Abstract
BackgroundBecause 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.MethodsThis 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.ResultsOf 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.ConclusionsAt 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.
Highlights
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
Even after adjusting for possible confounders including age, sex, Injury Severity Score (ISS), Revised Trauma Score (RTS), Charlson Comorbidity Index (CCI), presentation phase (2002–2005, 2006–2009, and 2010–2013), and injury type using logistic-regression models, there continued to be an increased risk of adverse events associated with off-hours presentation, but no differences were detected in mortality (p = 0.80); unexpected trauma death (p = 0.44); and good recovery (p = 0.80) between off hours and business hours
The present study showed that the response time of surgeons, interventional radiologists, and anesthesiologists from out of hospital does not adversely affect the outcomes of injured patients needing subspecialty intervention as long as they respond in a short time, and as long as initial assessment and care is provided by attendinglevel emergency room (ER) physician(s) with resident(s)
Summary
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. Offhour presentation is known to be a risk factor for patients presenting with unplanned critical conditions requiring rapid diagnosis and aggressive intervention, including cardiac arrest [6], myocardial infarction [7], stroke [1], ruptured aortic aneurysm [8], acute epiglottis [8], and pulmonary embolism [8] This phenomenon is termed the off-hour effect. A level I trauma center [15] has the highest concentration of medical resources, including 24-hour availability of in-house surgeons, anesthesiologists, and interventional radiologists
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