Daytime Admissions Research Articles

Abstract 12720: A Nationwide Multi Center Study From China, Comparing Long-Term and Standard Cardiopulmonary Resuscitation: Epidemiology, Risk Factors, and Outcomes

Introduction: The association between the duration of cardiopulmonary resuscitation (CPR) and patient outcomes remains largely unknown. Hypothesis: long-term CPR (LCPR) may benefit certain group of patients. Methods: In this retrospective cohort study, data from the Chinese Emergency Triage Assessment and Treatment database 1.0 (CETAT 1.0) were utilized. The study included CA patients admitted to 14 teaching hospitals in 7 provinces between July 2015 and July 2020. Patients were categorized into SCPR and LCPR groups based on the duration of resuscitation, where SCPR referred to CPR duration less than 60 mins, and LCPR referred to CPR duration equal to or more than 60 mins. The primary outcome measured was ROSC rates between the two groups, while the secondary and tertiary outcomes was 24-hour and 7-day survival rates. A multivariate logistic regression model was employed to analyze the factors influencing ROSC between groups. Results: A total of 529 patients were enrolled in the study, with 372 in the SCPR group and 157 in the LCPR group. Among them, 126 (33.9%) patients in the SCPR group and 56 (35.7%) in the LCPR group achieved ROSC without statistically difference between groups. Furthermore, 31 patients (8.3%) in the SCPR group and 7 patients (4.5%) in the LCPR group survived at 24 hours, while 13 patients (3.5%) in SCPR and 4 patients (2.5%) in LCPR group survived at 7 days, both without statistical difference. Factors associated with SCPR operation included Lower BMI, previous hypertension, daytime admission, hands-only compression, and ventilation. SpO2 and P ET CO2 were independent factors associated with ROSC, Moreover, in both groups higher SpO2 and P ET CO2 levels were associated with a higher rate of ROSC, suggesting that for this specific patient cohort, longer duration of CPR should be considered. Conclusions: Longer duration of CPR may need to be emphasize for certain group of patients, particularly those with high SpO2 and PET CO2 during CPR.

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

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

Comparison of Five Triage Tools for Identifying Mortality Risk and Injury Severity of Multiple Trauma Patients Admitted to the Emergency Department in the Daytime and Nighttime: A Retrospective Study.

Effective triage tools are indispensable for doctors to make a prompt decision for the treatment of multiple trauma patients in emergency departments (EDs). The Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), standardized early warning score (SEWS), Modified Rapid Emergency Medicine Score (mREMS), and Revised Trauma Score (RTS) are five common triage tools proposed for trauma management. However, few studies have compared these tools in a multiple trauma cohort and investigated the influence of nighttime admission on the performance of these tools. This retrospective study was aimed at evaluating and comparing the performance of MEWS, NEWS, SEWS, mREMS, and RTS for identifying the mortality risk and trauma severity of patients with multiple trauma admitted to the ED during the daytime and nighttime. Retrospective data were collected from the medical records of patients with multiple trauma admitted in the daytime or nighttime to calculate scores for each triage tool. Logistic regression analysis was conducted on each triage tool for identifying in-hospital mortality and severe trauma (injury severity score > 15) in the daytime and nighttime. The performance of the tools was evaluated and compared by calculating area under the receiver operating characteristic curve (AUROC) of the retrospective logistic model of each tool. We collected data for 1,818 admissions, including 1,070 daytime and 748 nighttime admissions. A comparison of performance for identifying in-hospital mortality between daytime and nighttime yielded the following results (AUROC): MEWS (0.95 vs. 0.93, p = 0.384), NEWS (0.95 vs. 0.94, p = 0.708), SEWS (0.95 vs. 0.94, p = 0.683), mREMS (0.94 vs. 0.92, p = 0.286), and RTS (0.93 vs. 0.93, p = 0.87). Similarly, a comparison of performance for identifying trauma severity between daytime and nighttime yielded the following results (AUROC): MEWS (0.78 vs. 0.78, p = 0.95), NEWS (0.8 vs. 0.8, p = 0.885), SEWS (0.78 vs. 0.78, p = 0.818), mREMS (0.75 vs. 0.69, p = 0.019), and RTS (0.75 vs. 0.74, p = 0.619). All five scores are excellent triage tools (AUROC ≥ 0.9) for identifying in-hospital mortality for both daytime and nighttime admissions. However, they have only moderate effectiveness (AUROC < 0.9) at identifying severe trauma. The NEWS is the best triage tool for identifying severe trauma for both daytime and nighttime admissions. The MEWS, NEWS, SEWS, and RTS exhibited no significant differences in performance for identifying in-hospital mortality or severe trauma during the daytime or nighttime. However, the mREMS was better at identifying severe trauma during the daytime.

Relationship between time of emergency department admission and adherence to the Surviving Sepsis Campaign bundle in patients with septic shock

BackgroundNighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock.MethodsWe conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED.ResultsA total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088–1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115–1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590–0.952, p = 0.018) and 0.714 (95% CI 0.564–0.904, p = 0.005), respectively.ConclusionSeptic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Does admission time matter in a paediatric intensive care unit? A prospective cohort study.

Studies assessing the association between admission time to paediatric intensive care unit (PICU) and mortality are sparse with conflicting results. We aimed to evaluate the impact of time of admission on PICU mortality within 48 h after admission. This was a single-centre prospective cohort. We collected data from all consecutive children aged 1 month to 16 years over 10 years. We included a total of 1368 admissions, with a PICU mortality of 6.6%. Compared with daytime admissions, the overall mortality rate (5.3% vs. 8.5%, P=0.026) and the mortality within 48 h after admission were higher for those admitted during night-time (2% vs. 4.2%, P=0.021). There were no differences between mortality rates and the day of admission (weekend admissions vs. weekday admissions). The adjusted odds of death within 48 h after admission was 2.5 (95% confidence interval=1.22-5.24, P=0.012) for patients admitted at night-time. A secondary analysis assessing trends in mortality rates during admission showed that the last 5 years of study were more responsible for the chances of death within 48 h (odds ratio=7.6, 95% confidence interval=1.91-30.17, P=0.0039). Admission to the PICU during night shifts was strongly associated with death compared to daytime admissions. A time analysis of the moment of admission is necessary as a metric of quality of care to identify the interruption or improvement in the continuity of care. Further studies are needed to assess the modified contributing factors.

Daytime admission is associated with higher 1-month survival for pediatric out-of-hospital cardiac arrest: Analysis of a nationwide multicenter observational study in Japan.

Hospital characteristics, such as hospital type and admission time, have been reported to be associated with survival in adult out-of-hospital cardiac arrest (OHCA) patients. However, findings regarding the effects of hospital types on pediatric OHCA patients have been limited. The aim of this study was to analyze the relationship between the hospital characteristics and the outcomes of pediatric OHCA patients. This study was a retrospective secondary analysis of the Japanese Association for Acute Medicine-out-of-hospital cardiac arrest registry. The period of this study was from 1 June 2014 to 31 December 2015. We enrolled all pediatric patients (those 0-17 years of age) experiencing OHCA in this study. We enrolled all types of OHCA. The primary outcome of this study was 1-month survival after the onset of cardiac arrest. We analyzed 310 pediatric patients (those 0-17 years of age) with OHCA. In survivors, the rate of witnessed arrest and daytime admission was significantly higher than nonsurvivors (56% vs. 28%, p < 0.001: 49% vs. 31%; p = 0.03, respectively). The multiple logistic regression model showed that daytime admission was related to 1-month survival (odds ratio, OR: 95% confidence interval, CI, 3.64: 1.23-10.80) (p = 0.02). OHCA of presumed cardiac etiology and witnessed OHCA were associated with higher 1-month survival. (OR: 95% CI, 3.92: 1.23-12.47, and 6.25: 1.98-19.74, respectively). Further analyses based on the time of admission showed that there were no significant differences in the proportions of patients with witnessed arrest and who received bystander cardiopulmonary resuscitation and emergency medical service response time by admission time. Pediatric OHCA patients who were admitted during the day had a higher 1-month survival rate after cardiac arrest than patients who were admitted at night.

Factors Associated With Early Extubation After Cardiac Surgery: A Retrospective Single-Center Experience

To identify factors associated with early extubation in cardiac surgery patients. Single center, retrospective. Tertiary university hospital. The study comprised 8,872 adult patients who underwent cardiothoracic surgery from 2011-2019. None. Of the 8,872 patients, 2,950 (33%) were extubated within six hours after surgery. Early extubated patients were younger, had a higher body mass index (BMI), were more likely to be male, and were fast-track designated. These patients more frequently underwent isolated coronary artery bypass graft, isolated valve, or adult congenital surgeries than did late extubated patients. Early extubated patients had a greater incidence of coronary artery disease (CAD) and anxiety and a higher left ventricular ejection fraction. They also were less likely to have difficult intubation or require mechanical circulatory support, reintubation, or readmission. Analysis of the 8,872 patients showed that male sex (odds ratio [OR] 1.222, 95% confidence interval [CI] 1.096-1.363), a BMI >30 kg/m2 (OR 1.702, 95% CI 1.475-1.965), undergoing isolated valve surgery (OR 1.187, 95% CI 1.060-1.328), and having a fast-track designation (OR 1.455, 95% CI 1.208-1.751) and CAD (OR 1.122, 95% CI 1.005-1.253) were associated with early extubation. Data on intensive care unit (ICU) admission after surgery were available only from 2014-2018. Within this subgroup of 5,977 patients, variables associated with early extubation included male sex (OR 1.356, 95% CI 1.193-1.541), BMI >30 kg/m2 (OR 1.267, 95% CI 1.084-1.480), daytime admission to the ICU (OR 1.712, 95% CI 1.527-1.919), and fast-track designation (OR 1.423, 95% CI 1.123-1.802). Male sex; a BMI >30 kg/m2; undergoing isolated valve surgery; and having a fast-track designation, CAD, and daytime admission to the ICU are associated with early extubation.

Association between admission time and in-hospital mortality in acute aortic dissection patients: A retrospective cohort study

PurposeThis study aimed to evaluate the relationship between admission time and in-hospital mortality in acute aortic dissection (AAD) patients. MethodsThe risk factors of in-hospital clinical outcomes were retrospectively evaluated in patients with AAD. All the patients were enrolled from January to December 2017 and were divided into two groups depending on the time of admission: daytime admissions were conducted from 8: 00 to 17: 30 hours whereas, nighttime admissions were from 17: 30 to 8: 00 hours. The primary endpoints were in-hospital mortality. Univariate and multivariable cox analyses were used to test the association between admission time and in-hospital mortality. ResultsThe average age of the 363 participants in the present study was 52.25 ± 11.77 years, of which 81.6% were male. A total of 183 (50.4%) of these patients were admitted during nighttime. In-hospital mortality rate was higher in the nighttime admission group than in the daytime admission group (HR=1.86; 95%CI, 1.13 to 3.06, P=0.015). After adjusting for age, sex, and other risk factors, nighttime admission suggested as an independent risk factor for in-hospital mortality (HR=2.67, 95%CI, 1.30 to 5.46; P=0.007). Further subgroup analysis showed that none of the variables had a significant effect on the association between nighttime admission and in-hospital mortality. ConclusionNighttime admission for type A acute aortic dissection is associated with a higher risk of in-hospital mortality. Therefore, health care systems should focus on managing the increased risk of in-hospital mortality among patients admitted at night, regardless of the cause.

Effects of the presence of a pediatric intensivist on treatment in the pediatric intensive care unit.

Background There are few studies on the effect of intensivist staffing in pediatric intensive care units (PICUs) in Korea. We aimed to evaluate the effect of pediatric intensivist staffing on treatment outcomes in a Korean hospital PICU. Methods We analyzed two time periods according to pediatric intensivist staffing: period 1, between November 2015 to January 2017 (no intensivist staffing, n=97) and period 2, between February 2017 to February 2018 (intensivists staffing, n=135). Results Median age at admission was 5.4 years (range, 0.7–10.3 years) in period 1 and 3.6 years (0.2–5.1 years) in period 2 (P=0.013). The bed occupancy rate decreased in period 2 (75%; 73%–88%) compared to period 1 (89%; 81%–94%; P=0.015). However, the monthly bed turnover rate increased in period 2 (2.2%; 1.9%–2.7%) compared to period 1 (1.5%, 1.1%– 1.7%; P=0.005). In both periods, patients with chronic neurologic illness were the most common. Patients with cardiovascular problems were more prevalent in period 2 than period 1 (P=0.008). Daytime admission occurred more frequently in period 2 than period 1 (63% vs. 39%, P<0.001). The length of PICU stay, parameters related with mechanical ventilation and tracheostomy, and pediatric Sequential Organ Failure Assessment score were not different between periods. Sudden cardiopulmonary resuscitations occurred in two cases during period 1, but no case occurred during period 2. Conclusions Pediatric intensivist staffing in the PICU may affect efficient ICU operations.

IS OUR MED-REC A MED-WRECK? QUALITY IMPROVEMENT STUDY

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: To improve patient care during hospitalization and decrease readmission rates. METHODS: This study was performed at Saint Peter’s University Hospital during the months of June- September 2018. Patient charts were randomly identified and reviewed by two physician residents (RC, JJ). Home medications were identified based on information provided by the patient, caregivers, and documents from the PCP’s office and/or patient’s pharmacy. Medication reconciliation was deemed accurate if there was 100% concurrence between the medication intake performed by the admitting staff and the reconciliation performed by the quality improvement team. All data was entered in Microsoft Excel. RESULTS: A total of 40 charts were reviewed in the study period. The mean age was 68±19.6 years, 25 (63.5%) patients were Caucasians, 6 (15%) were African-American, 6 (15%) others and 3 (7.5%) patients refused to answer. 21 males (52.5%). 35 (87.5%) spoke English, while the primary language of others was Spanish (1), Korean (1), Filipino (1), Mandarin (1), Vietnamese (1). 21 were daytime admissions (52.5%) and 19 were nighttime admissions (47.5 %). 25 (62.5%) admission medication reconciliations were accurate, 14 (35%) were inaccurate, and 1 (2.5%) was an outlier. For the daytime admissions, 61.9% were accurate and 38.1% were inaccurate. Of the nighttime admissions, 63.15% were accurate, 31.57% were inaccurate, and 5.26% was an outlier. Of the fifteen charts with a medication reconciliation errors incomplete list (53%), dosing errors (40%) and wrong medication (7%) were the causes of inaccuracy. The main causes for inaccurate medication reconciliation were reliability on patient knowledge of his or her own meds, unreported over-the-counter medications, initial reconciliation performed by different hospital staff (nurses, pharmacist, nurse aids, ED physicians), medications not double checked with pharmacies or primary care physicians, lack of time for patient encounters, and language barriers. CONCLUSIONS: Medication errors exist despite electronic medication reconciliation. Reconciliation errors were equal despite the time of admission. At the end of our study we concluded there should be a person designated for medication reconciliation of the patients admitted into the hospital. CLINICAL IMPLICATIONS: Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at different interfaces of care. Medication reconciliation process involves verification, clarification, and reconciliation. We conducted this quality improvement project to identify how accurate is our admission Medication intake process and evaluate the different causes of inaccuracy. DISCLOSURES: No relevant relationships by Rafael Caputi, source=Web Response No relevant relationships by Jose Jimenez Zuluaga, source=Web Response No relevant relationships by Janani Mohan, source=Web Response

Black Clouds vs Random Variation in Hospital Admissions.

Physicians often accuse their peers of being "black clouds" if they repeatedly have more than the average number of hospital admissions while on call. Our purpose was to determine whether the black-cloud phenomenon is real or explainable by random variation. We analyzed hospital admissions to the University of Iowa family medicine service from July 1, 2010 to June 30, 2015. Analyses were stratified by peer group (eg, night shift attending physicians, day shift senior residents). We analyzed admission numbers to find evidence of black-cloud physicians (those with significantly more admissions than their peers) and white-cloud physicians (those with significantly fewer admissions). The statistical significance of whether there were actual differences across physicians was tested with mixed-effects negative binomial regression. The 5-year study included 96 physicians and 6,194 admissions. The number of daytime admissions ranged from 0 to 10 (mean 2.17, SD 1.63). Night admissions ranged from 0 to 11 (mean 1.23, SD 1.22). Admissions increased from 1,016 in the first year to 1,523 in the fifth year. We found 18 white-cloud and 16 black-cloud physicians in simple regression models that did not control for this upward trend. After including study year and other potential confounding variables in the regression models, there were no significant associations between physicians and admission numbers and therefore no true black or white clouds. In this study, apparent black-cloud and white-cloud physicians could be explained by random variation in hospital admissions. However, this randomness incorporated a wide range in workload among physicians, with potential impact on resident education at the low end and patient safety at the high end.

Effects of night-time and weekend admissions on in-hospital mortality in acute myocardial infarction patients in Japan.

BackgroundPatients admitted to hospital during off-hours may experience poorer quality of care and clinical outcomes. However, few studies have examined the variations in clinical processes and outcomes across admission times and days of the week in acute myocardial infarction (AMI) patients. This study aimed to comparatively analyze the effect of weekend and weekday admissions stratified by admission time on in-hospital mortality in AMI patients.Methods and resultsUsing a large nationwide administrative database, we analyzed 103,908 AMI patients admitted to 639 Japanese acute care hospitals between April 2011 and March 2015. We divided patients into the following 4 groups: weekday daytime admissions, weekday night-time admissions, weekend daytime admissions, and weekend night-time admissions. A hierarchical logistic regression model was used to comparatively examine in-hospital mortality among the groups after adjusting for age, sex, ambulance use, Killip class, comorbidities, and the number of cardiologists in the admitting hospital. In addition, we also calculated and compared the adjusted odds ratios of various AMI therapies among the groups. The in-hospital mortality rate of weekend daytime admissions was higher than those admitted during other times (weekday daytime: 6.8%; weekday night-time; 6.5%, weekend daytime; 7.6%; weekend night-time: 6.6%; P < 0.001), even after adjusting for the covariates (adjusted odds ratio for weekend daytime admissions: 1.10; 95% confidence interval: 1.03–1.19). The prescription rates of guideline-based medications provided on the first day of admission were higher in night-time admissions than in daytime admissions.ConclusionsIn-hospital mortality rates were higher in AMI patients admitted during weekend daytime hours when compared with patients admitted during other times. Furthermore, patients admitted during daytime hours had lower prescription rates of guideline-based medications. Our findings indicate that weekend daytime admissions may be a potential target for improvement in the Japanese healthcare system.

Differences in the clinical course of 516 Japanese patients with upper gastrointestinal bleeding between weekday and weekend admissions

Background and aims: Patients suspected of having upper gastrointestinal bleeding (UGIB) admitted during the weekend tend to have a poor outcome in western countries. However, no Japanese studies have been reported on this matter. We aimed to evaluate differences in the clinical course of patients with UGIB between weekday and weekend admissions in Japan.Methods: Medical records of patients who had undergone emergency endoscopy for UGIB were retrospectively reviewed. The severity of UGIB was evaluated using the Glasgow-Blatchford (GB) and AIMS65 score. Patients in whom UGIB was stopped and showed improved iron deficiency anemia after admission were considered as having a good clinical course.Results: We reviewed 516 consecutive patients and divided them into two groups: Group A (daytime admission on a weekday: 234 patients) and Group B (nighttime or weekend admission: 282 patients). There was no significant difference in GB and AIM65 scores between the Groups. The proportions of patients with good clinical course were not significantly different between groups (A, 67.5% and B, 67.0%; p = .90). However, patients in Group B underwent hemostatic treatments more frequently compared with those in Group A (58.5% vs 47.4%, p = .012). Multivariate analysis showed that taking acid suppressants, no need for blood transfusions, use of hemostatic treatments, and GB score <12 were associated with a good clinical course.Conclusions: There were no significant differences in the clinical outcomes of patients with UGIB admitted during daytime on weekdays and those admitted at nighttime or weekends partly owing to the sufficient performance of endoscopic hemostatic treatments.

The relationship between time of admission and icu outcome

The relationship between admission time and ICU outcome is contentious with studies showing it is associated with a poor outcome [1], and contradictory studies that suggest there is no difference [2]. This study compared ICU outcomes between daytime (DT) and night-time (NT) admissions in our local medical intensive care unit. NT admissions were defined as those between 20:00 and 07:59.

Practice variation in gastroschisis: Factors influencing closure technique

BackgroundLittle is known about the factors influencing surgical practice variation in newborns with gastroschisis. The purpose of this study was to correlate prognostic variables with the intended and actual abdominal closure technique and assess related outcomes. MethodsGS cases were abstracted from a national database. Variables evaluated included GA, BW, bowel injury severity (GPS), neonatal illness severity (SNAP-II), inborn status, center volume and training status, and admission time. Evaluated outcomes by closure method included duration of TPN, LOS, and complications. Descriptive, univariate and multivariable regression analyses were conducted. ResultsThe cohort consisted of 679 patients. A total of 372 (55%) underwent attempted PR, of which 300 (81%) were successful, while 307 (45%) had a silo placed intentionally. Patients undergoing attempted PR were more likely to be inborn, have daytime admissions, and higher SNAP-II scores. Successful PR was predicted by low risk GPS and high volume center. With the exception of higher rates of SSI in the planned silo group, outcomes in the successful PR and planned silo groups were comparable. ConclusionPractice variation related to type of closure is predicted by situational and institutional factors (outborn, nighttime admission, and center volume), while outcome variation is attributable to patient factors rather than practice variation.

The role of admission timing in the outcome of intracerebral hemorrhage patients at a specialized stroke center

Introduction: Admission at ‘off times’ has been suggested to result in increased risk of poor outcome. The utilization of high volume centers may be a potential remedy to this variability in care.Objective: To assess the ability of a high volume center to mitigate variability in care due to timing of admission in a post hoc analysis of an observational study.Methods: The medical records of 200 hypertensive intracerebral hemorrhage (ICH) patients admitted to the Neurological Intensive Care Unit (NICU) from 12 January 2009 to 4 April 2013 were identified and examined for variable outcome based on admission timing using the modified Rankin Scale (mRS). Multiple logistic regression was used to assess predictors of poor outcome, correcting severity of admission.Results: Seventy-five admissions were recorded to have occurred on the weekend. The 3-month follow-up mRS of surviving patients was 3·78 in weekend admissions and 3·63 in weekday admissions (P = 0·62). One hundred and seven night admissions occurred. The average mRS at 3 months of surviving patients was 3·56 in night admissions and 3·84 in daytime admissions (P = 0·36). Thirteen patients were admitted in July. The 3-month mRS of surviving patients was 3·71 for July admissions and 3·38 for non-July admissions (P = 0·58). Only ICH score was found to be a predictor of outcome on multivariate analysis (P < 0·001).Conclusions: No significant difference in the outcome of patients was identified regardless of time of admission. High volume centers may be less prone to temporal variability in care, though the existence of temporal variability in care at low volume centers is controversial.

Effect of Day and Time of Admission on Mortality in an Intensive Care Unit

Variations in outcome relating to out-of-hours care have received considerable attention. We conducted a retrospective cohort study to determine the effect of day and time of admission on mortality in an intensive care unit (ICU) with representative admission severity of illness. Data pertaining to 4,183 patients admitted between 2000 and 2007 were extracted from a prospectively maintained database. Case-mix adjustment was undertaken using the UK APACHE II probability of hospital death. The mean APACHE score was 20.9 with a median predicted hospital mortality of 32.5%. Actual hospital mortality was 30.8%. Compared with Wednesdays as the reference day, admission to ICU on any other given day was not associated with higher crude or case-mix adjusted mortality. Admission to ICU in the evening, compared with daytime admission, was associated with lower odds of crude hospital mortality, but this difference was no longer significant after case-mix adjustment. Case-mix adjusted in-hospital mortality does not vary with day and time of admission, even in patients with higher severity of illness and higher predicted mortality than previously reported.

Effects of Out-of-Hours and Winter Admissions and Number of Patients per Unit on Mortality in Pediatric Intensive Care

To investigate the effect of out-of-hours and winter admissions, and unit size on risk adjusted mortality in pediatric intensive care. A national pediatric intensive care clinical audit provided data on over 86000 admissions to 29 pediatric intensive care units (2006-2011). Multivariate logistic regression modeled risk adjusted mortality prior to discharge with out-of-hours (night, weekend, public holiday) admissions, admissions per unit, winter admission, and potential confounders, overall and separately for emergency and planned admissions. Nearly one-half (47.1%) of admissions were out-of-hours (n = 40948) and 79.2% of those were emergencies. Mortality for all out-of-hours admissions was raised (OR 1.1; 95% CI 1.02-1.2; P = .013), accounted for by planned admissions (OR 1.99; 95% CI 1.67-2.37; P < .001) compared with a reduced risk for emergency admissions (OR 0.93; 95% CI 0.86-1.1; P = .07). Winter admissions were associated with increased risk. Unit size did not affect mortality. A child admitted to pediatric intensive care as an out-of-hours emergency is not at increased risk of dying compared with a weekday daytime admission, indicating pediatric intensive care units provide consistent quality of care around the clock. Excess mortality in planned out-of-hours admissions may be explained by admissions following complex operations where risk-adjustment models underestimate the true probability of mortality. In winter, a time of seasonally high bed occupancy, there was an increased mortality risk, an effect which requires further investigation. Despite the different characteristics of small units, the absence of any effect of unit size on mortality suggests that number of admissions per unit does not influence standards of care.

Abstract WP37: The Effect of Weekend Admission on Intracerebral Hemorrhage Outcome at High Volume Institutions

INTRODUCTION: Admission for urgent care on weekends has been suggested to result in increased risk of poor outcome. Studies have suggested that admissions for intracerebral hemorrhage (ICH) have resulted in a significant increase in in-hospital mortality on a national level. The utilization of regional, high volume centers specializing in the management of acute stroke may be a potential remedy to this variability in care. We sought to test this hypothesis by examining the outcomes of ICH patients admitted to the Columbia University Medical Center Neurological ICU (NICU). Methods: The medical records of 229 ICH patients admitted to the NICU from 2009 to 2012 were identified through the Intra-Cerebral Outcomes Project prospective database and examined for weekend versus weekday admission to the NICU, as well as day versus night admission. Multiple logistic regression was used to asses for predictors of in-patient mortality and poor outcome at 3 months, defined as a modified Rankin score of 4 or greater. Outcome measures were corrected for admission severity of presentation and demographics. Results: Sixty-five admissions were recorded to have occurred on the weekend, with 14 (21.5%) patients dying in hospital. Forty-nine (29.8%) of the 164 weekday admissions resulted in mortality (p=0.27). The 3 month follow up of surviving patients was 3.4 in weekend admissions and 3.1 in weekday admissions (p= 0.93). One hundred and one night admissions occurred, with 30 in-hospital mortalities. One hundred twenty-one patients were admitted during the day shift, with 32 in-patient mortalities occurring (p=0.54). The average outcome at 3 months was 3.0 in night admissions and 3.3 in day-time admissions (p=0.39). Conclusions: No significant difference in the mortality or 3 month outcome of patients was identified regardless of day or time of admission. This may be secondary to a higher number of weekend and night duty personnel capable of being mobilized during crisis situations compared to other centers, or the increased experience of medical staff in the work up and acute management of ICH patients. When possible, aggressive diversion of patients to high volume, specialized care centers may reduce the risk of variability in care based on time of admission.

The impact of 24-hr, in-hospital pediatric critical care attending physician presence on process of care and patient outcomes*

Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model. Retrospective comparison of before and after cohorts. A single large, academic tertiary medical/surgical pediatric intensive care unit. : Pediatric intensive care unit admissions in 2000-2006. Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004. A total of 18,702 patients were admitted to intensive care unit: 8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs [interquartile range 12-88] vs. 48 hrs [interquartile range 16-133], adjusted reduction of 35% [95% confidence interval 25%-44%], p < .001) and intensive care unit length of stay was shorter (median 2 days [interquartile range 1-4] vs. 2 days [interquartile range 1-5], adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours: 33% [95% confidence interval 20-45], p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission. Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.