Weekends: a dangerous time for having a stroke?

Invasiveness and Clinical Outcomes of Off-Hour Admissions in Patients with Intracerebral Hemorrhage

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.

The Association Between Stroke Mortality and Time of Admission and Participation in a Telestroke Network

OBJECTIVES

Acute ischemic stroke is one of the leading causes of death. Patient outcomes, such as in-patient mortality, may be impacted by the time of arrival to the hospital. Telestroke networks have been found to be effective and safe at treating acute ischemic strokes. This paper investigated the association between mortality and time of arrival and hospital's participation in a telestroke network.

METHODS

Data were collected on ischemic stroke patients who arrived at 15 nonteaching hospitals in Georgia's Paul Coverdell Acute stroke registry from 2009 to 2016. After controlling for patient and hospital characteristics, multivariate logistic regression was conducted to assess whether time of arrival and telestroke participation was associated with in-hospital mortality. Subgroup analysis was conducted based on hospital bed size.

RESULTS

Overall, a total of 19,759 admissions for acute ischemic stroke were included in this analysis. The odds of dying in the hospital when arriving during the nighttime are 1.22 times the odds of dying when arriving during the day (95% CI: 1.04-1.45) and the odds of dying at a telestroke hospital are 53% lower than at a nontelestroke hospital (OR .47, 95% CI .31-.71). The associations were more prominent in large hospitals.

CONCLUSIONS

Our study found that the hour of arrival for acute ischemic stroke is linked with in-hospital mortality in large hospitals, with patients more likely to die if they arrive during the nighttime hours as compared to the daytime hours. Telestroke participation is linked with lower odds of hospital mortality in all hospitals.

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

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.

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

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.

Effect of new year holidays on hospital mortality: a time series study

Background

Nowruz holidays, as one of the most important holidays in Iran, can lead to changes in the trend of hospital deaths. Due to changes in lifestyle and increased accidents, hospitals become crowded during the holidays. The present study aimed to investigate the effect of Nowruz holidays on hospital deaths at teaching hospitals affiliated with the Kerman University of Medical Sciences in southeast Iran.

Methods

The research population included all hospital deaths during the period from 23 August 2013 to 21 September 2016. Data on hospital deaths, including age, sex, work shift, cause of death and ward type were collected daily from the Hospital Information System. Data were analysed using t test and time series regression models, in Stata 13.0.

Results

The holiday deaths primarily occurred in males (57.14%) and people aged 60–79 years (29.20%). More than half of the holiday deaths occurred in the morning shift (59.88%). The leading cause of holiday deaths was injuries, poisoning and other consequences of external causes (25.31%). Most holiday deaths occurred in the ICU (53.88%). Death rate per day during the Nowruz holidays was higher than it was during working days and non-Nowruz holidays (1.36%).

Conclusions

Reduced quality of services during the holidays is a prominent issue and leads to increased hospital death. Hospital managers can improve the quality of services, by identifying the root causes and by taking measures such as increased and balanced distribution of human resources, equipping hospitals and improving supervision during holidays.

The weekend effect revisited: evidence from the Upper Austrian stroke registry

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.

"Weekend Effect" on 30-Day Readmissions among Stroke Survivors: An Analysis of the National Readmission Database

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Survival Outcomes Are Not Affected When Liver Transplant Surgery Is Done at Night, During Weekends, or Summer Months

Background

It has been suggested that hospitalized patients may get suboptimal care in nights or on weekends or summer holidays due to sleep deprivation, physician fatigue, or reduced medical staffing. Our objective was to determine whether there were differences in outcomes when surgery was performed in the night (10 pm-6 am), on weekends (Saturday or Sunday), or during summer months (June-August).

Methods

We used United Network for Organ Sharing (UNOS) data sets of adults transplanted between February 27, 2002, and September 30, 2016. We estimated the start time of liver transplant surgery by utilizing the cross-clamp time and cold ischemia time (cross-clamp time + cold ischemia time - 2 h). The survival outcomes were estimated by Kaplan-Meier survival analysis. Patients with hepatocellular carcinoma (HCC) were analyzed separately. The independent effect of time of transplant on outcomes was analyzed after adjusting for common confounders, including Model for End-stage Liver Diseases scores and transplant center volume.

Results

During the study period, 4 434 (9.6%) were done in the night, 12 147 (26.4%) over weekends, and 11 976 (26%) during summer months. The graft and patient survival and complications were not influenced by the time of transplant for both HCC and non-HCC population. Cox regression analysis after adjusting for risk factors, including Model for End-stage Liver Diseases, donor risk index, and liver center volume, confirmed that there were no significant differences in outcomes.

Conclusions

Our study showed that the time of transplant surgery whether done during nights, weekends, or summer months had no effect on graft or patient survival irrespective of center volume, patient, or donor risk factors.

Does the 'Chinese New Year effect' exist? Hospital mortality in patients admitted to internal medicine departments during official consecutive holidays: a nationwide population-based cohort study

OBJECTIVE

Our study aimed to compare the mortality risk among patients admitted to internal medicine departments during official consecutive holidays (using Chinese New Year holidays as an indicator) with that of weekend and weekday admissions.

DESIGN

Nationwide population-based cohort study.

SETTING

Taiwan's National Health Insurance Research Database.

PATIENTS

Patients admitted to internal medicine departments in acute care hospitals during January and February each year between 2001 and 2013 were identified. Admissions were categorised as: Chinese New Year holiday (n=10 779), weekend (n=35 870) or weekday admissions (n=143 529).

OUTCOME MEASURES

ORs for in-hospital mortality and 30-day mortality were calculated using multivariate logistic regression with adjustment for confounders.

RESULTS

Both in-hospital and 30-day mortality were significantly higher for patients admitted during the Chinese New Year holidays and on weekends compared with those admitted on weekdays. Chinese New Year holiday admissions had a 38% and 40% increased risk of in-hospital (OR=1.38, 95% CI 1.27 to 1.50, p<0.001) and 30-day (OR=1.40, 95% CI 1.31 to 1.50, p<0.001) mortality, respectively, compared with weekday admissions. Weekend admissions had a 17% and 19% increased risk of in-hospital (OR=1.17, 95% CI 1.10 to 1.23, p<0.001) and 30-day (OR=1.19, 95% CI 1.14 to 1.24, p<0.001) mortality, respectively, compared with weekday admissions. Analyses stratified by principal diagnosis revealed that the increase in in-hospital mortality risk was highest for patients admitted on Chinese New Year holidays with a diagnosis of ischaemic heart disease (OR=3.43, 95% CI 2.46 to 4.80, p<0.001).

CONCLUSIONS

The mortality risk was highest for patients admitted during Chinese New Year holidays, followed by weekend admissions, and then weekday admissions. Further studies are necessary to identify the underlying causes and develop strategies to improve outcomes for patients admitted during official consecutive holidays.

[Impact of weather, time of day and season on the admission and outcome of major trauma patients]

BACKGROUND AND OBJECTIVES

The potential association of external factors such as time of day, lunar phases or specific weather conditions on the daily management and outcome of trauma emergencies remains under debate. We undertook this trauma centre investigation to detect possible worthwhile factors of influence in order to optimize the organizational structure of trauma admissions.

MATERIALS AND METHODS

Retrospective cohort analysis over the years 2010-2013, including all emergency trauma admissions with a new injury severity score (NISS) ≥8 (major trauma) treated in a teaching hospital in the lowland of Switzerland (uni- and multivariable analysis; p < 0.05).

RESULTS

During the study period, 1178 major trauma patients were admitted to the hospital. The mean age of trauma victims was 53 ± 23 and the average ISS was 14 ± 8. More patients arrived within the summer months than during the rest of the year (p < 0.001). Higher energy trauma was found to correlate with higher daytime temperature, longer duration of sunshine (each p < 0.001), and change in weather conditions (p = 0.008). In contrast, snowfall and lunar phases did not demonstrate any association with the number or characteristics of trauma admissions. Multivariable analysis demonstrated that altogether longer sunshine, higher minimum daytime temperature and lower air humidity, compared to the previous day, accounted for 31 % of major trauma admissions. We could not find any impact of the investigated external factors on the outcome of patients.

CONCLUSIONS

The study shows a significant relationship between specific weather conditions, such as higher daytime temperature or change in circulation, and the admission of major trauma patients. Due to the small effect in our setting, our results do not implicate any according change in the management of resources. Nevertheless, for hospitals in other geographic or more exposed weather regions, such effects could indeed be relevant and therefore should be tested.

Weekend effect: analysing temporal trends in solid organ donation

BACKGROUND

Research suggests patients treated over weekends experience poorer outcomes. Only one US-based study explored this weekend effect in organ donation, specifically the kidney discard rate. In Australia potential donors are referred to a donation service, and donation proceeds if family consent is granted and the donor is deemed medically suitable to donate. Organ procurement occurs when utilization is almost certain hence discard rates are much lower than in the USA. We aimed to characterize the effect of weekend referral on organ donation in Australia.

METHODS

We retrospectively reviewed all New South Wales Organ and Tissue Donation Service logs from 2010 to 2016. Our primary outcome was progression to organ procurement, and secondary outcomes were family consent and meeting medical suitability thresholds. We used logistic regression with random effects adjusting for clustering of referral hospitals.

RESULTS

Of 3496 potential donors referred for consideration, 694 (20%) progressed to organ procurement. There were fewer referrals on weekends (average 415 versus 588 for weekdays). However, donation rates were no lower for weekend compared to weekday referrals (adjusted OR 1.17; 95% CI 0.95, 1.44). Family consent (adjusted OR 1.20; 95% CI 1.00, 1.44) and medical suitability (adjusted OR 1.15; 95% CI 0.96, 1.38) were not lower for weekend compared to weekday referrals. Similar results were found for all sensitivity analyses conducted.

CONCLUSIONS

In Australia, the donation pathway operates consistently throughout the week, with donation no less likely to proceed on weekends and holidays. This finding contrasts with findings in the USA.

The weekend effect in status epilepticus: a national cohort study

Higher mortality following admission to hospital at the weekend has been reported for several conditions. It is unclear whether this variation is due to differences in patients or their care. Status epilepticus mandates hospital admission and usually critical care: its study might provide new insights into the nature of any weekend effect. We studied 20,922 adults admitted to UK critical care with status epilepticus from 2010 to 2015. We used multiple logistic regression to evaluate the association between weekend admission and in-hospital mortality, comparing university hospitals with other hospitals. There were 2462 in-hospital deaths (12%). There was no difference in mortality after weekend admission to university hospitals, adjusted odds ratio (95%CI) 0.99 (0.84-1.16), p = 0.89. Mortality was less after weekend admission than after admissions Monday to Friday in hospitals not associated with a university, adjusted odds ratio (95%CI) 0.74 (0.64-0.87), p = 0.0001. There is no evidence that adults admitted to UK critical care at the weekend in status epilepticus are more likely to die than similar patients admitted during the week.

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

Introduction

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

Methodology

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

Results

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

Conclusions

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

Weekend Effect in Carotid Endarterectomy

Background and Purpose- Patients undergoing surgery on the weekend may experience worse outcomes, but this weekend effect has not been studied in carotid endarterectomy (CEA). Methods- We identified patients undergoing isolated CEA in the Vascular Quality Initiative between 2003 and 2018. Our primary outcome was in-hospital stroke or perioperative death (stroke/death), stratified by symptom status. For asymptomatic patients, we also compared rates of the Centers for Medicare and Medicaid Services quality metric prolonged length of stay (>2 days or failed discharge home). We calculated propensity scores and used multilevel, inverse probability weighted logistic regression clustering at the hospital level. Results- There were 86 123 repairs during the study period, 53% asymptomatic lesions and 47% symptomatic. Only 0.7% of asymptomatic patients underwent CEA on the weekend, compared with 3.1% of symptomatic patients. Patients undergoing weekend repairs were more often white, with lower rates of most comorbidities. In asymptomatic patients, weekend operations were associated significantly higher odds of stroke/death (odds ratio [OR], 2.3 [1.1-4.8]; P=0.02), and prolonged length of stay (OR, 3.6 [2.7-4.7]; P<0.001). In symptomatic patients, weekend operations were associated with significantly higher adjusted odds of stroke/death (OR, 1.7 [1.2-2.4]; P=0.007) and longer postoperative length of stay (3.3 days versus 2.0 days, P=0.002). However, the difference in stroke/death was driven by patients presenting with stroke (OR, 2.2 [1.5-2.3]; P<0.001), rather than those presenting with transient ischemic attack (OR, 1.2 [0.6-2.1]; P=0.56). Conclusions- We found evidence of a significant weekend effect in CEA, as weekend operations in asymptomatic patients and patients who presented with stroke were associated with higher rates of stroke/death and prolonged length of stay. However, there was no evidence of such an effect in patients with transient ischemic attack. These data suggest that weekend CEA should be avoided except in the case of expedited revascularization after transient ischemic attack.

Trends in use of echocardiography in hospitalized patients with syncope

PURPOSE

We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database.

METHODS

Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18 years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained.

RESULTS

A total of 3 174 619 patients with a primary discharge diagnosis of syncope were identified, of which 184 167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [P_trend  = 0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR = 0.827, P = 0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P < 0.001).

CONCLUSIONS

The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope.

Weekend effect on early allograft outcome after kidney transplantation- a multi-centre cohort study

Weekend surgery may be associated with a higher risk of early complications, but the effect of the timing of kidney transplant surgery on early allograft outcome remains uncertain. The aim of this study is to evaluate whether the association between weekend transplant surgery and allograft failure was modified by prevalent vascular disease. Using data from the Australia and New Zealand Dialysis and Transplant registry, we examined the association between weekend status and 90-day and 1-year allograft failure in deceased donor transplant recipients between 1994-2012. Two-way interaction between vascular disease and weekend status was examined. Of 6622 recipients, 1868 (28.2%) received transplants during weekends. Compared with weekday transplants, weekend transplants were associated with an adjusted hazard ratio (HR) for 90-day and 1-year allograft failure of 0.99 (0.78-1.25; P = 0.917) and 0.93 (0.76-1.13, P = 0.468), respectively. There was a significant interaction between prevalent vascular disease and weekend status for 90-day allograft failure (P_interaction = 0.008) but not at 1-year, such that patients with vascular disease were more likely to experience 90-day allograft failure if transplanted on weekend (versus weekdays), particularly failures secondary to vascular complications. Timing of transplantation does not impact on allograft outcome, although those with vascular disease may benefit from more intensive post-transplant follow-up for potential vascular complications.

No Weekend or After-Hours Effect in Acute Ischemic Stroke Patients Treated by Telemedicine

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.

Stroke admission outside daytime working hours delays mechanical thrombectomy and worsens short-term outcome

BACKGROUND AND PURPOSE

Rapid therapeutic decisions in acute stroke patients leading to earlier initiation of revascularization therapies are associated with better outcome. An association between regular working hours and reduced time to initiation of intravenous thrombolysis has been reported. However, its influence on mechanical thrombectomy (MT) remains uncertain. We aimed to analyze the effects of admission time on door-to-groin time and stroke outcome in a large prospective stroke registry of the Neurovascular Net Ruhr in Germany.

METHODS

Procedural times of a total of 512 patients treated with MT were analyzed. Admission to hospital during regular working days and hours (Monday to Friday, 8 am to 4 pm) was compared with admission outside these times. Door-to-groin time and the difference in NIH Stroke Scale between admission and discharge served as primary outcome parameters. Long-term functional outcome was centrally assessed with modified Rankin scale.

RESULTS

MT outside regular working hours was associated with a significant mean initiation delay of 20 min. By multivariate regression analysis, every 20 min delay of MT reduced the difference in NIHSS score between admission and discharge by 0.76 points (95% CI -1.24 to -0.28, p = 0.002). Favorable long-term outcome did not differ between both treatment groups.

CONCLUSIONS

Treatment outside regular working hours caused a significant delay in the initiation of MT, which was associated with a decreased short-term clinical efficacy of thrombectomy. Strategies like compulsory attendance of the interventional neuroradiologist at the hospital 24/7 might result in shorter door-to-groin times and consecutive in better stroke outcome.

The weekend effect in liver transplantation

Background

The weekend effect describes a phenomenon whereby patients admitted to hospitals on weekends are at higher risk of complications compared to those admitted during weekdays. However, if a weekend effect exists in orthotopic liver transplantation (oLT).

Methods

We analyzed oLT between 2006 and 2016 and stratified patients into weekday (Monday to Friday) and weekend (Saturday, Sunday) groups. Primary outcome measures were one-year patient and graft survival.

Results

364 deceased donor livers were transplanted into 329 patients with 246 weekday (74.77%) and 83 weekend (25.23%) patients. Potential confounders (e.g. age, ischemia time, MELD score) were comparable. One-year patient and graft survival were similar. Frequencies of rejections, primary-non function or re-transplantation were not different. The day of transplantation was not associated with one-year patient and graft survival in multivariate analysis.

Conclusions

We provide the first data for the Eurotransplant region on oLT stratified for weekend and weekday procedures and our findings suggest there was no weekend effect on oLT. While we hypothesize that the absent weekend effect is due to standardized transplant procedures and specialized multidisciplinary transplant teams, our results are encouraging showing oLT is a safe and successful procedure, independent from the day of the week.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cerebrovascular diseases in Poland-inconsistent seasonal patterns of hospitalisation and mortality

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.

Weekend Effect in Acute Pancreatitis-Related Hospital Admissions in the United States: An Analysis of the Nationwide Inpatient Sample

OBJECTIVE

This study aimed to assess the difference in overall outcomes between weekend admissions for acute pancreatitis (AP) and weekday admissions.

METHODS

Between 2005 and 2012, data were extracted from the Nationwide Inpatient Sample on adult patients with AP. Exclusion criteria were applied for chronic pancreatitis and other pancreatic and biliary malignancies. In-hospital mortality, length of stay, hospitalization costs, comorbidities, complications, and intervention rates were compared between the weekend and weekday admissions.

RESULTS

During the study period, there were a total of 432,303 weekday admissions and 147,435 weekend admissions for AP in the United States hospitals. Weekend AP admissions were more likely to develop alcohol withdrawal (5.9% vs 5.7%, P = 0.001) and ileus (4.1% vs 3.1%, P = 0.04). They were also more likely to develop acute respiratory distress syndrome (4.7% vs 4.4%, P < 0.001) and required more endotracheal intubation (3.9% vs 3.6%, P < 0.001). There was no significant in-hospital mortality difference between the weekend and weekday admissions on both univariate and multivariate analysis.

CONCLUSIONS

Weekend AP admissions develop more severe complications requiring intensive care. Despite this, there was no weekend effect for in-hospital mortality for AP-related admissions.

Interhospital Transfer of Neurosurgical Patients: Implications of Timing on Hospital Course and Clinical Outcomes

BACKGROUND

Interhospital transfer of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes. Lower survival rates have been reported for patients admitted at night and on weekends in other specialties. Whether time or day of admission affects neurosurgical patient outcomes, specifically those transferred from other facilities, is unknown.

OBJECTIVE

To examine the impact of the timing of interhospital transfer on the hospital course and clinical outcomes of neurosurgical patients.

METHODS

All consecutive admissions of patients transferred to our adult neurosurgical service were retrospectively analyzed for a 1-year study period using data from a central transfer database and the electronic health record.

RESULTS

Patients arrived more often at night (70.8%) despite an even distribution of transfer requests. The lack of transfer imaging did not affect length of stay, intervention times, or patient outcomes. Daytime arrivals had shorter total transfer time, but longer intenstive care unit and overall length of stay (8.7 and 11.6 days, respectively), worse modified Rankin Scale scores, lower rates of functional independence, and almost twice the mortality rate. Weekend admissions had significantly worse modified Rankin Scale scores and lower rates of functional independence.

CONCLUSIONS

The timing of transfer arrivals, both by hour or day of the week, is correlated with the time to intervention, hospital course, and overall patient outcomes. Patients admitted during the weekend suffered worse functional outcomes and a trend towards increased mortality. While transfer logistics clearly impact patient outcomes, further work is needed to understand these complex relationships.

Weekend Versus Weekday Admission and In-Hospital Mortality for Pulmonary Embolism: A 14-Year Retrospective Study on the National Hospital Database of Italy

We assessed the association between weekday (WD) or weekend (WE) admission and mortality for patients hospitalized with acute pulmonary embolism (PE). Weekend included holidays. We analyzed hospital administrative data of all patients discharged with a diagnosis of PE extracted from the Italian Health Ministry database (January 2001 to December 2014). A total of 265 035 hospitalizations with a diagnosis of PE were retrieved, in which PE was the primary diagnosis in 198 565 (74.9%); 200 166 (75.5%) patients were admitted on WD and 64 869 (24.5%) on WE. Admissions for PE were more frequent on Mondays (41 917 admissions, 15.8% of all events) and less frequent on Saturdays (32 295 admissions, 12.2%) and Sundays (32 574 admissions, 12.3%). Patients admitted on WE were on average 1 year older, presented more frequently with respiratory failure, and had more common comorbidities. After adjustment for age, gender, comorbidities, and presence of respiratory failure, in-hospital mortality for patients admitted on WE was greater (odds ratio: 1.15, 95% confidence interval: 1.13-1.18; P < .001). This study supports that, in Italy, hospitalization for PE on WE is associated with a significantly higher mortality rate than on WD.

Is there a "weekend effect" in kidney transplantation?

The ‘weekend effect’ describes increased adverse outcomes after weekend hospitalization.

We examined weekend-weekday differences in the outcome of 580 patients following renal transplantation (RTx, brain dead donors) between January 2007 and December 2014 at our center. 3-year patient and graft survival, incidence of delayed graft function (DGF), acute rejections and estimated glomerular filtration rate (eGFR, CKD-EPI) at 1 year as well as surgical complications were assessed. Of all 580 transplants, 416 (71.7%) were performed on weekdays (Monday-Friday) and 164 (28.3%) on weekends (Saturday-Sunday). 3-year patient and graft survival, frequencies of DGF, acute rejections and 1-year eGFR as well as length of hospital stay were similar between RTx patients transplanted on weekdays or weekends, respectively. However, a noticeable difference was detected with regard to surgical complications which were more frequent in RTx patients transplanted on weekends. All results remained consistent across all definitions of weekend status. Our results suggest that weekend transplant status does not affect functional short-term and long-term outcomes after RTx. The standardized protocols and operationalized processes applied in RTx might contribute to this finding and may provide a model for other medical procedures that are performed on weekends to improve efficiency and outcomes. The higher rate of surgical complications after weekend RTx needs further elaboration to fully assess the presence of a weekend effect in RTx.

Are «off hours» intubations a risk factor for complications during intubation? A prospective, observational study

OBJECTIVE

To compare the complications and the difficulty of orotracheal intubation procedures performed in the Intensive Care Unit during the off-hours period and the on-hours period.

DESIGN

A prospective, observational and non-interventional cohort study covering a period of 27 months was carried out. Working days between 8:00 a. m. and 7:59 p. m. were considered «on-hours», while the remaining shifts were regarded as «off-hours».

SCOPE

An 18-bed surgical in a Intensive Care Unit of a third-level hospital.

PATIENTS

All orotracheal intubation patients admitted to the ICU from January 2015 to March 2017 were included. Patients were stratified into 2groups according to whether intubation was performed on-hours or off-hours.

INTERVENTIONS

Non-interventional study.

VARIABLES OF INTEREST

The reason for intubation, time and day on which intubation was performed, degree of intubation difficulty (number of attempts, Cormack-Lehane laryngoscopic vision, need for accessory material) and complications during intubation.

RESULTS

A total of 252 patients were intubated; of these, 132 were included in the on-hours group and 120 patients in the off-hours group. In the off-hours group we observed a greater percentage of urgent and emergent intubations compared to the on-hours group. However, no differences were found between the 2groups in relation to the other variables studied.

CONCLUSIONS

During the off-hours period, orotracheal intubation was not associated to a greater number of complications or to greater difficulty of the technique in our Unit.

There is no weekend effect in hip fracture surgery - A comprehensive analysis of outcomes

BACKGROUND

Previous studies have shown that some patient groups suffer adverse outcomes if they are acutely admitted to hospital over a weekend. We aimed to investigate this 'weekend effect' at our centre in patients presenting with a hip fracture.

METHODS

Consecutive patients undergoing acute hip fracture surgery were identified from a prospective database. Patient demographics, co-morbidities, fracture type, admission blood parameters were examined. Outcomes analysed included 30-day, 90-day and 1-year mortality as well as length of stay, re-operations and delay to surgery. The data were analysed with regards to day of admission and day of surgery separately.

RESULTS

A total of 1326 patients were included, of which 368 patients were admitted over a weekend and 411 patients had their operation over a weekend. Overall 30-day mortality was 7.6% (101 patients), whilst the 90-day and 1-year mortalities were 15.3% and 26.8% (203 and 356 patients). There were no significant differences in any of the outcomes based on the day of admission or the day of surgery. Multivariate analysis for 30-day mortality demonstrated the following variables to be significant predictors: admission urea levels (hazard ratio (HR) 1.042, p = 0.027), age (HR 1.058, p < 0.001), admission source (HR 1.428, p < 0.001), surgical delay >48 h (HR 1.853, p = 0.004), male gender (HR 1.967, p = 0.003), previous stroke (HR 2.261, p = 0.038), acute chest infection (4.240, p < 0.001) and chronic liver disease (HR 4.581, p = 0.014).

CONCLUSION

This data suggests that there is no significant weekend effect in hip fracture surgery and mortality is affected by patient co-morbidities and delay to surgery.

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

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

Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards

INTRODUCTION

Patients admitted to hospital in an emergency at weekends have been found to experience higher mortality rates than those admitted during the week. The National Health Service (NHS) in England has introduced four priority clinical standards for emergency hospital care with the objective of reducing deaths associated with this 'weekend effect'. This study aimed to determine whether adoption of these clinical standards is associated with the extent to which weekend mortality is elevated.

METHODS

We used publicly available data on performance against the four priority clinical standards in 2015 and estimates of Trusts' weekend effects between 2013/2014 and 2015/2016 for 123 NHS Trusts in England. We examined whether adoption of the priority clinical standards was associated with the extent to which weekend mortality was elevated, and changes over a 3 year period in the extent to which mortality was elevated.

RESULTS

Levels of achievement of two of the four clinical standards (ongoing review and access to diagnostic services) had small positive associations with the magnitude of the weekend effect in 2015/2016. Levels of achievement of the remaining two standards (time to first consultant review and access to consultant directed interventions) had small negative associations with the magnitude of the weekend effect in 2015/2016. No association was statistically significant. The same pattern was observed in the associations between achievement of the standards and changes in the magnitudes of the weekend effect between 2013/2014 and 2015/2016.

DISCUSSION

We found no association between Trusts' performance against any of the four standards and the current magnitude of their weekend effects, or the change in their weekend effects over the past 3 years. These findings cast doubt on whether adoption of seven day clinical standards in the delivery of emergency hospital services will be successful in reducing the weekend effect.

Weekend admission and mortality for gastrointestinal disorders across England and Wales

BACKGROUND

Little has been reported on mortality following admissions at weekends for many gastrointestinal (GI) disorders. The aim was to establish whether GI disorders are susceptible to increased mortality following unscheduled admission on weekends compared with weekdays.

METHODS

Record linkage was undertaken of national administrative inpatient and mortality data for people in England and Wales who were hospitalized as an emergency for one of 19 major GI disorders.

RESULTS

The study included 2 254 701 people in England and 155 464 in Wales. For 11 general surgical and medical GI disorders there were little, or no, significant weekend effects on mortality at 30 days in either country. There were large consistent weekend effects in both countries for severe liver disease (England: 26·2 (95 per cent c.i. 21·1 to 31·6) per cent; Wales: 32·0 (12·4 to 55·1 per cent) and GI cancer (England: 21·8 (19·1 to 24·5) per cent; Wales: 25·0 (15·0 to 35·9) per cent), which were lower in patients managed by surgeons. Admission rates were lower at weekends than on weekdays, most strongly for severe liver disease (by 43·3 per cent in England and 51·4 per cent in Wales) and GI cancer (by 44·6 and 52·8 per cent respectively). Both mortality and the weekend mortality effect for GI cancer were lower for patients managed by surgeons.

DISCUSSION

There is little, or no, evidence of a weekend mortality effect for most major general surgical or medical GI disorders, but large weekend effects for GI cancer and severe liver disease. Lower admission rates at weekends indicate more severe cases. The findings for severe liver disease may suggest a lack of specialist hepatological resources. For cancers, reduced availability of end-of-life care in the community at weekends may be the cause.

Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle Time

Door-to-needle time (DNT) is a key performance indicator for efficient use of intravenous thrombolysis in acute ischemic stroke (AIS). We aimed to determine whether DNT improved over time in the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED) and the clinical predictors of DNT. Temporal trends in DNT were assessed across fourths of time since activation of study centers using generalized linear model. Predictors of long DNT (>60 min) were determined in logistic regression models. Overall mean DNT (min) was 71.8 (95% confidence interval [CI] 70.4–73.2), but decreased significantly over time (fourths): 77.9 (74.9–80.9), 69.3 (66.7–72.0), 69.1 (66.5–71.8) and 71.4 (68.7–74.2) (P for trend, 0.003). The reduction in DNT was particularly marked in China (P for trend, 0.001), but was not significant across the other participating countries (P for trend, 0.065). Independent predictors of long DNT were recruitment from China, short onset-to-door time, lower numbers of patients treated per center, higher diastolic blood pressure, off-hour admission, and absence of proximal clot occlusion. DNT in ENCHANTED declined progressively during the trial, especially in China. However, DNT in China is still longer than the key performance parameter of ≤60 minutes recommended in guidelines. Effective national programs are needed to improve DNT in China.

[Mortality and medical care of patients hospitalized during weekends]

BACKGROUND AND OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Pharmacist Participation in Acute Ischemic Stroke Decreases Door-to-Needle Time to Recombinant Tissue Plasminogen Activator

Background: Pharmacists are an important member of the stroke team and aid in obtaining medication and medical history, providing education, managing blood pressure, reviewing exclusion criteria for recombinant tissue plasminogen activator (rtPA), and facilitating reconstitution and administration of rtPA. Objective: To determine if pharmacist presence at bedside during acute ischemic stroke resulted in a reduction in door-to-needle (DTN) times. Methods: This was a retrospective cohort study between January 1, 2011 and December 31, 2015 of patients who received rtPA for acute ischemic stroke in either the emergency department or hospital. Results: Of the 125 included patients, 45 patients (36%) had a pharmacist present (PharmD group) and 80 patients (64%) did not (no PharmD group). Median DTN time was significantly shorter in the PharmD group: 48 minutes versus 73 minutes in the no PharmD group ( P < 0.01). The goal of DTN ≤60 minutes was met in 71% of patients in the PharmD group compared to 29% ( P < 0.01). Pharmacist at the bedside was the only factor found to be independently associated with reduction DTN time (βcoefficient −23.5 minutes, 95% confidence interval [95% CI] −38.6 to −8.50 minutes). Conclusion: A pharmacist at the bedside of emergency department or in-patient stroke codes reduced DTN time by a median of 23.5 minutes after adjusting for confounding factors and increased the percentage of patients meeting DTN goal time of ≤60 minutes by 49%. These findings support the inclusion of a stroke-competent pharmacist in the bedside response team for acute ischemic stroke patients.

Leveraging Telemedicine Infrastructure to Monitor Quality of Operating Room to Intensive Care Unit Handoffs

PURPOSE

To analyze in-room video recordings of operating room (OR) to intensive care unit (ICU) handoffs to determine tempo and quality of team interactions on nights and weekends compared with weekdays, and to demonstrate how existing telemedicine technology can be used to evaluate handoffs.

METHOD

This prospective observational study of OR-to-ICU bedside handoffs was conducted in the surgical ICU of the Hospital of the University of Pennsylvania in July 2014-January 2015. Handoff video recordings were obtained for quality improvement purposes using existing telemedicine cameras. Evaluators used adapted validated in-person assessment measures to analyze basic characteristics and quality measures (timing, report types, report duration, presence of physical exam, teamwork skills, engagement, report delivery skills, listening skills, interruptions, unprofessional comments or actions).

RESULTS

Sixteen weekday and 16 night and weekend handoffs were compared. There were no significant differences in basic characteristics. Most quality measures were similar on weekdays compared with nights and weekends. Surgeons demonstrated better report delivery skills and engagement on nights and weekends (P = .002 and P = .04, respectively), whereas OR anesthesiologists' scores were similar during both time frames.

CONCLUSIONS

This study presents a novel approach of assessing handoff quality in OR-to-ICU handoffs using an existing telemedicine infrastructure. Using this approach, quality measures of night and weekend handoffs were found to be no worse-and sometimes better-than those during weekdays. Video analysis may emerge as an ideal unobtrusive quality improvement methodology to monitor handoffs and improve education and compliance with institutional handoff policies.

What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers

Background

There is strong public support for acute hospital services to move to genuine 7-day models, including access to multidisciplinary team assessment. This study aimed to identify factors that might enable an effective and cost-effective weekend allied health services on acute hospital wards.

Methods

This qualitative study included 22 focus groups within acute wards with a weekend allied health service and 11 telephone interviews with weekend service providers. Data were collected from 210 hospital team members, including 17 medical, 97 nursing, and 96 allied health professionals from two Australian tertiary public hospitals. All were recorded and imported into nVivo 10 for analysis. Thematic analysis methods were used to develop a coding framework from the data and to identify emerging themes.

Results

Key themes identified were separated into issues perceived as being enablers or barriers to the effective or cost-effective delivery of weekend allied health services. Perceived enablers of effectiveness and cost-effectiveness included prioritizing interventions that prevent decline, the right person delivering the right service, improved access to the patient’s family, and ability to impact patient flow. Perceived barriers were employment of inexperienced weekend staff, insufficient investment to see tangible benefit, inefficiencies related to double-handling, unnecessary interventions and/or inappropriate referrals, and difficulty recruiting and retaining skilled staff.

Conclusions

Suggestions for ensuring effective and cost effective weekend allied health care models include minimization of task duplication and targeting interventions so that the right patients receive the right interventions at the right time. Further research into the effectiveness and cost effectiveness of these services should factor in hidden costs, including those associated with managing the service.

Potentially preventable complications in epilepsy admissions: The "weekend effect"

INTRODUCTION

Epilepsy affects approximately 1% of the population in the United States with frequent hospital admissions accounting for a significant burden on patients and society as a whole. Weekend admissions have generally been found to have poorer outcomes compared to weekday admissions with increased rates of preventable complications, such as nationally identified "hospital-acquired conditions" (HAC).

OBJECTIVE

This study aimed to assess the impact of weekend admission on HACs and mortality in the adult epilepsy population.

PARTICIPANTS

All adult patients with epilepsy hospitalized in the U.S. from 2000 to 2010 in the Nationwide Inpatient Sample.

RESULTS

There were 12,997,181 admissions for epilepsy with 10,106,152 (78%) weekday, 2,891,019 (22%) weekend, and 10 (<0.1%) missing admissions. Weekend admissions saw a 10% increased likelihood of both HACs (RR=1.10, 95% CI:1.09, 1.11, p<0.01) and mortality (RR=1.10, 95% CI: 1.09, 1.11, p<0.01) compared to weekday admissions. The occurrence of HAC was associated with higher inpatient charges (RR=1.36, 95% CI: 1.35, 1.36, p<0.01), pLOS (RR=1.21, 95% CI: 1.21, 1.22, p<0.01), and higher mortality (RR=1.13, 95% CI: 1.12, 1.14, p<0.01).

CONCLUSION

Prior studies have shown weekend admissions are usually associated with higher rates of complications leading to higher costs and a longer hospital stay. Likewise, weekend admissions for epilepsy were associated with increased rates of HACs and mortality; however, they were also negatively associated with LOS and total charge. Thus, weekend admissions for epilepsy should be considered high risk with greater effort made to mitigate these risks.

Survival analysis of weekend emergency medical admissions

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Lack of a "Weekend Effect" for Renal Transplant Recipients

The "weekend (WE) effect" defines the association between WE hospital admissions and higher rate of mortality. The aim of this study was to evaluate the relationship between WE effect and renal transplant recipients (RTRs) using the database of the Emilia-Romagna region (ERR), Italy. We included ERR admissions of RTRs ( International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM] code V420) between 2000 and 2013. In-hospital mortality, admissions due to cardiovascular events (CVEs), and the Elixhauser score were evaluated on the basis of ICD-9-CM codification. Out of 9063 hospital admissions related to 3648 RTRs (mean age 53 ± 13 years, 62.9% male), 1491 (16.5%) were recorded during the WE. During the follow-up period, 1581 (17.4%) patients deceased and 366 (4%) had CVEs. Length of hospital stay (LOS) was 9.7 ± 12.1 days. Logistic regression analysis showed that only LOS was independently associated with WE admissions (odds ratio: 1594, confidence interval: 1.385-1.833; P < .001). Renal transplant recipients are not exposed to higher risk of adverse outcome during WE admissions. However, WE admissions were characterized by an increased duration of hospitalization.

Mortality Associated with Night and Weekend Admissions to ICU with On-Site Intensivist Coverage: Results of a Nine-Year Cohort Study (2006-2014)

Background

The association between mortality and time of admission to ICU has been extensively studied but remains controversial. We revaluate the impact of time of admission on ICU mortality by retrospectively investigating a recent (2006–2014) and large ICU cohort with on-site intensivist coverage.

Patients and Methods

All adults (≥ 18 years) admitted to a tertiary care medical ICU were included in the study. Patients' characteristics, medical management, and mortality were prospectively collected. Patients were classified according to their admission time: week working days on- and off-hours, and weekends. ICU mortality was the primary outcome and adjusted Hazard-ratios (HR) of death were analysed by multivariate Cox model.

Results

2,428 patients were included: age 62±18 years; male: 1,515 (62%); and median SAPSII score: 38 (27–52). Overall ICU mortality rate was 13.7%. Admissions to ICU occurred during open-hours in 680 cases (28%), during night-time working days in 1,099 cases (45%) and during weekends in 649 cases (27%). Baseline characteristics of patients were similar between groups except that patients admitted during the second part of night (00:00 to 07:59) have a significantly higher SAPS II score than others. ICU mortality was comparable between patients admitted during different time periods but was significantly higher for those admitted during the second part of the night. Multivariate analysis showed however that admission during weeknights and weekends was not associated with an increased ICU mortality as compared with open-hours admissions.

Conclusion

Time of admission, especially weeknight and weekend (off-hour admissions), did not influence the prognosis of ICU patients. The higher illness severity of patients admitted during the second part of the night (00:00–07:59) may explain the observed increased mortality.

Management of polytrauma patients in the UK: Is there a 'weekend effect'?

BACKGROUND/PURPOSE

It has been suggested that hospital admission during weekends poses a risk for adverse outcomes and increased patient mortality, the so-called 'weekend effect'. We undertook an evaluation of the impact of weekend admissions to the management of polytraumatised patients, in a Level I Major Trauma Centre (MTC) in the UK.

MATERIALS AND METHODS

A retrospective review of prospectively documented data of polytrauma patients (injury severity score (ISS)>15), admitted between April 2013 and August 2015 was performed. Exclusion criteria included patients initially assessed in other institutions. All patients were initially managed at the emergency department (ED) according to ATLS^® principles and underwent a trauma computed tomography (CT) scan, unless requiring immediate surgical intervention.

RESULTS

During the study period 1735 patients (pts) were admitted under the care of the MTC. Four hundred and five pts were excluded as they were transferred from other institutions and 300 pts were excluded as their ISS was less than 16. Overall 1030 patients met the inclusion criteria, out of which 731 were males. Comparing the two groups (Group A: weekday admissions (670), Group B: weekend admissions (360)), there was no difference in pts gender, mechanism of injury, GCS at presentation, need for intubation and time to CT. Patients admitted over the weekend were younger (p<0.01) and presented with haemodynamic instability more frequently (p=0.02). Time to operating room was also lower during the weekend, but this did not reach statistical significance (p=0.08). Mortality was lower in Group B: 39/360 pts (10.8%) compared to Group A: 100/670 pts (14.9%) (p=0.07). The relative risk (RR) of weekend mortality was calculated as 0.726 (95% CI: 0.513-1.027).

DISCUSSION/CONCLUSION

Weekend polytrauma patients appear to be younger, more severely injured and present with a higher incidence of haemodynamic instability (shock). Overall, we failed to identify a "weekend effect" in relation to mortality, time to CT and time to operating room. On the contrary, a lower risk of mortality was noted for patents admitted during the weekend.

Weekend Discharge and Stroke Quality of Care: Get With The Guidelines-Stroke Data from a Comprehensive Stroke Center

OBJECTIVE

Get With The Guidelines-Stroke collects data on hospital compliance with evidence-based stroke quality of care indicators. Prior work has investigated a link between weekend hospital admission and increased mortality after stroke. There is, however, a paucity of work investigating a similar association between weekend hospital discharge and quality of care. We aimed to determine if weekend discharge affects care to enlighten opportunities for quality improvement.

MATERIALS AND METHODS

Through a retrospective analysis of records from a Comprehensive Stroke Center from July 2010 to June 2015, we identified patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Our quality of care indicators were dysphagia screening, rehabilitation assessment, smoking cessation counseling, stroke education, and weight reduction counseling. We created regression models to find adjusted differences in quality of care measure compliance for patients discharged on the weekend.

RESULTS

Our analysis included 2737 patients, of which 431 were discharged on the weekend. After adjustment, weekend discharge was significantly associated with reduced stroke education (odds ratio .67, confidence interval .51-0.88, P = .004) and reduced weight reduction counseling (odds ratio .65, confidence interval .45-0.93, P = .018).

CONCLUSIONS

Hospital discharge on the weekend was associated with an adjusted one-third decrease in odds of stroke education and weight reduction counseling. There is an opportunity for quality improvement in educating stroke patients before hospital discharge on the weekend.

Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan

Background

A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway.

Methods

This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation.

Results

Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034).

Conclusions

In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.