The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery

In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®

PURPOSE

Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma.

METHODS

We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality.

RESULTS

We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group.

CONCLUSIONS

There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.

Perioperative mortality among trauma patients in Northwest Ethiopia: a prospective cohort study

Trauma is the leading cause of mortality in persons under 45 and a significant public health issue. Trauma is the most frequent cause of perioperative mortality among all surgical patients. Little is known about perioperative outcomes among trauma patients in low-income countries. This study aimed to assess the incidence and identify predictors of perioperative mortality among adult trauma victims at Tibebe Ghion Specialised Hospital. From June 1, 2019, to June 30, 2021, a prospective cohort study was conducted at Tibebe Ghion Specialized Hospital. Demographic, pre-hospital and perioperative clinical data were collected using an electronic data collection tool, Research Electronic Data Capture (REDCap). Cox proportional hazard model regression was used to assess the association between predictors and perioperative mortality among trauma victims. Crude and adjusted hazard ratio (HR) with a 95% confidence interval (CI) was computed; a p-value < 0.05 was a cutoff value to declare statistical significance. One thousand sixty-nine trauma patients were enrolled in this study. The overall incidence of perioperative mortality among trauma patients was 5.89%, with an incidence rate of 2.23 (95% CI 1.74 to 2.86) deaths per 1000 person-day observation. Age ≥ 65 years (AHR = 2.51, 95% CI: 1.04, 6.08), patients sustained blunt trauma (AHR = 3.28, 95% CI: 1.30, 8.29) and MVA (AHR = 2.96, 95% CI: 1.18, 7.43), trauma occurred at night time (AHR = 2.29, 95% CI: 1.15, 4.56), ASA physical status ≥ III (AHR = 3.84, 95% CI: 1.88, 7.82), and blood transfusion (AHR = 2.01, 95% CI: 1.08, 3.74) were identified as a significant predictor for perioperative mortality among trauma patients. In this trauma cohort, it was demonstrated that perioperative mortality is a healthcare burden. Risk factors for perioperative mortality among trauma patients were old age, patients sustaining blunt trauma and motor vehicle accidents, injuries at night, higher ASA physical status, and blood transfusion. Trauma care services need improvement in pre-hospital and perioperative care.

Postoperative wound dehiscence in mandibular fractures

OBJECTIVE

To clarify the occurrence and causes of non-infection-related surgical wound dehiscence (SWD) in intraorally treated mandibular fractures.

MATERIAL AND METHODS

Patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach were included in this retrospective study. The primary outcome variable was SWD. Associations between patient-, fracture- and surgery-related variables and SWD were evaluated.

RESULTS

Altogether 232 patients with 270 mandibular angle, body, symphysis and/or parasymphysis fractures were included in the analysis. In all, 22 SWDs were detected. These occurred in 9.5% of patients and in 8.1% of fractures. Surgery performed at night-time showed a significantly higher SWD rate than daytime surgeries (p = .012). Additionally, a significantly greater SWD rate was found among smokers (p = .041). Other studied variables remained statistically non-significant for SWD. In a multivariate analysis, night-time was the only significant independent variable with an odds ratio of 3.297 (95% CI 1.238 - 8.780, p = .017) for SWD.

CONCLUSION

The approach or closure technique used and the fracture type had only a minor effect on non-infection-related SWD in patients with mandibular fractures. To avoid SWDs, mandibular fracture surgeries should be conducted during the daytime with adequate support from an experienced surgeon.

Effect of Nighttime on Prehospital Care and Outcomes of Road Traffic Injuries in Asia: A Cross-Sectional Study of Data from the Pan-Asian Trauma Outcomes Study (PATOS)

Introduction: Emergency response to a road traffic injury (RTI) plays a crucial role in patient survival, and the quality of the emergency response should be consistent regardless of the time of day. The aim of this study was to investigate prehospital care and survival outcomes compared between emergency response to RTI during the day and emergency response to RTI at night in Asia.Method: This cross-sectional study used data from the Pan-Asian Trauma Outcome Study (PATOS) that was conducted during 2015-2018. We included RTI patients who were transported to the emergency department (ED) by ground ambulance. That group was then categorized according to the time that the ambulance arrived on-scene. On-scene arrival during 8:00 am to 7:59 pm was defined as the daytime group, and arrival during 8:00 pm to 7:59 am was defined as the nighttime group. Multiple logistic regression was employed to identify factors associated with nighttime prehospital interventions and survival outcomes after adjustment for age, alcohol consumption, and injury severity score (ISS).Results: The final analysis included 20,105 RTI patients. Of those, 12,043 (60%) accidents occurred during the daytime, and 8,062 (40%) occurred at night. RTI patients at night were younger (mean age: 35.7 ± 17.3 vs. 39.5 ± 20.7; p < 0.001), had more alcohol consumption (15.0% vs. 4.2%; p < 0.001), and had more severe injuries (mean ISS: 6.5 ± 7.5 vs. 5.8 ± 7.0; p < 0.001) compared to the daytime group. The nighttime group had increased prehospital immobilization (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.14-1.31) and more prehospital intravenous (IV) access (aOR 1.36, 95%CI: 1.22-1.51). There was no significant difference in either basic or advanced airway management between the daytime and nighttime groups. The nighttime group had decreased survival in the ED (aOR: 0.80, 95%CI: 0.65-0.98); however, nighttime on-scene arrival did not impact survival to discharge (aOR: 1.10, 95%CI: 0.91-1.33).Conclusion: In the PATOS community, RTI patients that sustained their injuries at night received significantly more prehospital immobilization and IV access, and they had significantly decreased survival in the ED. The results of this study can be used to develop and enhance strategies to improve the care and outcomes of nighttime RTI in Asia.

The Patterns and Impact of Off-Working Hours, Weekends and Seasonal Admissions of Patients with Major Trauma in a Level 1 Trauma Center

Background: The trauma incidence follows specific patterns in different societies and is expected to increase over the weekend and nighttime. We aimed to explore and analyze the incidence, pattern, and severity of trauma at different times (working hours vs. out off-working hours, weekdays vs. weekends and season). Methods: A retrospective analysis was conducted at a level 1 trauma facility in Qatar. All injured patients admitted between June 2017 and May 2018 were included. The data were analyzed to determine whether outcomes and care parameters of these patients differed between regular working hours and off-working hours, weekdays vs. weekends, and between season intervals. Results: During the study period, 2477 patients were admitted. A total of 816 (32.9%) patients presented during working hours and 1500 (60.6%) during off-working hours. Off-working hours presentations differed significantly with the injury severity score (ISS) (p  <  0.001), ICU length of stay (p  =  0.001), blood transfusions (p = 0.001), intubations (p = 0.001), mortality rate (9.7% vs. 0.7%; p < 0.001), and disposition to rehabilitation centers. Weekend presentations were significantly associated with a higher ISS (p = 0.01), Priority 1 trauma activation (19.1% vs. 14.7%; p = 0005), and need for intubation (21% vs. 16%; p = 0.002). The length of stay (ICU and hospital), mortality, and disposition to rehabilitation centers and other clinical parameters did not show any significant differences. No significant seasonal variation was observed in terms of admissions at the trauma center. Conclusions: The off-working hours admission showed an apparent demographic effect in involved mechanisms, injury severity, and trauma activations, while outcomes, especially the mortality rate, were significantly different during nights but not during the weekends. The only observed seasonal effect was a decrease in the number of admissions during the summer break.

Rate and risk factors for wound complications after internal hemipelvectomy

AIMS

Although internal hemipelvectomy is associated with a high incidence of morbidity, especially wound complications, few studies have examined rates of wound complications in these patients or have identified factors associated with the consequences. The present study aimed to: 1) determine the rate of wound and other complications requiring surgery after internal hemipelvectomy; and 2) identify factors that affect the rate of wound complications and can be used to stratify patients by risk of wound complications.

METHODS

The medical records of 123 patients undergoing internal hemipelvectomy were retrospectively reviewed, with a focus on both overall complications and wound complications. Logistic regression analyses were performed to examine the association between host, tumour, and surgical factors and rates of postoperative wound complications.

RESULTS

The overall rate of postoperative complications requiring surgery was 49.6%. Wound complications were observed in 34.1% of patients, hardware-related complications in 13.2%, graft-related complications in 9.1%, and local recurrence in 5.7%. On multivariate analysis, extrapelvic tumour extension (odds ratio (OR) 23.28; 95% confidence interval (CI), 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumour extension (OR 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion ≥ 20 units (OR 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with postoperative wound complications.

CONCLUSION

Internal hemipelvectomy is associated with high rates of morbidity, especially wound complications. Several host, tumour, and surgical variables are associated with wound complications. The ability to stratify patients by risk of wound complications can help refine surgical and wound-healing planning and may lead to better outcomes in patients undergoing internal hemipelvectomy. Cite this article: Bone Joint J 2020;102-B(3):280-284.

Does arrival time affect outcomes among severely injured blunt trauma patients at a tertiary trauma centre?

BACKGROUND AND AIMS

We aimed to determine whether the outcome of severely injured patients differs based on admission time (office hours vs. non-office hours) at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. We also studied subgroups of patients presenting with a New Injury Severity Score (NISS) ≥ 25 and patients experiencing major bleeding.

PATIENTS AND METHODS

This trauma registry study consisted of severely injured patients (NISS > 15) with blunt trauma treated between 2006 and 2017 at a single institute. Causes of deaths were obtained from autopsy reports and classified as resulting from brain injury; exsanguination; multi-organ failure, adult respiratory distress syndrome, or sepsis; or other.

RESULTS

Among 1853 patients, 497 (27%) were admitted during office hours (OH) and 1356 (73%) during non-office hours (NOH). Further subgroup analysis consisted of 211 OH and 611 NOH patients with NISS ≥ 25, and 51 OH and 154 NOH patients experiencing major bleeding. The 30-day in-hospital mortality was 3.8%-7.4% lower in the NOH groups. We found no significant differences between the study groups in neither the standardised mortality ratio (SMR, defined as the ratio of observed to expected mortality) nor in the causes of death. In both groups, the primary cause of death resulted from brain injury.

CONCLUSIONS

We found that arrival time did not affect mortality among patients with severe blunt trauma treated at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. Thus, this type of unit can maintain a standard of care during non-office hours by investing in precise treatment protocols and continuous education. However, our results do not apply to penetrating trauma injury patients.

Safe on Saturday: Elective abdominal and perineal surgeries can be performed on Saturday without increased risk of poor post-operative outcome

BACKGROUND

The "weekend effect," whereby surgeries performed during weekend haven been associated with poorer postoperative outcomes. We explored whether Saturday elective procedures at our hospital were associated with poorer post-operative outcomes when compared with weekday surgeries.

METHODS

A retrospective cohort study of patients undergoing elective surgery on the abdomen or perineum from 2008 to 2015 was performed. Procedures were classified by day (Group 1: Monday, Tuesday, Wednesday; Group 2: Saturday). Multivariate regression analyses were performed to determine group differences in procedure duration, length-of-stay (LOS) and complications.

RESULTS

In adjusted analyses, there were no statistically significant differences between Group 1 (n = 816) and Group 2 (n = 269) procedures in terms of procedure duration (Group 2 - Group 1 = 13.6 min, p = .19), LOS (Group 2 - Group 1 = 1.9 days, p = .14) and complications (OR 0.58, p = .46).

CONCLUSION

Saturday elective procedures were not associated with poorer outcomes.

Who elects the weekend?

Chaim M. Bell and Lauren Lapointe-Shaw discuss the meaning of the "weekend effect" in outcomes for hospital admissions and surgeries, and comment on surprising new results published in PLOS Medicine this week.

"After-hours" staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy

OBJECTIVE

To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC).

DESIGN, PARTICIPANTS AND SETTING

Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011.

MAIN OUTCOME MEASURE

Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality.

RESULTS

There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87).

CONCLUSION

The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study

Background

Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours.

Methods

This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002–2005, 2006–2009, and 2010–2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models.

Results

Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1–2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours.

Conclusions

At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.

Outcomes of nonelective weekend admissions for lower extremity ischemia

OBJECTIVE

A "weekend effect" has been demonstrated for a number of diagnoses, including many cardiovascular pathologies. Whether patients with lower extremity ischemia admitted over the weekend have inferior outcomes compared with those admitted on a weekday is unknown.

METHODS

Nonelective admissions for critical limb ischemia (CLI) and acute limb ischemia (ALI) from lower extremity thrombosis or embolism were identified in the 2005 to 2010 Nationwide Inpatient Sample, and outcomes were compared based on weekend vs weekday admission by using multiple logistic and linear regression.

RESULTS

Of the 63,768 patients identified with lower extremity vascular emergencies, 15.4% were admitted during the weekend. Patients admitted on the weekend were less likely to have CLI than those admitted on a weekday (51.2% vs 65.4%; P < .001) and were more likely to have ALI than patients admitted during a weekday (48.8% vs 34.5%; P < .001). Weekend admission was independently associated with a lower likelihood of revascularization (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.85-0.95; P < .001), a longer time until revascularization (3.09 days vs 2.75 days; P < .001), an increased likelihood of major amputation (aOR, 1.35; 95% CI, 1.19-1.53; P < .001), in-hospital complications (aOR, 1.18; 95% CI, 1.11-1.25; P < .001), and discharge to a skilled nursing facility (aOR, 1.15; 95% CI, 1.06-1.25; P = .001), and a longer predicted length of stay (10.1 days vs 9.5 days; P < .001). There was no statistically significant association between weekend admission and in-hospital mortality (aOR, 1.15; 95% CI, 1.06-1.25; P = .10).

CONCLUSIONS

Patients admitted on the weekend for lower extremity vascular emergencies are significantly more likely to experience adverse outcomes, including major amputation, than patients admitted on a weekday, independent of their presenting diagnosis with ALI or CLI. Further investigation into the etiologies of these differences is needed to address this disparity. These data raise questions about the proper staffing models to optimize urgent treatment of lower extremity vascular emergencies.

A population based study on the night-time effect in trauma care

BACKGROUND

The so-called off hour effect-that is, increased mortality for patients admitted outside normal working hours-has never been demonstrated in trauma care. However, most of the studies excluded transferred cases. Because these patients are a special challenge for trauma systems, we hypothesised that their processes of care could be more sensitive to the off hour effect.

METHODS

The study design was retrospective, cohort and population based. We compared the mortality of all patients by daytime and night-time admittance to hospitals in an Italian region, with 4.5 million inhabitants, following a major injury in 2011. Logistic regression was used, adjusted for demographics and severity of injury (TMPM-ICD9), and stratified by transfer status.

RESULTS

1940 major trauma cases were included; 105 were acutely transferred. Night-time admission had a significant pejorative effect on mortality in the adjusted analysis (OR=1.49; 95% CI 1.05 to 2.11). This effect was most evident in transferred cases (OR=3.71; 95% CI 1.11 to 12.43).

CONCLUSIONS

The night-time effect in trauma care was demonstrated for the first time and was maximal in transferred cases. This may explain why it was not found in previous studies where these patients were mostly excluded. Also, the use of population based data-whereby patients not accessing trauma centre care and presumably receiving poorer care were included-may have contributed to the findings.

"Weekend effects" in patients with intracerebral hemorrhage

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

Hospital capacity planning: from measuring stocks to modelling flows

The metric of "bed numbers" is commonly used in hospital planning, but it fails to capture key aspects of how hospital services are delivered. Drawing on a study of innovative hospital projects in Europe, we argue that hospital capacity planning should not be based on beds, but rather on the ability to deliver processes. We propose using approaches that are based on manufacturing theory such as "lean thinking" that focuses on the value that different processes add for the primary customer, i.e. the patient. We argue that it is beneficial to look at the hospital, not from the perspective of beds or specialties, but rather from the path taken by the patients who are treated in them, the respective processes delivered by health professionals and the facilities appropriate to those processes. Systematized care pathways seem to offer one avenue for achieving these goals. However, they need to be underpinned by a better understanding of the flows of patients, work and goods within a hospital, the bottlenecks that occur, and translation of this understanding into new capacity planning tools.

Hospital mortality among major trauma victims admitted on weekends and evenings: a cohort study

BACKGROUND

Patient care may be inconsistent during off hours. We sought to determine whether victims of major trauma admitted to hospital on evenings, nights, and weekends suffer increased mortality rates. All victims of major trauma admitted to all four major acute care hospitals in the Calgary Health Region between April 1, 2002 and March 31, 2006 were included. Clinical and outcome information was obtained from regional databases. Weekends were defined as anytime Saturday or Sunday, evenings as 18:00-22:59, and nights as 23:00-07:59.

RESULTS

Four thousand patients were included; 2,901 (73%) were male, the median age was 39.5 [inter-quartile range (IQR), 22.4-58.2] years, and the median injury severity score (ISS) was 20 (IQR, 16-26). Thirty-five percent (1,405) of patients were admitted on a weekend, 30% (1,197) during evenings, and 36% (1,422) at night. Seventy-eight percent (3,106) of cases presented during the "after hours" (evenings, nights, and/or weekends). The in-hospital case-fatality rate was 447 (11%), and was not significantly different during daytime (165/1,381; 37%), evening (128/1,197; 30%), and night (154/1,422; 36%) admissions (p = 0.53), or among patients admitted on weekends as compared to weekdays (157/1,405; 11% vs. 290/2,595; 11%; p = 1.0). Admission during the after hours as compared to business hours (343/3,106; 11% vs. 104/894; 12%; p = 0.63) did not increased risk. A multivariable logistic regression model was developed to assess factors associated with in-hospital death (n = 3,891). Neither admission on weekends nor on evenings or nights increased the risk for in-hospital mortality.

CONCLUSION

In our region, the time of admission during the day or day of the week does not influence the risk for adverse outcome and may reflect our highly developed multi-hospital acute care and trauma system.

Short-term mortality in hip fracture patients admitted during weekends and holidays

BACKGROUND

Acute surgical admission during weekends, with reduced staffing levels, has been associated with increased risk of mortality, but the effect of longer vacation/holiday periods has not been studied. We therefore examined early postoperative mortality in hip fracture patients admitted during weekends and holiday periods, compared with normal weekdays.

METHODS

Prospective, descriptive study in 600 consecutive hip fracture patients treated with a well-defined multimodal care plan, in a specialized hip fracture unit between September 2002 and July 2004. Patients were stratified according to admission on a weekday or during weekends/holiday periods.

RESULTS

were analysed with univariate and multivariate analyses. Results. Three hundred and thirty-two patients were admitted during weekdays, 118 during weekends and 150 during holiday periods. Both 5- and 30-day postoperative mortality were significantly higher in patients admitted during holiday periods than during weekends and weekdays, 8.0% vs 2.5% and 1.8%, respectively (P=0.01) and 19.3% vs 12.7% and 11.1%, respectively (P=0.05). In a multivariate analysis, admission during holiday periods was still a significant independent risk factor for both 5-day (4.34, 95% CI 1.74-10.8) and 30-day mortality (1.84, 95% CI 1.08-3.12).

CONCLUSION

Staff reduction during holiday periods in units that care for acute surgical patients may adversely influence postoperative outcome. This may have important consequences both for outcome analysis of interventions and the planning of resource management in surgical units.