555624 DOI: 10.7461/jcen.2023.e2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/27/2023] [Accepted: 05/11/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE The term "weekend effect" refers to an increase in the mortality rate for hospitalizations occurring on weekends versus weekdays. In this study, we investigated whether such an effect exists in patients undergoing mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (currently the standard treatment for this condition) at a single center in Japan. METHODS We surveyed 151 patients who underwent mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (75 and 76 patients were treated during daytime and nighttime, respectively) from January 2019 to June 2021. The items evaluated in this analysis were the rate of modified Rankin Scale ≤2 or prestroke scale, mortality, and procedural treatment time. RESULTS The rates of modified Rankin Scale ≤2 or prestroke scale and mortality at 90 days after treatment did not differ significantly between daytime and nighttime (41.3% vs. 29.0%, p=0.11; 14.7% vs. 11.8%, p=0.61, respectively). The door-to-groin time tended to be shorter during daytime versus nighttime (57 [IQR: 42.5-70] min vs. 70 [IQR: 55-82]) min, p=0.0507). CONCLUSIONS This study did not reveal differences in treatment outcome between daytime and nighttime in patients undergoing mechanical thrombectomy for acute ischemic stroke with large vessel occlusion. Therefore, the "weekend effect" was not observed in our institution.
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Affiliation(s)
- Naoki Omura
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Hiroto Kakita
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Yusuke Fukuo
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Fuminori Shimizu
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
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Huang D, Lu Y, Sun Y, Sun W, Huang Y, Tai L, Li G, Chen H, Zhang G, Zhang L, Sun X, Qiu J, Wei Y, Jin H. Effect of weekend versus weekday admission on the mortality of acute ischemic stroke patients in China: an analysis of data from the Chinese acute ischemic stroke treatment outcome registry. Front Neurol 2023; 14:1206846. [PMID: 37528854 PMCID: PMC10389271 DOI: 10.3389/fneur.2023.1206846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023] Open
Abstract
Background Due to disparities in medical resources in rural and urban areas as well as in different geographic regions in China, the effect of weekend versus weekday admission on the outcomes of acute ischemic stroke (AIS) patients is unknown. Our aim was to investigate whether the outcomes of AIS patients differ according to the day of admission in China. Methods The data were extracted from the Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR), a multicenter prospective study database of patients diagnosed with AIS. The chi-square test (χ2) and logistic regression were used to assess mortality for weekday and weekend admissions among AIS patients stratified by rural or urban status and geographic region (including the eastern, northeastern, central, and western regions). Results In total, 9,256 patients were included in this study. Of these patients, 57.2% were classified as urban, and 42.8% were classified as rural. A total of 6,760 (73%) patients were admitted on weekdays, and 2,496 (27%) were admitted on weekends. There was no significant difference in the mortality rate among patients admitted on weekends compared with those admitted on weekdays in urban (7.5% versus 7.4%) or rural areas (8.8% versus 8.1%; p > 0.05). The mortality rate was the highest among patients admitted on weekends and weekdays (11.6% versus 10.3%) in the northeastern area, without statistical significance before and after adjusting for the patients' background characteristics (p > 0.05). In addition, regression analysis revealed that the mortality of patients admitted on weekdays was more likely to be influenced by regional subgroup, hospital level and intravenous thrombolysis than that of patients admitted on weekends. Conclusion The weekend effect was not observed in the mortality of patients with AIS regardless of rural-urban status or geographic region in China.
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Affiliation(s)
- Diandian Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuxuan Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yongan Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Wei Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Liwen Tai
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guozhong Li
- Department of Neurology, First Affiliated Hospital of Harbin Medical University, Neurology, Harbin, China
| | - Huisheng Chen
- Department of Neurology, The General Hospital of Shenyang Military Command, Shenyang, China
| | - Guiru Zhang
- Department of Neurology, Penglai People’s Hospital, Penglai, China
| | - Lei Zhang
- Department of Neurology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xuwen Sun
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jinhua Qiu
- Department of Neurology, Huizhou First Hospital, Huizhou, China
| | - Yan Wei
- Department of Neurology, Harrison International Peace Hospital, Hengshui, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
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Kim SB, Lee BM, Park JW, Kwak MY, Jang WM. Weekend effect on 30-day mortality for ischemic and hemorrhagic stroke analyzed using severity index and staffing level. PLoS One 2023; 18:e0283491. [PMID: 37347776 PMCID: PMC10287008 DOI: 10.1371/journal.pone.0283491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/11/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Previous studies on the weekend effect-a phenomenon where stroke outcomes differ depending on whether the stroke occurred on a weekend-mostly targeted ischemic stroke and showed inconsistent results. Thus, we investigated the weekend effect on 30-day mortality in patients with ischemic or hemorrhagic stroke considering the confounding effect of stroke severity and staffing level. METHODS We retrospectively analyzed data of patients hospitalized for ischemic or hemorrhagic stroke between January 1, 2015, and December 31, 2018, which were extracted from the claims database of the National Health Insurance System and the Medical Resource Report by the Health Insurance Review & Assessment Service. The primary outcome measure was 30-day all-cause mortality. RESULTS In total, 278,632 patients were included, among whom 84,240 and 194,392 had a hemorrhagic and ischemic stroke, respectively, with 25.8% and 25.1% of patients, respectively, being hospitalized during the weekend. Patients admitted on weekends had significantly higher 30-day mortality rates (hemorrhagic stroke 16.84%>15.55%, p<0.0001; ischemic stroke 5.06%>4.92%, p<0.0001). However, in the multi-level logistic regression analysis adjusted for case-mix, pre-hospital, and hospital level factors, the weekend effect remained consistent in patients with hemorrhagic stroke (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), while the association was no longer evident in patients with ischemic stroke (OR 1.01, 95% CI 0.96-1.06). CONCLUSIONS Weekend admission for hemorrhagic stroke was significantly associated with a higher mortality rate after adjusting for confounding factors. Further studies are required to understand factors contributing to mortality during weekend admission.
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Affiliation(s)
- Seung Bin Kim
- Interdepartment of Critical Care Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Bo Mi Lee
- HIRA Research Institute, Health Insurance Review & Assessment Service, Wonju, Republic of Korea
| | - Joo Won Park
- Center for Public Healthcare, National Medical Center, Seoul, Republic of Korea
| | - Mi Young Kwak
- Center for Public Healthcare, National Medical Center, Seoul, Republic of Korea
| | - Won Mo Jang
- Department of Public Health and Community Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea
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Off-Hour Admission Is Associated with Poor Outcome in Patients with Intracerebral Hemorrhage. J Clin Med 2022; 12:jcm12010066. [PMID: 36614867 PMCID: PMC9821144 DOI: 10.3390/jcm12010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
The mortality of stroke increases on weekends and during off-hour periods. We investigated the effect of off-hour admission on the outcomes of intracerebral hemorrhage (ICH) patients. We retrospectively analyzed a prospective cohort of ICH patients, admitted between January 2017 and December 2019 at the First Affiliated Hospital of Chongqing Medical University. Acute ICH within 72 h after onset with a baseline computed tomography and 3-month follow-up were included in our study. Multivariable logistic regression analysis was performed for calculating the odds ratios (OR) and 95% confidence interval (CI) for the outcome measurements. Of the 656 participants, 318 (48.5%) were admitted during on-hours, whereas 338 (51.5%) were admitted during off-hours. Patients with a poor outcome had a larger median baseline hematoma volume, of 27 mL (interquartile range 11.1-53.2 mL), and a lower median time from onset to imaging, of 2.8 h (interquartile range 1.4-9.6 h). Off-hour admission was significantly associated with a poor functional outcome at 3 months, after adjusting for cofounders (adjusted OR 2.17, 95% CI 1.35-3.47; p = 0.001). We found that patients admitted during off-hours had a higher risk of poor functional outcomes at 3 months than those admitted during working hours.
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Quaresima S, Mennini G, Manzia TM, Avolio AW, Angelico R, Spoletini G, Lai Q. The liver transplant surgeon Mondays blues: an Italian perspective. Updates Surg 2022; 75:531-539. [PMID: 35948742 PMCID: PMC10042950 DOI: 10.1007/s13304-022-01348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/30/2022] [Indexed: 11/29/2022]
Abstract
Poor data exist on the influence of holidays and weekdays on the number and the results of liver transplantation (LT) in Italy. The study's main objective is to investigate the impact of holidays and the different days of the week on the LT number and early graft survival rates in a multi-centric Italian series. We performed a retrospective analysis on 1,026 adult patients undergoing first deceased-donor transplantation between January 2004 and December 2018 in the three university centers in Rome. During the 4,504 workdays, 881 LTs were performed (85.9%; one every 5.1 days on average). On the opposite, 145 LTs were done during the 975 holidays (14.1%; one every 7.1 days on average). Fewer LTs were performed on holidays (P = 0.004). There were no substantial differences in donor-, recipient- and transplant-related characteristics in LTs performed on weekdays or holidays. On Monday, fewer transplants were performed (vs. other weekdays: P < 0.0001; vs. Sunday: P = 0.03). At multivariable Cox regression analysis, LTs performed during the holiday or during the different days of the week were not found to be independent risk factors for the risk of 3- and 12-month graft loss. At three-month survival curves, no differences were observed among the transplants performed during the holidays versus the workdays (86.2 vs. 85.0%; P-0.70). The range of graft survival rates based on the day of the week was 81.6-86.9%, without showing any significant differences (P = 0.57). Fewer transplants are performed on holidays and Mondays. Survivals are not affected by holidays or the day the transplant is performed.
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Affiliation(s)
- Silvia Quaresima
- General Surgery and Organ Transplantation Unit, Department of General Surgery and Surgical Specialties, Sapienza University of Rome, AOU Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of General Surgery and Surgical Specialties, Sapienza University of Rome, AOU Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Tommaso M Manzia
- Department of Surgery Science, University of Rome Tor Vergata, U.O.C. Chirurgia Epatobiliare e Trapianti, Fondazione PTV, Rome, Italy
| | - Alfonso W Avolio
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberta Angelico
- Department of Surgery Science, University of Rome Tor Vergata, U.O.C. Chirurgia Epatobiliare e Trapianti, Fondazione PTV, Rome, Italy
| | - Gabriele Spoletini
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of General Surgery and Surgical Specialties, Sapienza University of Rome, AOU Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy.
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Liu CY, Kung PT, Chang HY, Hsu YH, Tsai WC. Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312362. [PMID: 34886086 PMCID: PMC8656472 DOI: 10.3390/ijerph182312362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
(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.
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Affiliation(s)
- Chun-Yi Liu
- Department of Health Services Administration, China Medical University, Taichung 406040, Taiwan; (C.-Y.L.); (H.-Y.C.)
- Department of Education, China Medical University Hospital, Taichung 404332, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan;
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 404332, Taiwan
| | - Hui-Yun Chang
- Department of Health Services Administration, China Medical University, Taichung 406040, Taiwan; (C.-Y.L.); (H.-Y.C.)
| | - Yueh-Han Hsu
- Division of Nephrology, Department of Internal Medicine, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi 600566, Taiwan;
- Department of Medical Research, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi 600566, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan 736302, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taichung 406040, Taiwan; (C.-Y.L.); (H.-Y.C.)
- Correspondence: ; Tel.: +886-4-22994045; Fax: +886-4-22993643
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Effect of off-hour versus work-hour thrombolysis for acute ischemic stroke on emergency department patients' outcome: a retrospective study. Eur J Emerg Med 2021; 28:104-110. [PMID: 33136733 DOI: 10.1097/mej.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Early management of patients with acute ischemic stroke is crucial regardless of the time of presentation. The aim of the study was to evaluate the effect of off-hours management of patients with ischemic stroke that underwent thrombolytic therapy in the emergency department. METHODS This is a single-center retrospective study included ischemic stroke patients who received thrombolysis in the emergency department from January 2009 to April 2017. Patients who presented between 08:00 and 17:00 Monday to Friday were in the 'work-hour group (group 1)' versus others who were considered 'off-hours (group 2)'. Primary endpoint was 3-month mortality. Secondary endpoints included the National Institutes of Health Stroke Scale and dramatic recovery rate at 24 h, intracranial hemorrhage, systemic hemorrhage and modified Rankin Scale at the 3 months. Symptom-to-needle time, door-to-computed tomography time, and door-to-needle time were also compared between groups. RESULTS A total of 399 ischemic stroke patients were included in the analysis, 137 (34%) during work-hours and 262 (66%) during off-hours. The mortality rate was not different at 3 months between groups: 24 (17.5%) in the work-hours group versus 38 (14.5%) in the off-hours group [odds ratio 1.25; 95% confidence interval (CI), 0. 72-2.19]. There were no differences between groups on secondary endpoints. The mean time of symptom-to-needle was significantly higher during off-hours (mean difference: 18.4 min; 95% CI, 7.81-29.0). CONCLUSIONS In this study, there were no significant differences in mortality and functional outcomes at 3 months between patients who underwent off-hour or work-hour thrombolysis in the emergency department.
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Potts MB, Abdalla RN, Golnari P, Sukumaran M, Palmer AH, Hurley MC, Shaibani A, Jahromi BS, Ansari SA. Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers. J Stroke Cerebrovasc Dis 2021; 30:105632. [PMID: 33517033 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105632] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ramez N Abdalla
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Madhav Sukumaran
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Aaron H Palmer
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Michael C Hurley
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ali Shaibani
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States; Department of Neurology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
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11
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Risk of Short-Term Mortality after Intracerebral Haemorrhage due to Weekend Hospital Admission in Poland. Emerg Med Int 2020; 2020:2198384. [PMID: 33376607 PMCID: PMC7744225 DOI: 10.1155/2020/2198384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/31/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022] Open
Abstract
Background The mortality rate for spontaneous intracerebral haemorrhage (ICH) has remained high and stable for many years. The unfavourable prognostic factors include age, bleeding volume, location of the haematoma, high blood pressure, and disturbed consciousness on admission. Other risk factors associated with medical care also deserve attention. The study aimed to analyse the relationship between day of admission, concerning other prognostic factors, and short-term mortality in ICH, in a Polish specialist stroke unit. Methods Medical records of 156 patients (74 males, 82 females, mean age 68.7 years) diagnosed with spontaneous ICH and admitted to a specialist stroke center were retrospectively analysed. Demographics, location, volume of bleeding, blood pressure values, and the Glasgow Coma Scale (GCS), as well as the day of admission, were determined. The relationships were analysed between these factors and 30-day mortality in the patients with ICH. Results A total of 83 patients were admitted to the hospital during weekdays (Monday 8 am to Friday 3 pm) and 73 during weekends or holidays. Of these, 65 patients died within 30 days. Patients admitted at weekends initially presented with lower GCS scores. Admission on Saturday was associated with an increased risk of death (OR 3.38, 95% CI 1.2–9.48, p < 0.05), but after correction for clinical state measured with the GCS and ICH score, the association was no longer significant. Conclusions The time and mode of admission were not associated with increased risk of short-term mortality in ICH patients. Prehospital care issues should be additionally considered as prognostic factors of the outcome.
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12
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Simister R, Black GB, Melnychuk M, Ramsay AIG, Baim-Lance A, Cohen DL, Eng J, Xanthopoulou PD, Brown MM, Rudd AG, Morris S, Fulop NJ. Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units.
Objectives
To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations.
Design
This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data.
Setting
The setting was acute stroke services in London hyperacute stroke units.
Participants
A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours).
Intervention
Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.
Main outcome measures
Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay.
Data sources
Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period.
Results
We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions.
Limitations
We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled.
Conclusions
Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence.
Future work
Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Georgia B Black
- Department of Applied Health Research, University College London, London, UK
| | - Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Abigail Baim-Lance
- Center for Innovation in Mental Health, City University of New York, New York, NY, USA
| | - David L Cohen
- Stroke Service, Haldane and Herrick Wards, Northwick Park Hospital, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Martin M Brown
- Queen Square Institute of Neurology, University College London, London, UK
| | - Anthony G Rudd
- King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steve Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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13
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Arling G, Sico JJ, Reeves MJ, Myers L, Baye F, Bravata DM. Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration. BMJ Open Qual 2019; 8:e000641. [PMID: 31909209 PMCID: PMC6937041 DOI: 10.1136/bmjoq-2019-000641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 10/22/2019] [Accepted: 11/23/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Timely preventive care can substantially reduce risk of recurrent vascular events or death after a transient ischaemic attack (TIA). Our objective was to understand patient and facility factors influencing preventive care quality for patients with TIA in the US Veterans Health Administration (VHA). Methods We analysed administrative data from a retrospective cohort of 3052 patients with TIA cared for in the emergency department (ED) or inpatient setting in 110 VHA facilities from October 2010 to September 2011. A composite quality indicator (QI score) pass rate was constructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potency statin and antithrombotic medication, associated with the ED visit or inpatient admission after the TIA. We tested a multilevel structural equation model where facility and patient characteristics, inpatient admission, and neurological consultation were predictors of the resident’s composite QI score. Results Presenting with a speech deficit and higher Charlson Comorbidity Index (CCI) were positively related to inpatient admission. Being admitted increased the likelihood of neurology consultation, whereas history of dementia, weekend arrival and a higher CCI score made neurological consultation less likely. Speech deficit, higher CCI, inpatient admission and neurological consultation had direct positive effects on the composite quality score. Patients in facilities with fewer full-time equivalent neurology staff were less likely to be admitted or to have a neurology consultation. Facilities having greater organisational complexity and with a VHA stroke centre designation were more likely to provide a neurology consultation. Conclusions Better TIA preventive care could be achieved through increased inpatient admissions, or through enhanced neurology and other care resources in the ED and during follow-up care.
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Affiliation(s)
- Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA.,Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Jason J Sico
- Department of Internal Medicine and Neurology, Yale School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center, VA Connecticut Health System West Haven Campus, West Haven, Connecticut, USA
| | - Mathew J Reeves
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Epidemiology, Michigan State University, East Lansing, Michigan, USA
| | - Laura Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
| | - Fitsum Baye
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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14
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Invasiveness and Clinical Outcomes of Off-Hour Admissions in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 29:104505. [PMID: 31786043 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Whether time of hospital admission-during or outside regular working hours-affects functional outcome in intracerebral hemorrhage (ICH) is unestablished as previous analyses have focused on mortality only. We here investigate whether on- versus off-hour hospital admission in ICH is associated with levels of invasiveness and clinical outcomes. METHODS Based on the UKER registry (NCT03183167) we grouped ICH-patients according to on- versus off-hour hospital admission. Primary outcome measures was functional outcome after 3 months using the modified Rankin scale (mRS) dichotomized into favorable (mRS = 0-3) and unfavorable (mRS = 4-6). Multivariate regression analyses were used to adjust for baseline imbalances, and subgroup analyses were performed to explore associations of on- versus off-hour admission with invasiveness of therapeutic interventions. RESULTS A total of 438/1269 (34.5%) of ICH-patients were admitted during regular working hours. Mortality rates were not significantly different among patients with on- versus off-hour admission. On-hour patients showed a significantly larger proportion of patients with favorable outcome (on-hour: mRS = 0-3 after 3 months: 176/416 (42.3%) versus off-hour: 265/784 (33.8%); P = .004). Analysis of invasive therapeutic interventions revealed that likelihood of favorable outcome was significantly increased among on-hour admitted patients who did not require neurosurgical interventions (no external ventricular drain n = 349, OR: 1.67[1.13-2.48], P < .05; no hematoma evacuation surgery n = 423, OR: 1.51[1.07-2.14], P < .05). CONCLUSION This study verified an "off-hour effect" in ICH that relates to functional outcome, rather than mortality, and which may be linked to different levels of invasive therapeutic interventions in patients admitted during off-hour.
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15
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Melnychuk M, Morris S, Black G, Ramsay AIG, Eng J, Rudd A, Baim-Lance A, Brown MM, Fulop NJ, Simister R. Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services. BMJ Open 2019; 9:e025366. [PMID: 31699710 PMCID: PMC6858222 DOI: 10.1136/bmjopen-2018-025366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England. DESIGN Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. SETTING Acute stroke services in London hyperacute stroke units and the rest of England. PARTICIPANTS 68 239 patients with a primary diagnosis of stroke admitted between January and December 2014. INTERVENTIONS Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. MAIN OUTCOME MEASURES 16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay. RESULTS There was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05). CONCLUSIONS The London hyperacute stroke unit model achieved performance standards for 'front door' stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.
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Affiliation(s)
- Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
- Faculty of Law and Social Sciences, Universidad Rey Juan Carlos, Madrid, Spain
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Georgia Black
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London
| | - Anthony Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
| | - Abigail Baim-Lance
- Institute for Implementation Science in Population Health, City University of New York, New York, USA
| | - Martin M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Robert Simister
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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16
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Black GB, Ramsay AIG, Baim-Lance A, Eng J, Melnychuk M, Xanthopoulou P, Brown MM, Morris S, Rudd AG, Simister R, Fulop NJ. What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units. BMJ Open 2019; 9:e025367. [PMID: 31699711 PMCID: PMC6858131 DOI: 10.1136/bmjopen-2018-025367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). DESIGN Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al). SETTING Eight HASUs in London. PARTICIPANTS We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week. RESULTS Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays. CONCLUSIONS Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.
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Affiliation(s)
- Georgia B Black
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | | | | | - Mariya Melnychuk
- Department of Applied Health Research, Imperial College London, London, UK
| | | | - Martin M Brown
- Department of Neurology, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Anthony G Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
| | - Robert Simister
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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17
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Tavakoli S, Lacci J, Wong T, Godoy DA, Murugesan N, Seifi A. Did the introduction of comprehensive stroke centers impact the “weekend effect” on mortality for patients with intracranial hemorrhage in the United States? Clin Neurol Neurosurg 2019; 185:105463. [DOI: 10.1016/j.clineuro.2019.105463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/09/2019] [Accepted: 08/06/2019] [Indexed: 11/25/2022]
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18
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Neuro-Advancements and the Role of Nurses as Stated in Academic Literature and Canadian Newspapers. SOCIETIES 2019. [DOI: 10.3390/soc9030061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurosciences and neurotechnologies (from now on called neuro-advancements) constantly evolve and influence all facets of society. Neuroethics and neuro-governance discourses focus on the impact of neuro-advancements on individuals and society, and stakeholder involvement is identified as an important aspect of being able to deal with such an impact. Nurses engage with neuro-advancements within their occupation, including neuro-linked assistive technologies, such as brain-computer interfaces, cochlear implants, and virtual reality. The role of nurses is multifaceted and includes being providers of clinical and other health services, educators, advocates for their field and their clients, including disabled people, researchers, and influencers of policy discourses. Nurses have a stake in how neuro-advancements are governed, therefore, being influencers of neuroethics and neuro-governance discourses should be one of these roles. Lifelong learning and professional development could be one mechanism to increase the knowledge of nurses about ethical, social, and legal issues linked to neuro-advancements, which in turn, would allow nurses to provide meaningful input towards neuro-advancement discussions. Disabled people are often the recipients of neuro-advancements and are clients of nurses, therefore, they have a stake in the way nurses interact with neuro-advancements and influence the sociotechnical context of neuro-advancements, which include neuro-linked assistive devices. We performed a scoping review to investigate the role of narrative around nurses in relation to neuro-advancements within academic literature and newspapers. We found minimal engagement with the role of nurses outside of clinical services. No article raised the issue of nurses having to be involved in neuro-ethics and neuro-governance discussions or how lifelong learning could be used to gain that competency. Few articles used the term assistive technology or assistive device and no article covered the engagement of nurses with disabled people within a socio-technical context. We submit that the role narrative falls short of what is expected from nurses and shows shortcomings at the intersection of nurses, socio-technical approaches to neuro-assistive technologies and other neuro-advancements and people with disabilities. Neuro-governance and neuroethic discourses could be a useful way for nurses and disabled people to co-shape the socio-technical context of neuro-advancements, including neuro-assistive technologies. Lifelong learning initiatives should be put in place to provide the knowledge necessary for nurses to take part in the neuroethics and neuro-governance discussion.
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Angerer S, Buttinger K, Stummer H. The weekend effect revisited: evidence from the Upper Austrian stroke registry. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:729-737. [PMID: 30756194 DOI: 10.1007/s10198-019-01035-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/31/2019] [Indexed: 06/09/2023]
Abstract
Empirical evidence on the so-called 'weekend-effect' on stroke mortality is mixed with some studies reporting significantly higher mortality for weekend admissions and others finding no difference. The aim of this paper is to enhance the evidence on the weekend-effect on stroke mortality using a rich stroke registry data set from Upper Austria and to discuss underlying reasons for the heterogeneity in results. Using logistic regressions and ordinary least squares regressions with hospital and year-fixed effects, the outcomes of weekend versus weekday admissions are compared for patients admitted to 16 hospitals in Upper Austria with transient ischemic attack (TIA), cerebral infarction or hemorrhage between 2007 and 2015. The primary outcomes include in-hospital mortality, 30-day and 90-day all-cause mortality as well as the length of hospital stay. In addition, we analyze differences in process-quality indicators between weekdays and weekends. Our results show that on weekends there are on average 25% fewer admissions than on weekdays with significantly higher in-hospital mortality. Adjusting for case-mix, the association between weekend admissions and mortality becomes null suggesting that the higher mortality on weekends is explained by heterogeneities in admissions rather than health-care quality.
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Affiliation(s)
- Silvia Angerer
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria
| | - Klaus Buttinger
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria
- Salzkammergut Klinikum, Miller-von-Aichholz-Straße 49, 4810, Gmunden, Austria
| | - Harald Stummer
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
- University Seeburg Castle, Institut für Gesundheitsmanagement und Innovation, Seeburgstraße 8, 5201, Seekirchen am Wallersee, Austria.
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20
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Khaksari BJ, Kulick ER, Elkind MSV, Boehme AK. "Weekend Effect" on 30-Day Readmissions among Stroke Survivors: An Analysis of the National Readmission Database. Cerebrovasc Dis Extra 2019; 9:66-71. [PMID: 31234190 PMCID: PMC7036528 DOI: 10.1159/000500611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 04/20/2019] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose Previous studies suggested that quality of care may be lower on weekends than during the week. We hypothesized that, among patients hospitalized for an index ischemic stroke, those admitted on weekends would have a higher risk of 30-day readmission than those admitted on weekdays. Methods We utilized the 2013 Nationwide Readmission Database, which includes data on US inpatient admissions from the Agency for Healthcare Research and Quality Healthcare Utilization Project. The database includes a nationally representative weighted probability sample of inpatient hospitalizations regardless of insurance status. Patients with primary acute ischemic stroke were identified using previously validated ICD-9-CM diagnosis codes. We conducted a weighted analysis using survey design logistic regression models to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for the association between weekend admission and 30-day readmission in ischemic stroke patients. Results Among 319,317 patients admitted for ischemic stroke, 12.1% were readmitted within 30 days. Those with 30-day readmissions had an average of 8 chronic conditions, and all cardiovascular-related comorbidities increased the risk of 30-day readmissions. Ischemic stroke patients admitted on weekends had odds of 30-day readmission similar to patients admitted on weekdays (OR 1.02; 95% CI 0.98–1.06). Weekend admission also did not affect readmission at 7 or 60 days. Conclusions We found no association between weekend admission and 30-day readmissions, providing indirect evidence of homogeneity in the quality of care delivered during week day and weekend admissions.
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Affiliation(s)
- Bijan J Khaksari
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Erin R Kulick
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Amelia K Boehme
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA, .,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,
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Löwhagen Hendén P, Rentzos A, Karlsson JE, Rosengren L, Oras J, Ricksten SE. Off-hour admission and impact on neurological outcome in endovascular treatment for acute ischemic stroke. Acta Anaesthesiol Scand 2019; 63:208-214. [PMID: 30117146 DOI: 10.1111/aas.13241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/10/2018] [Accepted: 07/15/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE In the new era of endovascular treatment for acute ischemic stroke, one of the main predictors of good neurological outcome is a short time interval from stroke onset to recanalization of the occluded vessel. In this study, we examined the effect of on-hour vs off-hour admittance on the time intervals from stroke onset to recanalization in patients with acute ischemic stroke (AIS) undergoing endovascular treatment (EVT). METHODS One-hundred-ninety-eight patients receiving EVT for anterior AIS between 2007 and 2016 were included. Time of day and weekday for stroke admittance were recorded as well as several time intervals. Age, sex, co-morbidities, admission National Institutes of Health Stroke Scale (NIHSS), intraprocedural blood pressure, blood glucose, modified Thrombolysis in Cerebral Ischemia score (mTICI) and neurological outcome at 3 months, measured as modified Rankin Scale (mRS), were registered. On-hour was defined as 8 am-4 pm weekdays, and off-hour as weekdays outside these hours and weekends. RESULTS The time interval from CT (computed tomography) to recanalization was longer during off-hours, while no difference was seen in the time interval from stroke onset to CT. No statistically significant difference was seen in neurological outcome between the on- and off-hour groups in a univariate analysis. CONCLUSIONS Stroke admittance during off-hours is associated with longer time interval from CT examination to vessel recanalization. The study highlights the need of logistic improvement and probably more resources off-hour in order to deliver an effective stroke care around the clock.
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Affiliation(s)
- Pia Löwhagen Hendén
- Department of Anesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - Alexandros Rentzos
- Department of Radiology; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - Jan-Erik Karlsson
- Department of Neurology; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - Lars Rosengren
- Department of Neurology; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
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Voruganti DC, Subash Shantha GP, Deshmukh A, Giudici MC. Outcomes of hospitalizations with atrial fibrillation-flutter on a weekday versus weekend: an analysis from a 2014 nationwide inpatient sample. PeerJ 2019; 7:e6211. [PMID: 30671298 PMCID: PMC6339775 DOI: 10.7717/peerj.6211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/04/2018] [Indexed: 11/20/2022] Open
Abstract
Background Patients with atrial fibrillation-flutter (AF) admitted on the weekends were initially reported to have poor outcomes. The primary purpose of this study is to re-evaluate the outcomes for weekend versus weekday AF hospitalization using the 2014 Nationwide Inpatient Sample (NIS). Methods Included hospitalizations were aged above 18 years. The hospitalizations with AF were identified using the international classification of diseases 9 (ICD-9) codes (427.31, 427.32). In-hospital mortality, length of stay (LOS), other co-morbidities, cardioversion procedures, and time to cardioversion were recorded. All analysis was performed using SAS 9.4 statistical software (Cary, North Carolina). Results A total of 453,505 hospitalizations with atrial fibrillation and flutter as primary discharge diagnosis were identified. Among the total hospitalizations with a primary diagnosis of AF, 20.3% were admitted on the weekend. Among the weekend hospitalizations, 0.19% died in hospital compared to 0.74% among those admitted during the week. After adjusting for patient characteristics, hospital characteristics and disease severity, the adjusted odds for in-hospital mortality were not significantly different for weekend vs. weekday hospitalizations (OR = 0.91, 95% CI [0.77–1.11]; p = 0.33). The weekend admissions were associated with significantly lower odds of cardioversion procedures (OR = 0.72, 95% CI [0.69–0.76], P < 0.0001), lower cost of hospitalization (USD 8265.8 on weekends vs. USD 8966.5 on the weekdays, P < 0.001), slightly lower rate of anticoagulation (17.09% on the weekends vs. 18.73% on the weekdays. P < 0.0001), and slightly increased time to cardioversion (1.94 days on the weekend vs. 1.73 days on weekdays, P < 0.0005). The mean length of hospital stay (LOS) was statistically not different in both groups: (3.49 days ± 3.70 (SD) in the weekend group vs. 3.47 days ± 3.50 (SD) in the weekday group, P = 0.42) Discussion The weekend AF hospitalizations did not have a clinically significant difference in mortality and LOS compared to those admitted on a weekday. However, the use of cardioversion procedures and cost of hospitalization was significantly lower on the weekends.
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Affiliation(s)
- Dinesh C Voruganti
- Division of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
| | | | - Abhishek Deshmukh
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Michael C Giudici
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
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Cossey TC, Jagolino A, Ankrom C, Bambhroliya AB, Cai C, Vahidy FS, Savitz SI, Wu TC. No Weekend or After-Hours Effect in Acute Ischemic Stroke Patients Treated by Telemedicine. J Stroke Cerebrovasc Dis 2018; 28:198-204. [PMID: 30392833 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/15/2018] [Accepted: 09/22/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Stroke outcomes have been shown to be worse for patients presenting overnight and on weekends (after-hours) to stroke centers compared with those presenting during business hours (on-hours). Telemedicine (TM) helps provide evaluation and safe management of stroke patients. We compared time metrics and outcomes of stroke patients who were assessed and received intravenous recombinant tissue plasminogen activator (IV-tPA) via TM during after-hours with those during on-hours. METHODS Analysis of our TM registry from September 2015 to December 2016, identified 424 stroke patients who were assessed via TM and received IV-tPA. We compared baseline characteristics, clinical variables, time metrics, and outcomes between the after-hours (5 pm-7:59 am, weekends) and on-hours (weekdays 8 am-4:59 pm) patients. RESULTS Of the 424 patients, 268 were managed via TM during after-hours, and 156 during on-hours. Baseline characteristics and clinical variables were similar between the groups. Importantly, there were no differences in all relevant time metrics including door to IV-tPA bolus time. IV-tPA complications (including all intracerebral hemorrhage (ICH), any systemic bleeding, and angioedema), discharge disposition, and 90-day modified Rankin Scale were also similar in the groups. CONCLUSIONS There was no difference in IV-tPA treatment times, acute stroke evaluation times, or mortality between the patients treated after-hours versus on-hours. Unlike in-person neurology coverage at many centers, the coverage provided by TM does not differ depending on the hour or day. Access to stroke specialists 24/7 via TM can ensure dependable and timely clinical care for acute stroke patients regardless of the time of day or day of the week.
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Affiliation(s)
- T C Cossey
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Amanda Jagolino
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Christy Ankrom
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Arvind B Bambhroliya
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Chunyan Cai
- Institute for Stroke and Cerebrovascular Disease, Houston, TX.
| | - Farhaan S Vahidy
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
| | - Tzu-Ching Wu
- Institute for Stroke and Cerebrovascular Disease, Houston, TX; University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX.
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Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study. J Neurol 2018; 266:782-789. [DOI: 10.1007/s00415-018-9079-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
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Re-evaluating the Weekend Effect on SAH: A Nationwide Analysis of the Association Between Mortality and Weekend Admission. Neurocrit Care 2018; 30:293-300. [DOI: 10.1007/s12028-018-0609-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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26
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Poznanska A, Wojtyniak B, Chwojnicki K, Lewtak K, Rubikowska B, Seroka W. Cerebrovascular diseases in Poland-inconsistent seasonal patterns of hospitalisation and mortality. Eur J Public Health 2018; 28:376-381. [PMID: 29020302 DOI: 10.1093/eurpub/ckx133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A seasonal variation in the incidence of cerebrovascular diseases still remains inconsistently evidenced. Herein, we analyse the monthly patterns of two health phenomena: hospital admissions and deaths due to these diseases. Methods We identified 69 511 cases of hospital admissions and 14 956 deaths due to cerebrovascular diseases (ICD10: I60-I69 and G45) among the inhabitants of five Polish voivodeship capitals in 2004-13. The method of time series analysis (exponential smoothing with linear trend and monthly additive seasonality) was applied to calculate the monthly specific seasonal indices. The monthly variation in an in-hospital fatality and nonhospital deaths were also analysed. Results A summer season reduction in number of cases was observed for hospital admissions and deaths. Interestingly, the winter season effect is much more complex, mainly due to the contribution of December, when a high mortality is accompanied by a substantial decrease in the hospitalisation level. This unique discrepancy was observed for all the studied cities. Moreover, this month is characterised by a notably high in-hospital fatality. However, neither the number of non-hospital deaths nor the average length of hospital stay or the kind of hospitalised diseases evidenced that cerebrovascular problems were more serious in December than in any other month. Conclusion The obtained results confirmed a seasonal variation in cerebrovascular diseases among the inhabitants of Polish cities. Habitual and administrative limitations in hospital activities observed every December do not seem indifferent from the patient health's perspective since they may lead to a low hospitalisation level and a high in-hospital fatality.
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Affiliation(s)
- Anna Poznanska
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Bogdan Wojtyniak
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Kamil Chwojnicki
- Department of Neurology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Lewtak
- Department of Health Promotion and Postgraduate Education, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Barbara Rubikowska
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Wojciech Seroka
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
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Moreira HE, Verga F, Barbato M, Burghi G. Prognostic impact of the time of admission and discharge from the intensive care unit. Rev Bras Ter Intensiva 2018; 29:63-69. [PMID: 28444074 PMCID: PMC5385987 DOI: 10.5935/0103-507x.20170010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/01/2016] [Indexed: 11/20/2022] Open
Abstract
Objective To determine the impact of the day and time of admission and discharge from
the intensive care unit on mortality. Methods Prospective observational study that included patients admitted to the
intensive care unit of the Hospital Maciel in Montevideo
between April and November 2014. Results We analyzed 325 patients with an average age of 55 (36 - 71) years and a SAPS
II value of 43 (29 - 58) points. No differences were found in the mortality
of patients in the intensive care unit when time of admission (35% on the
weekend versus 31% on weekdays, p = ns) or the hour of entry (35% at night
versus 31% in the daytime, p = ns) were compared. The time of discharge was
associated with higher hospital mortality rates (57% for weekend discharges
versus 14% for weekday discharges, p = 0.000). The factors independently
associated with hospital mortality after discharge from the intensive care
unit were age > 50 years (OR 2.4, 95%CI, 1.1 - 5.4) and weekend discharge
(OR 7.7, 95%CI, 3.8-15.6). Conclusion This study identified the time of discharge from the intensive care unit as a
factor that was independently associated with hospital mortality.
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Affiliation(s)
| | - Federico Verga
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Gastón Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
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Han L, Meacock R, Anselmi L, Kristensen SR, Sutton M, Doran T, Clough S, Power M. Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services.
Objectives
We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels.
Methods
We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods.
Results
We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends.
Limitations
Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative.
Conclusions
In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective.
Future work
Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lu Han
- Department of Health Sciences, University of York, York, UK
| | - Rachel Meacock
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Laura Anselmi
- Centre for Health Economics, University of Manchester, Manchester, UK
| | | | - Matt Sutton
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Stuart Clough
- Haelo, Salford Royal NHS Foundation Trust, Salford, UK
| | - Maxine Power
- Haelo, Salford Royal NHS Foundation Trust, Salford, UK
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Balinskaite V, Bottle A, Shaw LJ, Majeed A, Aylin P. Reorganisation of stroke care and impact on mortality in patients admitted during weekends: a national descriptive study based on administrative data. BMJ Qual Saf 2017; 27:611-618. [DOI: 10.1136/bmjqs-2017-006681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 10/06/2017] [Accepted: 10/15/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveTo evaluate mortality differences between weekend and weekday emergency stroke admissions in England over time, and in particular, whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.Design, setting and participantsRisk-adjusted difference-in-difference time trend analysis using hospital administrative data. All emergency patients with stroke admitted to English hospitals from 1 January 2008 to 31 December 2014 were included.Main outcomesMortality difference between weekend and weekday emergency stroke admissions.ResultsWe identified 507 169 emergency stroke admissions: 26% of these occurred during the weekend. The 7-day in-hospital mortality difference between weekend and weekday admissions declined across England throughout the study period. In Greater London, where the reorganisation of stroke services took place, an adjusted 28% (relative risk (RR)=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant. In the rest of England, an 11% (RR=1.11, 95% CI 1.07 to 1.15) higher weekend/weekday 30-day mortality ratio declined to a non-significant 4% higher risk (RR=1.04, 95% CI 0.99 to 1.09) in 2014. We found no statistically significant association between decreases in the weekend/weekday admissions difference in mortality and the centralisation of stroke services in Greater London.ConclusionsThere was a steady reduction in weekend/weekday differences in mortality in stroke admissions across England. It appears statistically unrelated to the centralisation of stroke services in Greater London, and is consistent with an overall national focus on improving stroke services.
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Han L, Sutton M, Clough S, Warner R, Doran T. Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. BMJ Qual Saf 2017; 27:445-454. [PMID: 28971886 PMCID: PMC5965349 DOI: 10.1136/bmjqs-2017-006784] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/27/2017] [Accepted: 08/17/2017] [Indexed: 11/09/2022]
Abstract
Background Emergency hospital admission on weekends is associated with an increased risk of mortality. Previous studies have been limited to examining single years and assessing day—not time—of admission. We used an enhanced longitudinal data set to estimate the ‘weekend effect’ over time and the effect of night-time admission on all-cause mortality rates. Methods We examined 246 350 emergency spells from a large teaching hospital in England between April 2004 and March 2014. Outcomes included 7-day, 30-day and in-hospital mortality rates. We conducted probit regressions to estimate the impact on the absolute difference in the risk of mortality of two key predictors: (1) admission on weekends (19:00 Friday to 06:59 Monday); and (2) night-time admission (19:00 to 06:59). Logistic regressions were used to estimate ORs for relative mortality risk differences. Results Crude 30-day mortality rate decreased from 6.6% in 2004/2005 to 5.2% in 2013/2014. Adjusted mortality risk was elevated for all out-of-hours periods. The highest risk was associated with admission on weekend night-times: 30-day mortality increased by 0.6 percentage points (adjusted OR: 1.17, 95% CI 1.10 to 1.25), 7-day mortality by 0.5 percentage points (adjusted OR: 1.23, 95% CI 1.12 to 1.34) and in-hospital mortality by 0.5 percentage points (adjusted OR: 1.14, 95% CI 1.08 to 1.21) compared with admission on weekday daytimes. Weekend night-time admission was associated with increased mortality risk in 9 out of 10 years, but this was only statistically significant (p<0.05) in 5 out of 10 years. Conclusions There is an increased risk of mortality for patients admitted as emergencies both on weekends and during the night-time. These effects are additive, so that the greatest risk of mortality occurs in patients admitted during the night on weekends. This increased risk appears to be consistent over time, but the effects are small and are not statistically significant in individual hospitals in every year.
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Affiliation(s)
- Lu Han
- Department of Health Sciences, University of York, York, UK
| | - Matt Sutton
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | | | | | - Tim Doran
- Department of Health Sciences, University of York, York, UK
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Leslie-Mazwi T, Chen M, Yi J, Starke RM, Hussain MS, Meyers PM, McTaggart RA, Pride GL, Ansari AS, Abruzzo T, Albani B, Arthur AS, Baxter BW, Bulsara KR, Delgado Almandoz JE, Gandhi CD, Heck D, Hetts SW, Klucznik RP, Jayaraman MV, Lee SK, Mack WJ, Mocco J, Prestigiacomo C, Patsalides A, Rasmussen P, Sunenshine P, Frei D, Fraser JF. Post-thrombectomy management of the ELVO patient: Guidelines from the Society of NeuroInterventional Surgery. J Neurointerv Surg 2017; 9:1258-1266. [PMID: 28963364 DOI: 10.1136/neurintsurg-2017-013270] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/22/2017] [Accepted: 08/06/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Thabele Leslie-Mazwi
- Neurointerventional Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Chen
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Julia Yi
- University Illinois at Chicago, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami, Miami, Florida, USA
| | | | | | - Ryan A McTaggart
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - G Lee Pride
- Department of Neuroradiology, University of Texas Southwestern, Dallas, Texas, USA
| | - A Sameer Ansari
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Todd Abruzzo
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Barbara Albani
- Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
| | | | - Blaise W Baxter
- Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
| | - Ketan R Bulsara
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josser E Delgado Almandoz
- Department of Neurointerventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Don Heck
- Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
| | - Steven W Hetts
- Department of Radiology, University of California in San Francisco, San Francisco, California, USA
| | - Richard P Klucznik
- Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Mahesh V Jayaraman
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Seon-Kyu Lee
- The University of Chicago, Chicago, Illinois, USA
| | - William J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - J Mocco
- Mount Sinai School of Medicine, Mount Sinai Health System, New York, New York, USA
| | | | - Athos Patsalides
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
| | - Peter Rasmussen
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Donald Frei
- Swedish Medical Center, Denver, Colorado, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
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Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective. BMC Health Serv Res 2017; 17:118. [PMID: 28166772 PMCID: PMC5294915 DOI: 10.1186/s12913-017-2035-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 01/19/2017] [Indexed: 12/30/2022] Open
Abstract
Background Health services that operate 7 days per week are under pressure to show the increased cost of providing weekend services can be measured in improved patient outcomes. The evidence for weekend allied health services in acute medical and surgical wards is weak and there is wide variation between the services offered at different hospitals. Methods This qualitative study was undertaken during a multi-site stepped wedge randomised controlled trial involving twelve acute medical and surgical wards from two Australian hospitals, in which weekend allied health services were removed before being reinstated with a stakeholder driven model. In-depth interviews were conducted with twenty-two staff responsible for managing weekend services at the involved hospitals. Participants were asked about their perceptions of the advantages and disadvantages of providing a weekend allied health service. Results Managers perceive the services improve patient flow and quality of care and reduce adverse incidents, such as falls and intensive care admissions. They also highlighted the challenges involved in planning, staffing and managing these services and the uncertainties about how to provide it most effectively. Conclusions Rising healthcare costs provide opportunity for public and professional debate about the most effective way of providing weekend allied health care services, particularly when health services provide limited other weekend services. Some managers perceived weekend allied health services to improve patient quality of care, but without studies which show these services on acute medical and surgical wards clearly change patient outcomes or provide health economic gains, these resources may need to be redirected. The resources may be better spent in areas with clear evidence to show the addition of weekend allied health services improves patient outcomes, such as on acute assess units and rehabilitation wards.
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Bar M, Kral J, Jonszta T, Marcian V, Kuliha M, Mikulik R. Interrater variability for CT angiography evaluation between neurologists and neuroradiologist in acute stroke patients. Br J Radiol 2017; 90:20160670. [PMID: 28118025 PMCID: PMC5601522 DOI: 10.1259/bjr.20160670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: The diagnosis of arterial occlusion has a considerable impact on the indication of mechanical thrombectomy, and CT angiography (CTA) is recommended in the management of acute stroke. The goal of the present study is to assess the interrater agreement in the diagnosis of occlusion of intracranial arteries on CTA between a neuroradiologist and neurologists. Methods: CTA images of 75 acute stroke patients were evaluated for occlusion of intracranial arteries by an experienced interventional neuroradiologist, and stroke and general neurologists. Results: 75 patients who were treated by intravenous thrombolysis were enrolled in the study. CTA images were available for all 75 patients (34 females; mean age ± SD, 72 ± 14 years; National Institutes of Health Stroke Scale 10; median 8–14; and Alberta Stroke Program Early CT mean 9.7). The agreement between the neuroradiologist and neurologists in evaluation of intracranial artery occlusion was as follows: occlusion of the middle cerebral artery segment M1: observer agreement 77%, kappa (κ) = 0.61 and middle cerebral artery M2: observer agreement 77%, κ 0.48; internal carotid artery: observer agreement 92%, κ 0.84; T occlusion: observer agreement 90.0%, κ 0.33; posterior cerebral artery segments P1 and P2: observer agreement 98%, κ 0.97; basilar artery: observer agreement 96%, κ 0.92; and vertebral artery segment V4: observer agreement 88%, κ 0.48. Conclusion: Interrater agreement of CTA evaluation of occlusion between the neurologists and the neuroradiologist was very strong. The ability of the trained neurologists to read an intracranial large vessel occlusion correctly may improve the door-to-needle times in acute stroke. Advances in knowledge: In this study, the neurologists were able to recognize occlusion of intracranial arteries. This could accelerate the management of acute stroke care.
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Affiliation(s)
- Michal Bar
- 1 Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic.,2 Department of Neurology and Psychiatry, Faculty of Medicine, University Ostrava, Czech Republic
| | - Jiri Kral
- 1 Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic.,3 Department of Neurology, St Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Tomas Jonszta
- 4 Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Vaclav Marcian
- 1 Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic.,2 Department of Neurology and Psychiatry, Faculty of Medicine, University Ostrava, Czech Republic
| | - Martin Kuliha
- 1 Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic
| | - Robert Mikulik
- 3 Department of Neurology, St Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic.,5 International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
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Adil MM, Vidal G, Beslow LA. Weekend Effect in Children With Stroke in the Nationwide Inpatient Sample. Stroke 2016; 47:1436-43. [DOI: 10.1161/strokeaha.116.013453] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/18/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Malik M. Adil
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Gabriel Vidal
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Lauren A. Beslow
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
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Romero Sevilla R, Portilla Cuenca J, López Espuela F, Redondo Peñas I, Bragado Trigo I, Yerga Lorenzana B, Calle Escobar M, Gómez Gutiérrez M, Casado Naranjo I. A stroke care management system prevents outcome differences related to time of stroke unit admission. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2015.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Turner M, Barber M, Dodds H, Dennis M, Langhorne P, Macleod MJ. Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes. J Neurol Neurosurg Psychiatry 2016; 87:138-43. [PMID: 26285585 PMCID: PMC4752676 DOI: 10.1136/jnnp-2015-311273] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/22/2015] [Indexed: 12/04/2022]
Abstract
BACKGROUND The presence of a 'weekend' effect has been shown across a range of medical conditions, but has not been consistently observed for patients with stroke. AIMS We investigated the impact of admission time on a range of process and outcome measures after stroke. METHODS Using routine data from National Scottish data sets (2005-2013), time of admission was categorised into weekday, weeknight and weekend/public holidays. The main process measures were swallow screen on day of admission (day 0), brain scan (day 0 or 1), aspirin (day 0 or 1), admission to stroke unit (day 0 or 1), and thrombolysis administration. After case-mix adjustment, multivariable logistic regression was used to estimate the OR for mortality and discharge to home/usual place of residence. RESULTS There were 52,276 index stroke events. Compared to weekday, the adjusted OR (95%CI) for early stroke unit admission was 0.81 (0.77 to 0.85) for weeknight admissions and 0.64 (0.61 to 0.67) for weekend/holiday admissions; early brain scan 1.30 (0.87 to 1.94) and 1.43 (0.95 to 2.18); same day swallow screen 0.86 (0.81 to 0.91) and 0.85 (0.81 to 0.90); thrombolysis 0.85 (0.75 to 0.97) and 0.85 (0.75 to 0.97), respectively. Seven-day mortality, 30-day mortality and 30-day discharge for weekend admission compared to weekday was 1.17 (1.05 to 1.30); 1.08 (1.00 to 1.17); and 0.90 (0.85 to 0.95), respectively. CONCLUSIONS Patients with stroke admitted out of hours and at weekends or public holidays are less likely to be managed according to current guidelines. They experience poorer short-term outcomes than those admitted during normal working hours, after correcting for known independent predictors of outcome and early mortality.
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Affiliation(s)
- Melanie Turner
- Division of Applied Medicine, Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, UK
| | - Mark Barber
- Stroke Unit, Monklands General Hospital, Airdrie, UK
| | - Hazel Dodds
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Martin Dennis
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, University of Glasgow, Royal Infirmary, Glasgow, UK
| | - Mary-Joan Macleod
- Division of Applied Medicine, Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, UK
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Weeda ER, Hodgdon N, Do T, Unachukwu K, Cui A, Lundbye JB, Coleman CI. Association between weekend admission for atrial fibrillation or flutter and in-hospital mortality, procedure utilization, length-of-stay and treatment costs. Int J Cardiol 2015; 202:427-9. [PMID: 26433165 DOI: 10.1016/j.ijcard.2015.09.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Erin R Weeda
- University of Connecticut School of Pharmacy, Storrs, CT, USA; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT, USA
| | - Nicole Hodgdon
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Tina Do
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | | | - Allison Cui
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | | | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, USA; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT, USA.
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Wang G, Liu G, Zhang R, Ji R, Gao B, Wang Y, Pan Y, Li Z, Wang Y. Evaluation of Off-Hour Emergency Care in Acute Ischemic Stroke: Results from the China National Stroke Registry. PLoS One 2015; 10:e0138046. [PMID: 26379280 PMCID: PMC4574931 DOI: 10.1371/journal.pone.0138046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/24/2015] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose The quality of after-hour emergency care of patients with acute ischemic stroke is debatable. We therefore, sought to analyze the performance measures, quality of care and clinical outcomes in these patients admitted during off-hours. Methods Our study included 4493 patients from a selected cohort of patients admitted to the hospitals with ischemic stroke in the China National Stroke Registry (CNSR) from September 2007 to August 2008. On-hour presentation was defined as arrival at the emergency department from the scene between 8AM and 5PM from Monday through Friday. Off-hours included the remainder of the on-hours and statutory holidays. The association between off-hour presentation and outcome was analyzed using multivariate logistic-regression models. Results Off-hour presentation was identified in 2672 (59.5%) patients with ischemic stroke. Comparison of patients admitted during off-hours with those admitted during on-hours revealed an unadjusted odds ratio of in-hospital mortality of 1.38 (95% confidence interval, 1.04–1.85), which declined to 1.34 (95% confidence interval, 0.93–1.93) after adjusting for patient characteristics (especially, pre-hospital delay). No difference in 30-day mortality, total death or dependence at three, six and 12 months between two groups was observed. No association between off-hour admission and quality of care was found. Conclusions In the CNSR database, compared with on-hour patients, off-hour patients with acute ischemic stroke admitted to the emergency departments from scene manifested a higher incidence of in-hospital mortality. However, the difference in incidence and quality of care between the groups disappeared after adjusting for pre-hospital delay and other variables.
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Affiliation(s)
- Guifen Wang
- Department of Pediatrics, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Runhua Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ruijun Ji
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Baoqin Gao
- Department of Pediatrics, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- * E-mail:
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Romero Sevilla R, Portilla Cuenca JC, López Espuela F, Redondo Peñas I, Bragado Trigo I, Yerga Lorenzana B, Calle Escobar M, Gómez Gutiérrez M, Casado Naranjo I. A stroke care management system prevents outcome differences related to time of stroke unit admission. Neurologia 2015; 31:149-56. [PMID: 26385014 DOI: 10.1016/j.nrl.2015.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 06/27/2015] [Accepted: 07/19/2015] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Evidence supports that admitting patients with stroke during different hospital work periods is related to distinct outcomes. We aimed to analyse outcomes in patients according to the period and time of admission to the stroke unit. METHODS Retrospective study. For purposes of data analysis, patients were grouped according to the following time periods: a) day of the week, b) period of the year, c) shift. We analysed demographic characteristics, stroke type and severity, and the percentage undergoing thrombolysis in each group. The measures used to evaluate early outcomes were the National Institutes of Health Stroke Scale (NIHSS), neurological complications (NC), and in-hospital mortality. Functional outcome at 3 months was determined using the modified Rankin scale. RESULTS The stroke unit admitted 1250 patients. We found NC to be slightly more frequent for weekend admissions than for weekday admissions, but this trend does not seem to have influenced in-hospital mortality. Regarding functional outcome at 3 months, 67.0% of weekday vs. 60.7% of weekend admissions were independent (P=.096), as were 65.5% of patients admitted during the academic months vs. 63.5% of those admitted during summer holidays (P=.803). We identified no significant differences in 3-month mortality linked to the day or period of admission; however, for the variable 'shift', 13.2% of the patients died during the morning shift, 11.5% during the afternoon shift, and 6.0% during the night shift (P=.017). We identified a trend toward higher rates of thrombolysis administration on weekdays, during the morning shift, and during the academic months. CONCLUSIONS Time of admission to the stroke unit did not affect early outcomes or functional independence at 3 months.
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Affiliation(s)
- R Romero Sevilla
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - J C Portilla Cuenca
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - F López Espuela
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - I Redondo Peñas
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - I Bragado Trigo
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - B Yerga Lorenzana
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - M Calle Escobar
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - M Gómez Gutiérrez
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
| | - I Casado Naranjo
- Unidad de Ictus, Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, España.
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Inoue T, Fushimi K. Weekend versus Weekday Admission and In-Hospital Mortality from Ischemic Stroke in Japan. J Stroke Cerebrovasc Dis 2015; 24:2787-92. [PMID: 26365617 DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/29/2015] [Accepted: 08/09/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The initial treatment of acute ischemic stroke critically affects patient outcome. Patient outcome may also be associated with the day of hospital admission due to differences in the number of the hospital staff between weekdays and weekends. We aimed to assess the effect of weekend admission on in-hospital mortality among patients with ischemic stroke in Japan. METHODS We analyzed patients with ischemic stroke from a large nationwide administrative dataset. The patients were grouped according to the treatment ward to which they were initially admitted: a general medical ward (GMW) or an intensive or stroke care unit (S-ICU). The primary outcome, in-hospital mortality, was compared between the patients admitted on a weekday versus weekend according to the initial treatment ward. A generalized estimated equation was applied for multivariate analysis. RESULTS In total, 47,885 patients were included in the study. Of these patients, 32.0% were admitted to an S-ICU and 27.8% were admitted to a GMW on a weekend. The estimated in-hospital mortality rate was significantly higher among the patients admitted to a GMW on a weekend compared with those admitted on a weekday (7.9% versus 7.0%), but this difference was not significant after adjusting for the patients' background characteristics. The estimated in-hospital mortality rates of the patients admitted to an S-ICU were similar between weekend and weekday admissions (10.0% versus 9.9%). CONCLUSIONS No significant effect of weekend admission in-hospital mortality was observed in our study population regardless of the initial treatment ward.
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Affiliation(s)
- Takahiro Inoue
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Japan.
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Patel AA, Mahajan A, Benjo A, Pathak A, Kar J, Jani VB, Annapureddy N, Agarwal SK, Sabharwal MS, Simoes PK, Konstantinidis I, Yacoub R, Javed F, El Hayek G, Menon MC, Nadkarni GN. A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status. Neurohospitalist 2015; 6:51-8. [PMID: 27053981 DOI: 10.1177/1941874415601164] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. MATERIALS AND METHODS We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. RESULTS Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. CONCLUSION Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.
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Affiliation(s)
- Achint A Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandre Benjo
- Department of Internal Medicine, Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Ambarish Pathak
- Department of Public Health, New York Medical College, Valhalla, NY
| | - Jitesh Kar
- Neurology Consultants of Huntsville, Huntsville, AL, USA
| | - Vishal B Jani
- Department of Neurology, Michigan State University, East Lansing, MI, USA
| | - Narender Annapureddy
- Division of Rheumatology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shiv Kumar Agarwal
- Division of Cardiology, Department of Internal Medicine, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Manpreet S Sabharwal
- Department of Internal Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | - Priya K Simoes
- Department of Internal Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | - Ioannis Konstantinidis
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rabi Yacoub
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fahad Javed
- Department of Internal Medicine, Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Georges El Hayek
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N Nadkarni
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Rodríguez-Rivera IV, Santiago F, Estapé ES, González-Sepúlveda L, Brau R. Impact of Day of the Week and Time of Arrival on Ischemic Stroke Management. PUERTO RICO HEALTH SCIENCES JOURNAL 2015; 34:164-9. [PMID: 26356742 PMCID: PMC4633410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the association between measures of patient arrival day (weekday or weekend day), day part (nighttime vs. daytime) and hour (regular hours vs. off hours) at the stroke unit of the Emergency Department of the Puerto Rico Medical Center and the following time-to-treatment measures: door-to-CT-scan, door-to-needle, and stroke-onset-to-treatment. METHODS In this retrospective study, the data of 54 patients was obtained from the stroke unit of the Puerto Rico Medical Center through the Get With The Guidelines- Stroke Registry. Inclusion criteria were as follows: having an ischemic stroke within the period covering from August 2008 through February 2010 and being at least 18 years old. Associations between patient arrival time and timeliness of interventions were assessed using t-tests/Mann-Whitney tests and chi-square tests/Fisher's exact tests, as appropriate. RESULTS The majority of the patients (74%) were men. The mean and standard deviation of age was 67±14 years. The median of times for door-to-CT-scan and onset to treatment were 15 minutes (interquartile range=15) and 2.7 hours (interquartile range=0.6), respectively. The mean and standard deviation for door-to-needle time was 77±18 minutes. No differences were found for any of the variables in terms of arrival date, day part or hour (p>0.05). The median time for door-to-CT- scan was shorter for patients receiving intravenous tissue plasminogen activator treatment than it was for those not receiving such treatment (12 minutes vs. 20 minutes; p=0.02). CONCLUSION The timeliness of the stroke management interventions did not differ significantly in terms of arrival day, day part, or hour.
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Affiliation(s)
- Ingrid V Rodríguez-Rivera
- Section of Neurosurgery, Department of Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Fernando Santiago
- Department of Neurology, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Estela S Estapé
- Graduate Department, School of Health Professions, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Lorena González-Sepúlveda
- Puerto Rico Clinical and Translational Research Consortium, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Ricardo Brau
- Section of Neurosurgery, Department of Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
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Blood Pressure Guideline Adherence in Patients with Ischemic and Hemorrhagic Stroke in the Neurointensive Care Unit Setting. Neurocrit Care 2015; 23:313-20. [DOI: 10.1007/s12028-015-0116-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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44
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Giri S, Pathak R, Aryal MR, Karmacharya P, Bhatt VR, Martin MG. Lack of "Weekend Effect" on Mortality for Pulmonary Embolism Admissions in 2011: Data from Nationwide Inpatient Sample. Int J Cardiol 2015; 180:151-3. [DOI: 10.1016/j.ijcard.2014.11.201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
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45
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Kristiansen NS, Mainz J, Nørgård BM, Bartels PD, Andersen G, Johnsen SP. Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality. Stroke 2014; 45:3663-9. [PMID: 25378421 DOI: 10.1161/strokeaha.114.005535] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Studies have reported higher risks of death and other adverse outcomes in acute stroke patients admitted off-hours; however, little is known about the underlying mechanisms. According to time of admission, our aim was to examine compliance with performance measures for acute stroke care processes, including the effect of a systematic quality improvement program, and to examine 30 days case-fatality. METHODS A population-based historical cohort study, including patients admitted to Danish hospitals with a first ever acute stroke (January 1, 2003, to December 31, 2011; N=64 975). Off-hours were weekends and evening and nighttime shifts on weekdays. Compliance with performance measures was compared using general linear modeling, and odds ratios for 30 days case-fatality were obtained using multivariable logistic regression. RESULTS Patients admitted off-hours had a lower chance of compliance with 8 out of 10 performance measures; however, these differences diminished over time. Unadjusted odds ratio for 30 days case-fatality, for patients admitted off-hours compared with patients admitted on-hours, was 1.15 (95% confidence interval, 1.09-1.21). Adjusting for patient characteristics (in particular, stroke severity) decreased the odds ratio to 1.03 (95% confidence interval, 0.97-1.10). Additional adjustment for hospital characteristics and compliance with performance measures had no effect on the odds ratio. CONCLUSION Patients admitted off-hours received a poorer quality of care. However, the admission time-related differences in care were substantially reduced over time, and the differences in 30 days case-fatality appeared primarily to be explained by differences in stroke severity.
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Affiliation(s)
- Nina Sahlertz Kristiansen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
| | - Jan Mainz
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Bente Mertz Nørgård
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Paul D Bartels
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Grethe Andersen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Søren Paaske Johnsen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
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Kamitani S, Nishimura K, Nakamura F, Kada A, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Miyamoto Y, Iwata M, Suzuki A, Ishikawa KB, Kataoka H, Morita K, Kobayashi Y, Iihara K. Consciousness level and off-hour admission affect discharge outcome of acute stroke patients: a J-ASPECT study. J Am Heart Assoc 2014; 3:e001059. [PMID: 25336463 PMCID: PMC4323811 DOI: 10.1161/jaha.114.001059] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Poor outcomes have been reported for stroke patients admitted outside of regular working hours. However, few studies have adjusted for case severity. In this nationwide assessment, we examined relationships between hospital admission time and disabilities at discharge while considering case severity. Methods and Results We analyzed 35 685 acute stroke patients admitted to 262 hospitals between April 2010 and May 2011 for ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). The proportion of disabilities/death at discharge as measured by the modified Rankin Scale (mRS) was quantified. We constructed 2 hierarchical logistic regression models to estimate the effect of admission time, one adjusted for age, sex, comorbidities, and number of beds; and the second adjusted for the effect of consciousness levels and the above variables at admission. The percentage of severe disabilities/death at discharge increased for patients admitted outside of regular hours (22.8%, 27.2%, and 28.2% for working‐hour, off‐hour, and nighttime; P<0.001). These tendencies were significant in the bivariate and multivariable models without adjusting for consciousness level. However, the effects of off‐hour or nighttime admissions were negated when adjusted for consciousness levels at admission (adjusted OR, 1.00 and 0.99; 95% CI, 1.00 to 1.13 and 0.89 to 1.10; P=0.067 and 0.851 for off‐hour and nighttime, respectively, versus working‐hour). The same trend was observed when each stroke subtype was stratified. Conclusions The well‐known off‐hour effect might be attributed to the severely ill patient population. Thus, sustained stroke care that is sufficient to treat severely ill patients during off‐hours is important.
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Affiliation(s)
- Satoru Kamitani
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.)
| | - Fumiaki Nakamura
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Akiko Kada
- Clinical Research Center, Nagoya Medical Center, Nagoya, Japan (A.K.)
| | - Jyoji Nakagawara
- Department of Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Suita, Japan (J.N.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Kuniaki Ogasawara
- Department of neurosurgery, Iwate Medical University, Morioka, Japan (K.O.)
| | - Junichi Ono
- Chiba Cardiovascular Center, Chiba, Japan (J.O.)
| | | | - Toru Aruga
- Showa University Hospital, Shinagawa-ku, Japan (T.A.)
| | - Shigeru Miyachi
- Department of Neurosurgery, Nagoya University, Nagoya, Japan (S.M.)
| | | | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, Universityof Occupational and Environmental Health, Kitakyushu, Japan (S.M.)
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.)
| | - Michiaki Iwata
- Department of Intellectual Asset Management, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.)
| | - Akifumi Suzuki
- Research Institute for Brain and Blood Vessels, Akita, Japan (A.S.)
| | - Koichi B Ishikawa
- Center for Cancer Controland Information Services, National Cancer Center, Chuo-ku, Japan (K.B.I.)
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.)
| | - Kenichi Morita
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.)
| | - Yasuki Kobayashi
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (K.I.)
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Ullah N, Thompson MJ, Qureshi AI. Earlier thrombolytic treatment is associated with better outcomes following acute ischaemic stroke. Evid Based Nurs 2014; 17:107. [PMID: 24504528 DOI: 10.1136/eb-2013-101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Naseeb Ullah
- Zeenat Qureshi Stroke Institute and Department of Cerebrovascular Diseases, Centracare Health, St Cloud, MN, USA
| | - Michelle J Thompson
- Zeenat Qureshi Stroke Institute and Department of Cerebrovascular Diseases, Centracare Health, St Cloud, MN, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Cerebrovascular Diseases, Centracare Health, St Cloud, MN, USA
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48
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Nakajima M, Inatomi Y, Yonehara T, Watanabe M, Ando Y. Outcome in Patients Admitted outside Regular Hospital Working Hours: Does Time until Regular Working Hours Matter? Int J Stroke 2014; 10:79-84. [DOI: 10.1111/ijs.12351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 06/12/2014] [Indexed: 11/29/2022]
Abstract
Aims The aim of this study was to investigate whether stratifying patients according to the time period from admission to the start of regular working hours would help detect a weekend effect in acute stroke patients. Methods Ischemic stroke patients admitted between October 2002 and March 2012 were analyzed. Working hours were defined as 9:00–17:00 on weekdays. Patients were divided into those admitted during working hours (no-wait group) and three other groups according to the time from admission to working hours: ⩽24 h (short-wait group), 24–48 h (medium-wait group), and >48 h (long-wait group). The modified Rankin Scale score and mortality at three-months were compared among the groups. Results Of 5625 patients, 3323 (59%) were admitted outside working hours. The proportion of patients with an mRS score 0–1 at three-months showed a decreasing trend with the time period before working hours: 47% (no-wait group), 42% (short-wait group), 42% (medium-wait group), and 38% (long-wait group), respectively ( P < 0·001). When the no-wait group was used as a reference, the odds ratio for modified Rankin Scale score 0–1 was 0·88 (95% confidence interval, 0·75–1·04) in the short-wait group, 0·86 (0·69–1·07) in the medium-wait group, and 0·67 (0·53–0·85) in the long-wait group after adjusting for sex, age, premorbid mRS score, previous morbidity, stroke severity, and vascular risk factors. Mortality at three-months was not different between the no-wait group and the other groups. Conclusion A weekend effect might be evident if patients were stratified according to the time period from admission until working hours.
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Affiliation(s)
- Makoto Nakajima
- Stroke Center, Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuichiro Inatomi
- Stroke Center, Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Toshiro Yonehara
- Stroke Center, Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Masaki Watanabe
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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49
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Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Med 2014; 11:e1001705. [PMID: 25137386 PMCID: PMC4138029 DOI: 10.1371/journal.pmed.1001705] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 07/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this "weekend effect" is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke. METHODS AND FINDINGS We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91-1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose-response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07-1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77-0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services. CONCLUSIONS Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors' Summary.
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50
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Sorita A, Ahmed A, Starr SR, Thompson KM, Reed DA, Dabrh AMA, Prokop L, Kent DM, Shah ND, Murad MH, Ting HH. Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis. Eur J Intern Med 2014; 25:394-400. [PMID: 24721584 DOI: 10.1016/j.ejim.2014.03.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/07/2014] [Accepted: 03/15/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Studies have suggested that patients with acute ischemic stroke who present to the hospital during off-hours (weekends and nights) may or may not have worse clinical outcomes compared to patients who present during regular hours. METHODS We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through August 2013, and included any study that evaluated the association between time of patient presentation to a healthcare facility and mortality or modified Rankin Scale in acute ischemic stroke. Quality of studies was assessed with the Newcastle-Ottawa Scale. A random-effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2). A priori subgroup analyses were used to explain observed heterogeneity. RESULTS A total of 21 cohort studies (23 cohorts) with fair quality enrolling 1,421,914 patients were included. Off-hour presentation for patients with acute ischemic stroke was associated with significantly higher short-term mortality (OR, 1.11, 95% CI 1.06-1.17). Presenting at accredited stroke centers (OR 1.04, 95% CI 0.98-1.11) and countries in North America (OR 1.05, 95% CI 1.01-1.09) were associated with smaller increase in mortality during off-hours. The results were not significantly different between adjusted (OR, 1.11, 95% CI 1.05-1.16) and unadjusted (OR, 1.13, 95% CI 0.95-1.35) outcomes. The proportion of patients with modified Rankin Scale at discharge ≥ 2-3 was higher in patients presenting during off-hours (OR, 1.14, 95% CI 1.06-1.22). DISCUSSION The evidence suggests that patients with acute ischemic stroke presenting during off-hours have higher short-term mortality and greater disability at discharge.
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Affiliation(s)
- Atsushi Sorita
- Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States
| | - Adil Ahmed
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States
| | - Stephanie R Starr
- Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kristine M Thompson
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Darcy A Reed
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Larry Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, United States
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | | | - Henry H Ting
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States.
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