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

Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India

Background

The current study aimed to assess any association between intensive care unit (ICU) and hospital outcomes with ICU admission timings of critically ill patients.

Methods

Retrospective observational single-center study involving all adult admissions. Each patient admission was categorized in "after-hours" (08:00 p.m.-07:59 a.m.), or "normal-hours" (08:00 a.m.-07:59 p.m.), "Weekday" (Monday-Saturday), or "Weekend" (Sunday), "Same day" (admission directly to ICU) or "other day admission" (admission to ICU after a hospital stay of ≥24 hours). Intensive care unit and hospital mortality, length of stay (LOS), and ICU readmission were assessed for any association with different admission timings.

Results

Among 3,029 patients, 54.2% (1,668) were male, with mean age 66.49 (SD ± 15.69) years, mean acute physiology and chronic health evaluation-IV (APACHE-IV) score 55.5 (SD ± 26.3). Around 86.1% of admission occurred during weekdays, 13.9% on weekends, 57.4% normal-hours, 42.6% after-hours, 66.3% same day and 33.7% other day admission. Intensive care unit and hospital mortality were 10.8 and 14.2% respectively. Neither ICU nor hospital mortality were significantly different among patients admitted normal vs after-hours (p = 0.32, 0.23), and weekdays vs weekends (p = 0.09, 0.93), nor was ICU LOS (p = 0.21, 0.74). Intensive care unit and hospital mortality (p = 0.001), DORB (p = 0.001), hospital LOS (p = 0.001), and readmission to ICU (p = 0.001) were significantly higher in the other day admission group compared to same-day admission. In a multivariate regression analysis age, APACHE IV score along with other day admission to ICU did have a significant effect on both ICU and hospital mortality.

Conclusion

Intensive care unit and hospital mortality and LOS did not differ significantly with hours or days of ICU admission though they were significantly higher in other day admission groups.

How to cite this article

Bhattacharyya M, Todi SK. Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India. Indian J Crit Care Med 2024;28(5):436-441.

[Effect on the time of admission to the Intensive Care Unit of the start-up of an Critical Care Outreach Team]

INTRODUCTION

The implementation of the Critical Care Outreach Teams can influence the time of admission of patients to the Intensive Care Unit (ICU).

MATERIAL AND METHODS

Retrospective, descriptive, quasi-experimental "before-after" cohort study. All patients admitted to the unit urgently from Monday to Friday for two periods (between February 1, 2022 and June 30 and between February 1, 2023 and June 30, 2023) are included. The patients were divided into regular shift admissions (08-15h) and on-call (15-08h). The secondary objective was to assess whether there were differences in mortality between the two periods.

RESULTS

During the first period of the study, 239 patients were admitted. 29.29% entered the ordinary shift and 70.71% on duty shift. During the second period, 211 patients were included with 43.13% of admissions in the ordinary shift. The comparison between the two periods observed a significant increase in the percentage of admissions in the morning hours in the second period (P=.0031). Mortality in the first period was 13.80% and in the second period 9.95%. The comparison between the two periods did not reveal significant differences.

CONCLUSIONS

The start-up of the Critical Care Outreach Teams is associated with an increase in the proportion of ICU admissions in the morning period without any observed changes in mortality.

Mortality and readmission differences associated with after-hours hospital admission: A population-based cohort study in Queensland Australia

Background and Aims

Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after-hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after-hours hospital admission.

Methods

Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after-hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models.

Results

After adjusting for case-mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after-hours held true in sensitivity analyses which explored broader definitions of after-hours care: an "Extended" definition comprising a weekend extending into Friday night and early Monday morning; and a "Twilight" definition comprising weekends and weeknights.There were no significant differences in 30-day readmissions for emergency or elective patients admitted after-hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day-of-week effect. Workforce metrics that played a role in observed outcome differences within hours/after-hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend.

Conclusion

Patients admitted after-hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs

Background. Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. Methods. All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00–16:59) or nighttime (17:00–07:59). Student’s t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. Results. The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups ( $p=0.22$ ). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days ( $p=0.001$ ) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6, $p=0.012$ ); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0, $p=0.046$ ). Total ICU cost was significantly higher for daytime admissions ( $p=0.003$ ). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Conclusion. Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.

Association between ICU admission during off-hours and in-hospital mortality: a multicenter registry in Japan

BACKGROUND

The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan.

METHODS

This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital.

RESULTS

A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84-0.99]).

CONCLUSIONS

ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Association of Surge Conditions with Mortality Among Critically Ill Patients with COVID-19

Objective

To determine whether surge conditions were associated with increased mortality.

Design

Multicenter cohort study.

Setting

U.S. ICUs participating in STOP-COVID.

Patients

Consecutive adults with COVID-19 admitted to participating ICUs between March 4 and July 1, 2020.

Interventions

None

Measurements and Main Results

The main outcome was 28-day in-hospital mortality. To assess the association between admission to an ICU during a surge period and mortality, we used two different strategies: (1) an inverse probability weighted difference-in-differences model limited to appropriately matched surge and non-surge patients and (2) a meta-regression of 50 multivariable difference-in-differences models (each based on sets of randomly matched surge- and non-surge hospitals). In the first analysis, we considered a single surge period for the cohort (March 23 – May 6). In the second, each surge hospital had its own surge period (which was compared to the same time periods in matched non-surge hospitals).

Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5% men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge conditions. In analysis 1, the increase in mortality seen during surge was not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58], p = .6). In analysis 2, surge was associated with an increased odds of death (odds ratio 1.39 [95% CI, 1.34-1.43], p < .001).

Conclusions

Admission to an ICU with COVID-19 in a hospital that is experiencing surge conditions may be associated with an increased odds of death. Given the high incidence of COVID-19, such increases would translate into substantial excess mortality.

Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions

Background

Very few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions.

Methods

We conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions.

Results

Of the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered ‘too well to benefit’ from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered ‘too sick to benefit’ according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered ‘too well to benefit’, 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients ‘too well to benefit’) were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to “ICU admission”) were independently associated with 30-day mortality.

Conclusion

The ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered “too well to benefit” from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00898-2.

After-Hours/Nighttime Transfers Out of the Intensive Care Unit and Patient Outcomes: A Systematic Review and Meta-Analysis

PURPOSE

We evaluated the effects of after-hours/nighttime patient transfers out of the ICU on patient outcomes, by performing a systematic review and meta-analysis (PROSPERO CRD 42017074082).

DATA SOURCES

MEDLINE, PubMed, EMBASE, Google Scholar, CINAHL, and the Cochrane Library from 1987-November 2019. Conference abstracts from the Society of Critical Care Medicine, American Thoracic Society, CHEST, Critical Care Canada Forum, and European Society of Intensive Care Medicine from 2011-2019.

DATA EXTRACTION

Observational or randomized studies of adult ICU patients were selected if they compared after-hours transfer out of the ICU to daytime transfer on patient outcomes. Case reports, case series, letters, and reviews were excluded. Study year, country, design, co-variates for adjustment, definitions of after-hours, mortality rates, ICU readmission rates, and hospital length of stay (LOS) were extracted.

DATA SYNTHESIS

We identified 3,398 studies. Thirty-one observational studies (1,418,924 patients) were selected for the systematic review and meta-analysis. Included studies had varying definitions of after-hours, with the after-hours period starting anytime between 16:00-22:00 and ending between 06:00-09:00. Approximately 16% of transfers occurred after-hours. After-hours transfers were associated with increased in-hospital mortality for both unadjusted (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.30-1.75, I² = 96%, number of studies [n] = 26, P < 0.001, low certainty) and adjusted (OR 1.32, 95% CI 1.25-1.38, I ² = 33%, n = 10, P < 0.001, low certainty) data, compared to daytime transfers. They were also associated with increased ICU readmission (pooled unadjusted OR 1.28, 95% CI 1.18-1.38, I² = 85%, n = 17, P < 0.001, low certainty) and longer hospital LOS (standardized mean difference 0.13, 95% CI 0.09-0.18, I ² = 93%, n = 9, P < 0.001, low certainty), compared to daytime transfers.

CONCLUSIONS

After-hours transfers out of the ICU are associated with increased in-hospital mortality, ICU readmission, and hospital LOS, across many settings. While the certainty of evidence is low, future research is needed to reduce the number and effects of after-hours transfers.

There is no association between weekend admissions and delays in antibiotic administration for patients admitted to the emergency department with suspicion of sepsis: A retrospective cohort study

Admission to the emergency department (ED) on weekends has been associated with an increase in mortality and poor outcomes, but the associated findings are not consistent. It has been hypothesized that this association may be due to lower adherence to standards of care.This study was conducted to evaluate whether weekend admissions to the ED increases the time to antibiotic administration in septic patients.A retrospective cohort study of adult patients who were included in the sepsis protocol at a tertiary ED between January 2015 and December 2017 was performed. The sepsis protocol was activated for all patients with suspected severe infection.A total of 831 patients with a mean age of 59 ± 21 years were evaluated, of whom 217 (26.1%) were admitted on weekends. In addition, 391 (47.1%) patients were male, and 84 (10.1%) died in the hospital. Overall, the mean sequential organ failure assessment score was 2 ± 1.9, and the mean Charlson comorbidity index was 3.7 ± 3. The time to antibiotic administration was similar between patients admitted on weekends (36.29 ± 50 minutes CI 95%) and patients admitted on weekdays (44.44 ± 69 minutes CI 95%), P = .06; U = 60174.0. Additionally, mortality was similar in both groups of patients, with a 10.3% mortality rate on weekdays and a 9.8% mortality rate on weekends, P = 821.In this cohort of patients with suspicion of sepsis in the ED, admission on weekends was not associated with increased delays in antibiotic therapy or higher mortality rates.

Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period

BACKGROUND

The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach.

MATERIALS AND METHODS

We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty.

RESULTS

A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect.

CONCLUSIONS

The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible.

Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study

OBJECTIVES

Diagnostic errors can harm critically ill children. However, we know little about their prevalence in PICUs and factors associated with error. The objective of this pilot study was to determine feasibility of record review to identify patient, provider, and work system factors associated with diagnostic errors during the first 12 hours after PICU admission.

DESIGN

Pilot retrospective cohort study with structured record review using a structured tool (Safer Dx instrument) to identify diagnostic error.

SETTING

Academic tertiary referral PICU.

PATIENTS

Patients 0-17 years old admitted nonelectively to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four of 50 patients (8%) had diagnostic errors in the first 12 hours after admission. The Safer Dx instrument helped identify delayed diagnoses of chronic ear infection, increased intracranial pressure (two cases), and Bartonella encephalitis. We calculated that 610 PICU admissions are needed to achieve 80% power (α = 0.05) to detect significant associations with error.

CONCLUSIONS

Our pilot study found four patients with diagnostic error out of 50 children admitted nonelectively to a PICU. Retrospective record review using a structured tool to identify diagnostic errors is feasible in this population. Pilot data are being used to inform a larger and more definitive multicenter study.

Associations between hospital occupancy, intensive care unit transfer delay and hospital mortality

PURPOSE

Hospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes.

MATERIALS AND METHODS

7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality.

RESULTS

Median (IQR) ICU transfer delay was 4.8 h (1.6-11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14).

CONCLUSIONS

ICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.

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

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

Time of Day and its Association with Risk of Death and Chance of Discharge in Critically Ill Patients: A Retrospective Study

Outcomes following admission to intensive care units (ICU) may vary with time and day. This study investigated associations between time of day and risk of ICU mortality and chance of ICU discharge in acute ICU admissions. Adult patients (age ≥ 18 years) who were admitted to ICUs participating in the Austrian intensive care database due to medical or surgical urgencies and emergencies between January 2012 and December 2016 were included in this retrospective study. Readmissions were excluded. Statistical analysis was conducted using the Fine-and-Gray proportional subdistribution hazards model concerning ICU mortality and ICU discharge within 30 days adjusted for SAPS 3 score. 110,628 admissions were analysed. ICU admission during late night and early morning was associated with increased hazards for ICU mortality; HR: 1.17; 95% CI: 1.08-1.28 for 00:00-03:59, HR: 1.16; 95% CI: 1.05-1.29 for 04:00-07:59. Risk of death in the ICU decreased over the day; lowest HR: 0.475, 95% CI: 0.432-0.522 for 00:00-03:59. Hazards for discharge from the ICU dropped sharply after 16:00; lowest HR: 0.024; 95% CI: 0.019-0.029 for 00:00-03:59. We conclude that there are "time effects" in ICUs. These findings may spark further quality improvement efforts.

Time of admission to intensive care unit, strained capacity, and mortality: A retrospective cohort study

PURPOSE

We sought to study the association between afterhours ICU admission and ICU mortality considering measures of strained ICU capacity.

MATERIALS AND METHODS

Retrospective analysis of 4141 admissions to 2 ICUs in Lisbon, Portugal (06/2016-06/2018). Primary exposure was ICU admission on 20:00 h-07:59 h. Primary outcome was ICU mortality. Measures of strained ICU capacity were: bed occupancy rate ≥ 90% and cluster of ICU admissions 2 h before or following index admission.

RESULTS

There were 1581 (38.2%) afterhours ICU admissions. Median APACHE II score (19 vs. 20) was similar between patients admitted afterhours and others (P = .27). Patients admitted afterhours had higher crude ICU mortality (15.4% vs. 21.9%; P < .001), but similar adjusted ICU mortality (aOR [95%CI] = 1.15 [0.97-1.38]; P = .12). While bed occupancy rate ≥ 90% was more frequent in patients admitted afterhours (23.1% vs. 29.1%) or deceased in ICU (23.6% vs. 33.7%), cluster of ICU admissions was more frequent in patients admitted during daytime hours (75.2% vs. 58.9%) or that survived the ICU stay (70.1% vs. 63.9%; P ≤ .001 for all). These measures of strained ICU capacity were not associated with adjusted ICU mortality (P ≥ .10 for both).

CONCLUSIONS

Afterhours ICU admission and measures of strained ICU capacity were associated with crude but not adjusted ICU mortality.

Does time of surgery influence the rate of false-negative appendectomies? A retrospective observational study of 274 patients

Background

Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours.

Methods

Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate.

Results

Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference.

Conclusions

This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues.

Admission to surgical intensive care unit in time with intensivist coverage and its association with postoperative 30-day mortality: The role of intensivists in a surgical intensive care unit

BACKGROUND

This study aimed to investigate the association between postoperative surgical Intensive Care Unit (ICU) admission during a time when there was intensivist coverage and 30-day mortality after ICU admission.

METHODS

This was a retrospective observational study in a tertiary care academic hospital ICU, with daytime intensivist coverage. We collected the electronic medical records for all patients who were admitted to the postoperative ICU after undergoing a surgery between January 1, 2007 and December 31, 2016. The primary outcome was to examine the differences in 30-day mortality after ICU admission according to ICU admission during times of intensivist or non-intensivist coverage.

RESULTS

Overall, 13,906 patients were included (6634 [47.7%] patients were admitted with intensivist coverage, and 7272 [52.3%] patients without intensivist coverage). After performing propensity Score matching, 10,708 patients (5354 patients in each group) were analysed. In the matched cohorts, 30-day mortality after postoperative ICU admission in the group without intensivist coverage was higher than that with intensivist coverage [30-day mortality, 251/5354 (4.7%) and 173/5354 (3.2%) in the groups without and with intensivist coverage, respectively, P < 0.001]. Post-operative ICU admission in the group without intensivist coverage was associated with an increased risk of 30-day mortality (risk ratio: 1.45, 95% confidence interval: 1.20-1.75, P < 0.001).

CONCLUSION

This study showed an increase in post-operative 30-day mortality, and length of hospital and ICU stay for surgical ICU admission among those without intensivist coverage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patients admitted via the emergency department to the intensive care unit: An observational cohort study

OBJECTIVE

Timely and appropriate assessment and management within the ED impacts patient outcomes including in-hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source.

METHODS

A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates.

RESULTS

In total, 423 ICU admissions occurred within 24 h of ED arrival; 395 were admitted directly to ICU; 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS.

CONCLUSION

Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision-making.

Temporal Variation in Ankle Fractures and Orthopedic Resident Program Planning in an Urban Level 1 Trauma Center

Previous studies have described the mechanism of ankle fractures, their seasonal variation, and fracture patterns but never in conjunction. In addition, the cohorts previously studied were either not from trauma centers or were often dominated by low-energy mechanisms. The present study aimed to describe the epidemiology of ankle fractures presenting to an urban level 1 trauma center. The records from an urban level 1 trauma center located in the Midwestern United States were retrospectively reviewed, and the injury mechanism and energy, time of injury, day of week, month, and patient characteristics (age, gender, comorbidities, smoking status) were collected. The fractures were classified using the AO (Arbeitsgemeinschaft für Osteosynthesefragen), Lauge-Hansen, and Danis-Weber systems. Of these systems, the Lauge-Hansen classification system resulted in the greatest number of "unclassifiable" cases. Most ankle fractures were due to high-energy mechanisms, with motor vehicle collisions the most common high-energy mechanism. The review found that most ankle fractures were malleolar fractures, regardless of the mechanism of injury. The ankle fracture patients had greater rates of obesity, diabetes, and smoking than present in the region where the hospital is located. The fractures were most likely to occur in the afternoon, with more fractures presenting on the weekend than earlier in the week and more fractures in the fall and winter than in the spring and summer. The temporal variation of these fractures should be considered for health services planning, in particular, in regard to resident physician staffing at urban level 1 trauma centers.

Association between afterhours admission to the intensive care unit, strained capacity, and mortality: a retrospective cohort study

Background

Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00–06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity.

Methods

This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00–06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity.

Results

Of 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7–37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44–70) vs 60 (47–70) years, p < 0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p < 0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p < 0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p = 0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923–1.135, p = 0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p = 0.90) or hospital length of stay (LOS) (p = 0.27), although ICU LOS was shorter (p = 0.049). Early-morning admission (00:00–06:59 h) with ICU occupancy ≥ 90% was associated with short-term (≤ 7 days) and all-cause ICU mortality.

Conclusions

One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2027-8) contains supplementary material, which is available to authorized users.

Adverse outcomes after planned surgery with anticipated intensive care admission in out-of-office-hours time periods: a multicentre cohort study

BACKGROUND

Increasing mortality for patients admitted to hospitals during the weekend is a contentious but well described phenomenon. However, it remains uncertain whether adverse outcomes, including prolonged hospital length-of-stay (LOS), may also occur after patients undergoing major planned surgery are admitted to an intensive care unit (ICU) out-of-office-hours, either during weeknights (after 18:00) or on weekends.

METHODS

All planned surgical admissions requiring admission to one of 183 ICUs across Australia and New Zealand between 2006 and 2016 were included in this retrospective population-based cohort study. Primary outcomes were hospital LOS and hospital mortality.

RESULTS

Of the total 504 713 planned postoperative ICU admissions, 33.6% occurred during out-of-office-hours. After adjusting for available risk factors, out-of-office-hours ICU admissions were associated with a significant increase in hospital LOS [+2.6 days, 95% confidence interval (CI) 2.5-2.6], mortality [odd ratio (OR) 1.5, 95%CI 1.4-1.6], and a reduced chance of being directly discharged home (OR 0.8, 95%CI 0.8-0.8). The strongest association for adverse outcomes occurred with weekend ICU admissions (hospital LOS: +3.0 days, 95%CI 3.2-3.6; hospital mortality: OR 1.7, 95%CI 1.6-1.8). Clustering of adverse outcomes by hospitals was not observed in the generalised estimating equation analyses.

CONCLUSIONS

Despite a greater clinical staff availability and higher monitoring levels, planned surgery requiring anticipated out-of-office-hours ICU admission was associated with a prolonged hospital LOS, reduced discharge directly home, and increased mortality compared with in-office-hours admissions. Our findings have potential clinical, economic and health policy implications on how complex planned surgery should be planned and managed.

Is the weekend effect really ubiquitous? A retrospective clinical cohort analysis of 30-day mortality by day of week and time of day using linked population data from New South Wales, Australia

OBJECTIVE

To examine the associations between day of week and time of admission and 30-day mortality for six clinical conditions: ischaemic and haemorrhagic stroke, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease and congestive heart failure.

DESIGN

Retrospective population-based cohort analyses. Hospitalisation records were linked to emergency department and deaths data. Random-effect logistic regression models were used, adjusting for casemix and taking into account clustering within hospitals.

SETTING

All hospitals in New South Wales, Australia, from July 2009 to June 2012.

PARTICIPANTS

Patients admitted to hospital with a primary diagnosis for one of the six clinical conditions examined.

OUTCOME MEASURES

Adjusted ORs for all-cause mortality within 30 days of admission, by day of week and time of day.

RESULTS

A total of 148 722 patients were included in the study, with 17 721 deaths within 30 days of admission. Day of week of admission was not associated with significantly higher likelihood of death for five of the six conditions after adjusting for casemix. There was significant variation in mortality for chronic obstructive pulmonary disease by day of week; however, this was not consistent with a strict weekend effect (Thursday: OR 1.29, 95% CI 1.12 to 1.48; Friday: OR 1.25, 95% CI 1.08 to 1.44; Saturday: OR 1.18, 95% CI 1.02 to 1.37; Sunday OR 1.05, 95% CI 0.90 to 1.22; compared with Monday). There was evidence for a night effect for patients admitted for stroke (ischaemic: OR 1.30, 95% CI 1.17 to 1.45; haemorrhagic: OR 1.58, 95% CI 1.40 to 1.78).

CONCLUSIONS

Mortality outcomes for these conditions, adjusted for casemix, do not vary in accordance with the weekend effect hypothesis. Our findings support a growing body of evidence that questions the ubiquity of the weekend effect.

Day or overnight transfusion in critically ill patients: does it matter?

BACKGROUND AND OBJECTIVES

The timing of blood administration in critically ill patients is first driven by patients' needs. This study aimed to define the epidemiology and significance of overnight transfusion in critically ill patients.

MATERIALS AND METHODS

This is a post hoc analysis of a prospective multicentre observational study including 874 critically ill patients receiving red blood cells, platelets, fresh frozen plasma (FFP) or cryoprecipitate. Characteristics of patients receiving blood only during the day (8 am up until 8 pm) were compared to those receiving blood only overnight (8 pm up until 8 am). Characteristics of transfusion were compared, and factors independently associated with major bleeding were analysed.

RESULTS

The 287 patients transfused during the day only had similar severity and mortality to the 258 receiving blood products overnight only. Although bleeding-related admission diagnoses were similar, major bleeding was the indication for transfusion in 12% of patients transfused in daytime only versus 30% of patients transfused at night only (P < 0·001). Similar total amount of blood products were transfused at day and night (2856 versus 2927); however, patients were more likely to receive FFP and cryoprecipitate at night compared with daytime. Overnight transfusion was independently associated with increased odds of major bleeding (odds ratio, 3·16, 95% confidence interval, 2·00-5·01).

CONCLUSION

Transfusion occurs evenly across day and night in ICU; nonetheless, there are differences in type of blood products administered that reflect differences in indication. Critically ill patients were more likely to receive blood for major bleeding at night irrespective of admission diagnosis.

Time of Admission to the PICU and Mortality

OBJECTIVES

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

DESIGN

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

SETTING

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

PATIENTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Weekends affect mortality risk and chance of discharge in critically ill patients: a retrospective study in the Austrian registry for intensive care

Background

In this study, we primarily investigated whether ICU admission or ICU stay at weekends (Saturday and Sunday) is associated with a different risk of ICU mortality or chance of ICU discharge than ICU admission or ICU stay on weekdays (Monday to Friday). Secondarily, we analysed whether weekend ICU admission or ICU stay influences risk of hospital mortality or chance of hospital discharge.

Methods

A retrospective study was performed for all adult patients admitted to 119 ICUs participating in the benchmarking project of the Austrian Centre for Documentation and Quality Assurance in Intensive Care (ASDI) between 2012 and 2015. Readmissions to the ICU during the same hospital stay were excluded.

Results

In a multivariable competing risk analysis, a strong weekend effect was observed. Patients admitted to ICUs on Saturday or Sunday had a higher mortality risk after adjustment for severity of illness by Simplified Acute Physiology Score (SAPS) 3, year, month of the year, type of admission, ICU, and weekday of death or discharge. Hazard ratios (95% confidence interval) for death in the ICU following admission on a Saturday or Sunday compared with Wednesday were 1.15 (1.08–1.23) and 1.11 (1.03–1.18), respectively. Lower hazard ratios were observed for dying on a Saturday (0.93 (0.87–1.00)) or Sunday (0.85 (0.80–0.91)) compared with Wednesday. This is probably related to the reduced chance of being discharged from the ICU at the weekend (0.63 (0.62–064) for Saturday and 0.56 (0.55–0.57) for Sunday). Similar results were found for hospital mortality and hospital discharge following ICU admission.

Conclusions

Patients admitted to ICUs at weekends are at increased risk of death in both the ICU and the hospital even after rigorous adjustment for severity of illness. Conversely, death in the ICU and discharge from the ICU are significantly less likely at weekends.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1812-0) contains supplementary material, which is available to authorized users.

Out-of-office hours' elective surgical intensive care admissions and their associated complications

BACKGROUND

The 'weekend' effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during 'out-of-office hours' time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during 'out-of-office hours' time periods mitigates this affect through higher staffing ratios and seniority.

METHODS

Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred 'in-office hours' (Monday-Friday 08.00-18.00 hours) or 'out-of-office hours' (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data.

RESULTS

Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P < 0.001) and unplanned re-operations (P = 0.027). Out-of-office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P < 0.0001) and without (2.8 days longer, P < 0.001) adjusting for severity of acute and chronic illnesses and inter-hospital transfers (12.3 versus 9.8%, P = 0.024). Hospital mortality (1.2 versus 0.7%, P = 0.111) was low and similar between both groups.

CONCLUSION

Out-of-office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Effect of day of the week on short- and long-term mortality after emergency general surgery

BACKGROUND

The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality.

METHODS

This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival.

RESULTS

A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday.

CONCLUSION

There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.

Intensive care discharge delay is associated with increased hospital length of stay: A multicentre prospective observational study

BACKGROUND

Some patients experience a delayed discharge from the intensive care unit (ICU) where the intended and actual discharge times do not coincide. The clinical implications of this remain unclear.

OBJECTIVE

To determine the incidence and duration of delayed ICU discharge, identify the reasons for delay and evaluate the clinical consequences.

METHODS

Prospective multi-centre observational study involving five ICUs over a 3-month period. Delay in discharge was defined as >6 hours from the planned discharge time. The primary outcome measure was hospital length stay after ICU discharge decision. Secondary outcome measures included ICU discharge after-hours, incidence of delirium, survival to hospital discharge, discharge destination, the incidence of ICU acquired infections, revocation of ICU discharge decision, unplanned readmissions to ICU within 72 hours, review of patients admitting team after ICU discharge decision.

RESULTS

A total of 955 out of 1118 patients discharged were included in analysis. 49.9% of the patients discharge was delayed. The most common reason (74%) for delay in discharge was non-availability of ward bed. The median duration of the delay was 24 hours. On univariable analysis, the duration of hospital stay from the time of ICU discharge decision was significantly higher in patients who had ICU discharge delay (Median days-5 vs 6; p = 0.003). After-hours discharge was higher in patients whose discharge was delayed (34% Vs 10%; p<0.001). There was no statistically significant difference in the other secondary outcomes analysed. Multivariable analysis adjusting for known confounders revealed delayed ICU discharge was independently associated with increased hospital length of stay.

CONCLUSION

Half of all ICU patients experienced a delay in ICU discharge. Delayed discharge was associated with increased hospital length of stay.

Effects of time and day of admission on the outcome of critically ill patients admitted to ICU

Background

Studies have shown that patients admitted to hospitals on weekends and after-hours experience worse outcome than those admitted on weekdays and daytime hours. Although admissions of patients to intensive care units (ICUs) occur 24 hours a day, not all critical care units maintain the same level of staffing during nighttime, weekends, and holidays. This raises concerns in view of evidence showing that the organizational structure of an ICU influences the outcome of critically ill patients. The objective of this study is to evaluate the effects of day and time of admission to ICU on patients’ outcome.

Methods

A single-center, prospective, observational study was conducted among all consecutive admissions to ICU in a community teaching hospital during a 4-month period.

Results

A total of 282 patients were admitted during the study period. Their mean age was 59.5 years (median 59, range 17–96), and the majority were male (157, 55.7%). Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 18.9 (median 33, range 1–45), and mean ICU length of stay was 3.1 days (median 2, range 1–19). Of the patients, 104 patients (36.9%) were admitted during weekends and 178 (63.1%) during weekdays. A total of 122 patients (43.3%) were admitted after-hours, constituting 68.5% of all admissions during weekdays. Fifty-six patients (19.9%) were admitted during daytime hours, representing 31.5% of all weekday admissions. Forty-five patients (15.9%) died in ICU. Compared to patients admitted on weekends, those admitted on weekdays had increased ICU mortality (operating room (OR)=0.437; 95% confidence interval=0.2054–0.9196; p=0.0293).

Conclusion

Admissions to ICU during weekends were not independently associated with increased mortality. A linear relationship between weekdays and after-hours admissions to ICU with mortality was observed at our institution.

Patient outcomes following after-hours and weekend admissions for cardiovascular disease in a tertiary hospital in Calabar, Nigeria

BACKGROUND

There are various reports of higher mortality rates occurring after admissions over the weekend and during after-hours. This study aimed to determine if there was a difference in mortality rates occurring during the weekend and after-hours among cardiovascular admissions in a tertiary hospital in Nigeria.

METHODS

A review of cardiovascular admissions (including stroke) was carried out at the University of Calabar Teaching Hospital in Nigeria from January 2010 to December 2013. All admissions to the medical wards from the emergency department and medical out-patient department clinics during the study period were included.

RESULTS

A total of 339 patients were studied and stroke was the commonest type of cardiovascular disease (CVD) admitted (187; 55.2%). Hypertension was the commonest cause of heart failure (70; 48.6%). Presentation to hospital during after-hours and length of stay of more than 14 days were significant predictors of death (OR: 3.37; 0.22).

CONCLUSION

An increase in CVD mortality rates occurred during after-hours, most likely a consequence of uneven staffing patterns and poor access to equipment. Healthcare providers in Nigeria need to consider remedies to this with a view to reducing excess mortality rates.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

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

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Unplanned ICU Transfers from Inpatient Units: Examining the Prevalence and Preventability of Adverse Events Associated with ICU Transfer in Pediatrics

Background Adverse events have been associated with unplanned intensive care unit (ICU) transfers in adults. Objective To examine trends in unplanned ICU transfers in pediatrics resulting from adverse events. Design, Setting, Patients Retrospective observational study of pediatric and cardiac ICU transfers from acute care units during a 2-year period in a tertiary care children's hospital. Methods Transfers were identified via electronic health record query and investigated for adverse events. Predefined adverse events included ICU transfers within 12 hours of admission to an acute care unit, readmissions to an ICU within 24 hours, and cardiopulmonary arrest on an acute care unit. Other adverse events examined were not predefined. Adverse events were evaluated for preventability and categorized by type, diagnosis, time of day and weekday versus weekend occurrence, and level of associated patient harm. Results There were 1,008 ICU transfers during the study period; 67% were unplanned. Of the unplanned transfers, 32% were attributed to adverse events, 35% of which were preventable. Unplanned transfers associated with a high rate of preventable adverse events included readmission to an ICU within 24 hours (58%, p = 0.002) and ICU transfer within 12 hours of acute care admission (34%). Conclusions We observed a high rate of preventable adverse events associated with unplanned pediatric ICU transfers, many of which were due to inappropriate triage. Readmission to an ICU within 24 hours of transfer to an acute care unit was significantly associated with preventability.

Effect upon mortality of the extension to holidays and weekends of the "ICU without walls" project. A before-after study

OBJECTIVE

To determine whether extension to holidays and weekends of the protocol for the early proactive detection of severity in hospital ("ICU without walls" project) results in decreased mortality among patients admitted to the ICU during those days.

DESIGN

A quasi-experimental before-after study was carried out.

SETTING

A level 2 hospital with 210 beds and a polyvalent ICU with 8 beds.

PATIENTS OR PARTICIPANTS

The control group involved no "ICU without walls" activity on holidays or weekends and included those patients admitted to the ICU on those days between 1 January 2010 and 30 April 2013. The intervention group in turn extended the "ICU without walls" activity to holidays and weekends, and included those patients admitted on those days between 1 May 2013 and 31 October 2014. Patients arriving from the operating room after scheduled surgery were excluded.

VARIABLES OF INTEREST

An analysis was made of the demographic variables (age, gender), origin (emergency room, hospital ward, operating room), type of patient (medical, surgical), reason for admission, comorbidities and SAPS 3 score as a measure of severity upon admission, stay in the ICU and in hospital, and mortality in the ICU and in hospital.

RESULTS

A total of 389 and 161 patients were included in the control group and intervention group, respectively. There were no differences between the 2 groups except as regards cardiovascular comorbidity (49% in the control group versus 33% in the intervention group; P<.001), severity upon admission (median SAPS 3 score 52 [percentiles 25-75: 42-63) in the control group versus 48 [percentiles 25-75: 40-56] in the intervention group; P=.008) and mortality in the ICU (11% in the control group [95% CI 8-14] versus 3% [95% CI 1-7] in the intervention group; P=.003). In the multivariate analysis, the only 2 factors associated to mortality in the ICU were the SAPS 3 score (OR 1.08; 95% CI 1.06-1.11) and inclusion in the intervention group (OR 0.33; 95% CI 0.12-0.89).

CONCLUSIONS

Extension of the "ICU without walls" activity to holidays and weekends results in a decrease in mortality in the ICU.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes variability in non-emergent esophageal foreign body removal: Is daytime removal better?

OBJECTIVE

The objective of this study is to investigate differences between esophageal foreign body removal performed during standard operating room hours and those performed after-hours in asymptomatic patients.

METHODS

A retrospective chart review at a tertiary children's hospital identified 264 cases of patients with non-emergent esophageal foreign bodies between 2006 and 2011. Variables pertaining to procedure and recovery times, hospital charges, complications, length of stay, American Society of Anesthesiology (ASA) classification, and presence of mucosal injury were summarized and compared between cases performed during standard operating hours and those performed after-hours.

RESULTS

Cases performed during standard hours had significantly longer average wait times compared with after-hours cases (13.1h versus 9.0h, p<0.001). No other clinical characteristics or outcomes were significantly different between groups. Longer wait times are not associated with mucosal injury or postoperative complications.

CONCLUSION

There were no significant differences in procedure time, charges, or safety in after-hours removal of non-emergent esophageal foreign bodies compared to removal during standard operating hours. OR wait time was about 4h longer during standard hours compared with after-hours. This study could not assess the factors to determine the impact in differences in hospital resource utilization or work force, which may be significant between these two groups.

The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week

Objective

To examine the association of mortality by day of the week for emergency and elective patients.

Design

Retrospective observational study using the international dataset from the Global Comparators (GC) project consisting of hospital administrative data.

Setting

28 hospitals from England, Australia, USA and the Netherlands during 2009–2012.

Participants

Emergency and surgical-elective patients.

Main outcome measures

In-hospital deaths within 30 days of emergency admission or of elective surgery.

Results

We examined 2 982 570 hospital records; adjusted odds of 30-day death were higher for weekend emergency admissions to 11 hospitals in England (OR 1.08, 95% CI 1.04 to 1.13 on Sunday), 5 hospitals in USA (OR 1.13, 95% CI 1.04 to 1.24 on Sunday) and 6 hospitals in the Netherlands (OR 1.20, 95% CI 1.09 to 1.33 on Saturday). Emergency admissions to the six Australian hospitals showed no daily variation in adjusted 30-day mortality, but showed a weekend effect at 7 days post emergency admission (OR 1.12, 95% CI 1.04 to 1.22 on Saturday). All weekend elective patients showed higher adjusted odds of 30-day postoperative death; we observed a ‘Friday effect’ for elective patients in the six Dutch hospitals.

Conclusions

We show that mortality outcomes for our sample vary within each country and per day of the week in agreement with previous studies of the ‘weekend effect’. Due to limitations of administrative datasets, we cannot determine the reasons for these findings; however, the international nature of our database suggests that this is a systematic phenomenon affecting healthcare providers across borders. Further investigation is needed to understand the factors that give rise to the weekend effect. The participating hospitals represent varied models of service delivery, and there is a potential to learn from best practice in different healthcare systems.