Nighttime Admissions Research Articles

Does timely reporting of preoperative CT scans influence outcomes for patients following emergency laparotomy?

Timely preoperative computed tomography (CT) scans are important for patients requiring emergency laparotomy. United Kingdom guidelines state that a CT scan should be reported within 1h for 'critical' patients (will alter management at the time) and within 12h for 'urgent' patients (will alter management but not necessarily that day). An observational study included patients who were added to the National Emergency Laparotomy Audit (NELA) at a National Health Service trust from 2014 to 2021. The association of compliance with timings guidance and mortality was investigated. Multivariable logistic regression was used to determine the odds ratio of adherence to guidelines according to age, gender, night time admission, American Society of Anesthesiology (ASA) score, NELA mortality risk and category of scan. Further models determined the influence of adherence to guidelines on mortality, also adjusted for these variables. There were 1,299 patients (48% 'critical' and 52% 'urgent' CT scans). Only 360/1,299 (28%) of scans were undertaken with adherence to the timing guidelines. Critical scans were less likely to adhere to guidelines. Although univariable analysis suggested that adherence to guidelines was associated with reduced mortality, this was not the case in the multivariable model: only age, ASA and NELA mortality risk remained significantly associated with mortality. A minority of patients met the recommended preoperative CT report timings, and this was less likely for scans designated 'critical'. This did not appear to affect mortality when adjusted for key variables of risk. This illustrates the phenomenon of guideline adherence appearing to affect patient outcomes as a product of selection bias rather than causality.

The impact of surgical timing on outcome in acute appendicitis in adults: a retrospective observational population-based cohort study.

Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence. This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy). 855694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery. This work found an increase of a CCE after TAS of 12h for complicated appendicitis and an increase of the CCE after TAS of 24h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours.

Impact of Off-Hour Admission on In-Hospital Outcomes for Patients With Stroke Receiving Reperfusion Therapy in China.

The structure and staffing of hospitals greatly impact patient outcomes, with frequent changes occurring during nights and weekends. This retrospective cohort study assessed the impact of admission timing on in-hospital management and outcomes for patients with stroke receiving reperfusion therapy in China using data from a nationwide registry. Data from patients receiving reperfusion therapy were extracted from the Chinese Stroke Center Alliance. Hospital admission time was categorized according to day/evening versus night and weekday versus weekend. Primary outcomes were in-hospital death or discharge against medical advice, hemorrhage transformation, early neurological deterioration, and major adverse cardiovascular events. Logistic regression was performed to compare in-hospital management performance and outcomes based on admission time categories. Overall, 42 381 patients received recombinant tissue-type plasminogen activator (r-tPA) therapy, and 5224 underwent endovascular treatment (EVT). Patients admitted during nighttime had a higher probability of receiving r-tPA therapy within 4.5 hours from onset or undergoing EVT within 6 hours from onset compared with those admitted during day/evening hours (adjusted odds ratio, 1.04 [95% CI, 1.01-1.08]; P=0.021; adjusted odds ratio, 1.72 [95% CI, 1.59-1.86]; P<0.001, respectively). However, no significant difference was observed between weekend and weekday admissions for either treatment. No notable differences were noted between weekends and weekdays or nighttime and daytime periods in door-to-needle time for r-tPA or door-to-puncture time for EVT initiation. Furthermore, weekend or nighttime admission did not have a significant effect on the primary outcomes of r-tPA therapy or EVT. Nevertheless, in patients undergoing EVT, a higher incidence of pneumonia was observed among those admitted at night compared with those admitted during day/evening hours (adjusted odds ratio, 1.22 [95% CI, 1.05-1.42]; P=0.011). Patients admitted at nighttime were more likely to receive r-tPA therapy or EVT within the time window recommended in the guidelines. However, patients receiving EVT admitted at night had an increased risk of pneumonia.

Emergency department reorganisation introducing increased autonomy: A mixed effects approach to evaluate the effects of a national policy.

In 2007, a Danish national policy to future-proof emergency department (ED) performance was launched. The policy included several recommendations for the management and organisation of care that essentially introduced greater ED autonomy. In this study, we evaluate the effects of increased ED autonomy on readmission, mortality and episode costs for two large patient groups. A non-randomised stepped wedge study-design where all EDs gradually implemented the policy at different steps during the study period (2008-2016). The timing and extent of policy implementation was determined from a retrospective cross-sectional survey of all 21 Danish EDs. This was linked to all episodes of hip fracture (n = 79,697) and erysipelas (n = 39,900) identified in the Nation Patient Registry and with episode-level outcomes. Mixed effect models were specified for the outcomes of 30-day readmission, 30-day mortality and episode costs, and adjusted for relevant ED- and episode-level heterogeneity. Increased ED autonomy was associated with more readmissions (p<0.05) and higher episode costs (p<0.001) in hip fracture episodes. In erysipelas episodes, no general associations were found. When restricted to night-time admissions, increased ED autonomy was associated with poorer outcomes for erysipelas episodes and increased episode costs for both patient groups. The intended policy effects were not found for these two patient groups; in fact, reorganisation appeared to have harmed hip fracture patients and increased episode costs. Uncertainty remains regarding the longer-term consequences.

Pattern of disease and determinants of mortality among ICU patients on mechanical ventilator in Sub-Saharan Africa: a multilevel analysis

BackgroundThe global mortality rate of patients with MV is very high, despite a significant variation worldwide. Previous studies conducted in Sub-Saharan Africa among ICU patients focused on the pattern of admission and the incidence of mortality. However, the body of evidence on the clinical outcomes among patients with MV is still uncertain.ObjectiveThe objective of this study was to investigate the pattern of disease and determinants of mortality among patients receiving mechanical ventilation in Southern Ethiopia.MethodsSix hundred and thirty patients on mechanical ventilation were followed for 28 days, and multilevel analysis was used to account for the clustering effect of ICU care in the region.ResultsThe incidence of 28-day mortality among patients with MV was 49% (95% CI: 36–58). The multilevel multivariate analysis revealed that being diabetic, having GSC < 8, and night time admission (AOR = 7.4; 95% CI: 2.96–18.38), (AOR = 5.9; (5% CI: 3.23, 10.69), and (AOR = 2.5; 95% CI: 1.24, 5.05) were predictors.ConclusionThe higher 28-day mortality among ICU patients on mechanical ventilation in our study might be attributed to factors such as delayed patient presentation, lack of resources, insufficient healthcare infrastructure, lack of trained staff, and financial constraints. Trial Registration. The protocol was registered retrospectively on (NCT05303831).

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.

Quality and timeliness of emergency obstetric care and its association with maternal outcome in Keren Hospital, Eritrea

Despite the critical role quality comprehensive emergency obstetric care (CEmOC) plays in ensuring safe motherhood, only a few studies have attempted to measure the impact of substandard and delayed care on maternal outcome thus far. This study evaluates the association between various process and timeliness indicators of CEmOC and adverse maternal outcome in Keren Hospital. This study compared women with potentially life-threatening condition (PLTC) and women with severe maternal outcome (SMO) with respect to various process and timeliness indicators. Logistic regression analysis was employed to assess the association of timeliness and process indicators with SMO using SPSS version-22 computer software. In this study, we included 491 cases of PLTC and 210 cases of SMO (171 maternal near misses and 39 maternal deaths). The following process indicators showed significant association with SMO: failure to give uterotonics for the treatment of postpartum hemorrhage, failure to administer prophylactic antibiotics, and delayed laporatomy for uterine rupture. Moreover, delays in referral, triaging, seeing an obstetrician, and receiving definitive treatement were strongly associated with SMO. The following causes of delay were also found to be independently associated with SMO: erroneous diagnosis, inappropriate management, multiple referrals between health facilities, unavailability of a senior obstetrician, and poor communication during referral. Among the miscellaneous factors, nighttime admission and referral during the rainy season showed significant association with SMO. Findings of this study indicate that huge gap exists in providing quality and timely care in Keren Hospital. In general, most incidents of substandard and delayed care were due to poor referral system, insufficiency of medical staff, inadequacy of drugs and equipment, and unavailability of standard management protocol. Improving the referral system, upgrading the technical skills of health professionals, making sure life-saving drugs and equipment are available all the time, and posting standard treatment and management protocols in the maternity and emergency rooms will play a vital role in reducing the occurrence of SMO in Keren Hospital.

Supporting Nurses to Ease the Workforce Crisis

Supporting Nurses to Ease the Workforce Crisis

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.

The development and validation of a resource consumption score of an emergency department consultation

BackgroundEmergency Department (ED) visits and health care costs are increasing globally, but little is known about contributing factors of ED resource consumption. This study aims to analyse and to predict the total ED resource consumption out of the patient and consultation characteristics in order to execute performance analysis and evaluate quality improvements.MethodsCharacteristics of ED visits of a large Swiss university hospital were summarized according to acute patient condition factors (e.g. chief complaint, resuscitation bay use, vital parameter deviations), chronic patient conditions (e.g. age, comorbidities, drug intake), and contextual factors (e.g. night-time admission). Univariable and multivariable linear regression analyses were conducted with the total ED resource consumption as the dependent variable.ResultsIn total, 164,729 visits were included in the analysis. Physician resources accounted for the largest proportion (54.8%), followed by radiology (19.2%), and laboratory work-up (16.2%). In the multivariable final model, chief complaint had the highest impact on the total ED resource consumption, followed by resuscitation bay use and admission by ambulance. The impact of age group was small. The multivariable final model was validated (R2 of 0.54) and a scoring system was derived out of the predictors.ConclusionsMore than half of the variation in total ED resource consumption can be predicted by our suggested model in the internal validation, but further studies are needed for external validation. The score developed can be used to calculate benchmarks of an ED and provides leaders in emergency care with a tool that allows them to evaluate resource decisions and to estimate effects of organizational changes.

Patient survival after acute myocardial infarction treated with primary percutaneous coronary intervention within the left main coronary artery according to time of admission

Abstract Background Previously published studies assessing the time effect of primary percutaneous intervention (PCI) on long-term clinical outcomes in an overall group of patients with acute coronary syndromes has been widely investigated. It has been suggested that night-time admission may negatively influence long-term overall mortality. Patients treated within the left main coronary artery (LMCA) belong a narrow group of high-risk procedures that require an operator and a team with high skills. Purpose The aim of the presented study was to assess the relationship between the time of pPCI (day- vs. night-time) and overall mortality among patients treated due to AMI within the LMCA. Methods This observational study was performed on 443,805 patients hospitalised due to non-ST segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI). Patients were prospectively enrolled between January 2006 and December 2018 in the ongoing Polish Registry of Acute Coronary Syndromes (PL-ACS). From the overall group of patients, the authors selected 5,404 patients treated within the LMCA. After taking exclusion criteria into consideration, the patients were divided according to time of PCI treatment: daytime hours (7:00 a.m.-10:59 p.m.) – 2,809 patients and night-time hours (11:00 p.m. - 6.59 a.m.) – 473 patients. Results Patients treated during night-time and daytime did not differ significantly in age (70.79 [61.52–79.73] vs. 69.73 [60.8–78.82] years, p=0.13) or gender – males (67.6% vs. 67.0%, p=0.79). Patients treated during daytime presented with significantly higher rate of STEMIs (67.2% vs. 49.9%) and lower rate of NSTEMIs (32.8% vs. 50.1%) in comparison to those treated during night-time (p&amp;lt;0.001). The 30-day and 12-month overall mortality rates were significantly greater among patients treated during night-time hours (20.3% vs. 14.9%, p=0.003) and (31.7% vs. 26.2%, p=0.001). Kaplan-Maier survival curves confirmed this relationship (p=0.001). Multiple regression analysis did not confirm that the time of pPCI (day- vs. night-time) is significantly related to survival (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 0.96–1.55, p=0.099). However, significance was achieved for the left ventricle ejection fraction (HR: 0.95; 95% CI: 0.94–0.95, p&amp;lt;0.001), systolic blood pressure on admission (HR: 0.995; 95% CI: 0.991–0.998, p=0.005), age (HR: 1.04; 95% CI: 1.03–1.05, p&amp;lt;0.001), the use of intra-aortic balloon counterpulsation (HR: 1.04; 95% CI: 1.03–1.05, p&amp;lt;0.001) and diagnosed peripheral artery disease (HR: 1.55; 95% CI: 1.2–2.01, p&amp;lt;0.001). Conclusions The time of pPCI (day- vs. night-time) in patients with AMI and treated within the LMCA is related to the overall 30-day and 12-month survival which is poorer in those treated during the night-time. However, this relationship was not confirmed by multiple regression analysis and was not found to be significant among other stronger predictors. Funding Acknowledgement Type of funding source: None

Effects of consultant residence out-of-hours on acute paediatric admissions

Acute paediatric units require round-the-clock skilled resident medical cover. Fully trained doctors remaining resident on-site at night and weekends may improve care at these times, but costs are higher. In...

The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study

BackgroundThe degree to which elevated mortality associated with weekend or night-time hospital admissions reflects poorer quality of care (‘off-hours effect’) is a contentious issue. We examined if off-hours admissions for...

Effect of day- and night-time admissions on long-term clinical outcomes of patients with acute myocardial infarction treated with percutaneous coronary intervention.

It has been suggested that the time of admission during the day and night may influence the clinical outcomes of patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI). The aim of this study was to assess the impact of day- and night‑time admissions on the clinical outcomes of patients with AMI undergoing PCI. This retrospective cohort study was based on the data on PCIs performed in Poland from January 2014 to December 2017, prospectively collected in the National Registry of Invasive Cardiology Procedures (ORPKI). Day hours were defined as the time interval between 7:00 am and 10:59 pm. The study endpoints included the all‑cause in‑hospital mortality rate and major adverse cardiovascular and cerebrovascular events (MACCEs) at 30‑day,12‑month, and 36‑month follow‑up. A total of 2919 patients were included in the study (2462 [84.3%] treated during the day hours). ST‑segment elevation myocardial infarction (1993 [68.3%]) was the main indication for PCI. We demonstrated that the 30‑day mortality rate was significantly higher in patients treated during the night hours than during the day hours (P = 0.01). Night hours were also among the independent predictors of increased 30‑day mortality (hazard ratio, 1.54; 95% CI, 1.11-2.16; P = 0.01). No significant differences were observed in in‑hospital, 12‑month, and 36‑month mortality rates between patients treated during the night and day hours. There were no significant differences in the MACCE rates at the follow‑up timepoints. Primary PCI for AMI is associated with increased 30‑day mortality among patients treated during the night hours compared with those managed during the day hours.

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.

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

Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi.

BackgroundIn sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD.MethodsUtilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD.ResultsOf 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment.ConclusionIHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.

The 24-Hour Intensivists Staffing Model Improves the Outcome for Nighttime Admitted Patients: A Matched Historical Control Study.

We previously showed that a "10-hour daytime on-site" and "nighttime (NT) on-call" staffing strategy was associated with higher mortality for intensive care unit (ICU) patients admitted during NT than it was for patients admitted during office hours (OH). In here, we evaluated the clinical effects of a 24-hour intensivist staffing model. We formed an intervention group of 3034 consecutive ICU patients hospitalized from January 2013 to December 2015, and a control group of 2891 patients from our previous study (2009-2011). We applied propensity score matching (PSM) for whole and subgroup analyses adjusting for confounding factors. We compared clinical outcomes of patients under the 2 staffing models using multivariate logistic regression and survival analyses. After PSM, we balanced the clinical data between the complete cohorts and the subgroups. Comparison of ICU survivals between the intervention and control cohorts yielded no significant differences. However, the intervention was significantly associated with a higher ICU survival in the NT (5:30 pm-07:30 am) admission patients (P = .049) than in those admitted during OH (07:30 am to 5:30 pm; P = .456). Additionally, the intervention shortened the LOSHOS (P = .001) and/or LOSICU (P < .001), reduced the hospital (P = .672) and/or ICU (P = .004) expenses, and resulted in earlier mechanical ventilation extubation (P = .442) as compared to the same variables in the control group, especially for NT admissions. The 24-hour intensivists staffing could significantly improve ICU outcomes, especially for NT-admission patients in high-acuity, high-volume ICUs with frequent NT admissions.

Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay.

Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.