Assessment of the “Weekend Effect” in Lower Extremity Vascular Trauma
Arvin K. JundoriaBrian GrantOlubode A. OlufajoEnrique De La CruzDavid MetcalfeMallory WilliamsEdward E. CornwellKakra Hughes
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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 in-hospital 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 Sundays/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.
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1.The authors, compared in-patient mortality between duringoffice hours and off-office hours admissions, and between weekday and weekend admissions. Although we agree that this local analysis is timely for healthcare planning to provide quality and effective hospital care to patients, the method which the data was analyzed and interpreted may not be accurate. The reported odds ratio (OR) of 1.67 for mortality in admissions during the off-office hours is very alarming but it could be an overestimation. Lee et al. had included both elective and emergency admissions in their analysis which we find inappropriate. Most of the elective and day surgery admissions are during office hours and these admissions are expected to have lower mortality 2 . The inclusion of these admissions would certainly increase the survival rate of patients admitted at these times, causing unfavourable but distorted results for admission after office hours. As we cannot differentiate elective and emergency admissions, we analyzed the same hospital data 3 by looking into the mortality of patients, comparing patients who died within 24 hours of admission and its relationship with time of admission from Monday to Thursday; office hours defined as 8.00 am to 5.00 pm, after office hours as otherwise. By focusing only on patients who died, we would have excluded majority of elective surgical and day care cases who survived. Besides that, we are also looking at the mortality pattern of the severely ill patients, of which the outcome is more dependent on the disease severity. The result shows that ‘night admissions’ effects on mortality is no longer statistically significant with OR = 1.11 (CI 0.93-1.31, p = 0.24). This shows that for patients who would have died within 24 hours of admission, there was no difference in mortality rate whether they were admitted during office hours or after office hours. We hypothesised that the night admissions effect is more closely related to disease-severity rather than health care system of the hospital. In addition, we also hypothesised that the weekend effects on mortality were also overestimated for the same reason mentioned earlier. Odds ratio of 1.221 reported by the authors was higher compared to a large study in UK of similar cohort of patients (OR 1.11) 4 . Once again, we tried to exclude elective and day surgery admissions by focusing on the mortality pattern of the patients. We compared patients who died within 24 hours of admission and its relationship with day of admission (weekdays or weekends). The difference became not significant with odds ratio 1.08 (CI 0.93 to 1.25, p = 0.33) 3 . The similarity of the ratios between different countries strengthen the hypothesis that the weekend effect is probably a combination of disease characteristic, patients’ health seeking behaviour and health system. Besides having more elective cases admitted on weekdays, 4 out of 10 most common reasons for admission during weekend were cardiac related such as congestive heart failure, chest pain, heart attack and irregular heart beat 2 who have higher risk of mortality compared to elective admissions. Therefore, it is a hasty conclusion by the authors to have attributed the weekend effect solely to hospital staffing and training.
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Despite extensive research on the "weekend effect" i.e., the increased mortality associated with hospital admission during weekend, knowledge about disease severity in previous studies is limited. The aim of this study is to examine patient characteristics, including disease severity, 30-day mortality, and length of stay (LOS), according to time of admission to an emergency department. Our study encompassed all patients admitted to a Danish emergency department in 2014–2015. Using data from electronic patient records, this study examines patient characteristics including age, gender, Charlson Comorbidity Index score, triage score, and primary diagnosis. Triage score and transfer to intensive care unit (ICU) were used as indicators of disease severity. LOS within the department and within the hospital was examined. Age- and sex-standardized 30-day mortality rates comparing patients with the same triage score admitted at daytime, evening, and nighttime on weekdays and on weekends were computed. To test differences, a Cox regression analysis was added. We included 35,459 patient visits, of which 10,435 (32%) started on a weekend. There were no large differences in baseline characteristics between patients admitted on weekdays and those admitted on weekends. The relative risk (RR) for being triaged orange or red was 1.16 (95% confidence interval (CI) 1.06–1.28, P = 0.0017) for weekend admissions as compared with weekday admissions. Weekend admissions were twice as likely as weekday admissions to be transferred to the ICU (RR, 1.96; 95% CI 1.53–2.52, P = 0.0000). No significant changes were found in LOS. The 30-day mortality rate increased with disease severity regardless of time of admission. When comparing the 30-day mortality rate for patients with the same triage score, the trend was toward a higher mortality when admission occurred during the weekend. Increasing mortality rate was significant for patients admitted at evening on weekends with a hazard ratio of 1.32 (95% CI 1.03–1.70, P = 0.027) when compared with patients admitted on daytime on weekdays. When comparing weekday and weekend admissions, the 30-day mortality rate increased for patients admitted at evening on weekends after adjusting for comorbidity and triage score, indicating that the weekend effect was independent of changes in illness severity.
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Background and Purpose: With the “weekend effect” being well described, the Brain Attack Coalition released a set of “best practice” guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a “weekend effect” in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. Materials and Methods: We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. Results: Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. Conclusion: Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.
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To analyse mortality associated to emergency admissions on weekends, differentiating whether the patients were admitted to the Internal Medicine department or to the hospital as a whole. Retrospective follow-up study of patients discharged between 2015 and 2019 in: (a) the Internal Medicine department (n = 7656) and (b) the hospital as a whole (n = 83,146). Logistic regression models were fitted to analyse the risk of death, adjusting for age, sex, severity, Charlson index, sepsis, pneumonia, heart failure and day of admission. Cox models were also adjusted for the time from admission until normal inpatient care. There was a significant increase in mortality for patients admitted in weekends with short stays in Internal Medicine (48, 72 and 96 h: OR = 2.50, 1.89 and 1.62, respectively), and hospital-wide (OR = 2.02, 1.41 and 1.13, respectively). The highest risk in weekends occurred on Fridays (stays ≤ 48 h: OR = 3.92 [95% CI 2.06-7.48]), being no significative on Sundays. The risk increased with the time elapsed from admission until the inpatient department took over care (OR = 5.51 [95% CI 1.42-21.40] when this time reached 4 days). In Cox models patients reached HR = 2.74 (1.00-7.54) when the delay was 4 days. Whether it was Internal Medicine or hospital-wide patients, the risk of death associated with emergency admission in WE increased with the time between admission and transfer of care to the inpatient department; consequently, Friday was the day with the highest risk while Sunday lacked a weekend effect. Healthcare systems should correct this serious problem.
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The management of patients admitted during weekends may be compromised because the level of staffing in the hospital is often lower then. This study was conducted to assess what independent influence, if any, weekend admission might have on inhospital mortality. The authors analyzed the clinical data of 429,880 adults >14 years of age who were admitted to internal medicine wards in Spain after having presented to the hospitals' emergency departments. Overall mortality and early mortality (occurring in the first 48 hours) were examined, taking into account whether a patient was admitted on a weekend or a weekday, in addition to other parameters. Weekend admissions were associated with a significantly higher inhospital mortality than weekday admissions among patients admitted to an internal medicine service (odds ratio [OR] = 1.1; 95% confidence interval [CI] = 1.14-1.08). Differences in mortality persisted after adjustment for age, sex, and coexisting disorders (OR = 1.071; 95% CI = 1.046-1.097). Analyses of deaths within 2 days after admission showed larger relative differences in mortality between weekend and weekday admissions (OR = 1.28; 95% CI = 1.22-1.33). For patients admitted to an internal medicine service via an acute care visit to the emergency room, admission on weekends is associated with higher mortality than admission during the week.
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Abstract Objectives To analyse mortality associated to emergency admissions on weekends and holidays (WE), differentiating whether the patients were admitted to the Internal Medicine department or to the hospital as a whole. Methods Retrospective follow-up study of patients discharged between 2015 and 2019 in: a) the Internal Medicine (IM) department (n = 7656) and b) the hospital as a whole (n = 83146). Logistic regression models were fitted to analyse mortality. Results There was a significant increase in mortality for patients admitted in WE with short stays in IM (48, 72 and 96 hours: OR = 2.50, 1.89 and 1.62, respectively), and hospital-wide (OR = 2.02, 1.41 and 1.13). The highest risk per WE admission occurred on Fridays (stays ≤ 48 hours: OR = 3.92 [95% CI = 2.06–7.48] in IM), with no effect on Sundays. The risk of death increased with the time elapsed from admission until the inpatient department took over care (OR = 5.51 [95% CI = 1.42–21.40] in IM when this time reached 4 days). Conclusions Whether it was MI patients or hospital-wide patients, the risk of death associated with emergency admission in WE increased with the time between admission and transfer of care to the inpatient department; consequently, Friday was the day with the highest risk while Sunday lacked a weekend effect. Healthcare systems should correct this serious problem.
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Levels of staffing and access to diagnostics at weekends are recognised to be significantly lower than on weekdays. It is unclear if subsequent inpatient mortality and readmission rates for acute medical admissions are increased for weekend admissions compared to those on a weekday. A large Canadian study demonstrated increased weekend mortality but does the Edinburgh healthcare model support these findings? This study analysed all hospital admissions in 2001 to the Royal Infirmary of Edinburgh for six predetermined diagnoses (total 3,244): chronic obstructive pulmonary disease, cerebrovascular accidents, pulmonary embolism, pneumonia, collapse and upper gastrointestinal bleed. We compared hospital mortality rates, readmission rates and hospital length of stay for weekend admissions as compared to those on a weekday. Weekend admission was not associated with significantly higher in-hospital mortality, readmission rates or increased length of stay compared to the weekday equivalent for any of the six conditions. The implementation of an acute medical admissions unit in the Royal Infirmary of Edinburgh, with consistent staffing levels and 24-hour access to diagnostics for the early phase of critical illness, may have helped address the discrepancy in care suggested by previous studies.
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Abstract Introduction: Nights and weekends represent a potentially high‐risk time for hospitalized patients. Data regarding night or weekend admission and its impact on outcomes is limited. We studied the association between night or weekend admission and outcomes. Methods: We reviewed 857 admissions to the general medicine services from the emergency department (ED) at our tertiary care hospital for demographic information, time and day of admission, and hospitalization‐relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat ED visit within 30 days, readmission within 30 days, and poor outcome [ICU transfer, cardiac arrest, or death] within the first 24 hours of admission). Outcomes were compared between groups using univariate and multivariate modeling. Results: Complete data for analysis were available for 824 patients. A total of 58% of patients were admitted at night and 22% were admitted during the weekend. Patients admitted at night as compared to those admitted during the day had similar a LOS (4.1 vs. 4.3, P = 0.38), hospital charges (25,200 vs. 27,500, P = 0.17), ICU transfer during hospitalization (3% vs. 6%, P = 0.06), 30 day repeat ED visit (22% vs. 20%, P = 0.42), 30 day readmission (20% vs. 17%, P = 0.23), and poor outcomes within 24 hours of admission (1% vs. 2%, P = 0.15). Patients admitted during the weekend as compared to those admitted during the week had lower hospital charges and lower likelihood of an ICU transfer but were otherwise similar. Conclusion: Night or weekend admission was not associated with worse hospitalization‐relevant outcomes at our tertiary care hospital. Journal of Hospital Medicine 2011. © 2010 Society of Hospital Medicine.
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