Overnight Care Research Articles

First dose of misoprostol administration at home or in hospital for medical abortion between 12–22 gestational weeks in Sweden (PRIMA): a multicentre, open-label, randomised controlled trial

Medical abortion after 12 gestational weeks often requires a stay in hospital. We hypothesised that administering the first misoprostol dose at home could increase day-care procedures as compared with overnight care procedures, shorten inpatient stays, and improve patient satisfaction. This multicentre, open-label, randomised controlled trial was done at six hospitals in Sweden. Participants were pregnant people aged 18 years and older who were undergoing medical abortion at 85-153 days of pregnancy. Randomisation was done in blocks 1:1 to mifepristone administered in-clinic followed by home administration or hospital administration of the first dose of misoprostol. Allocation was done by opening of opaque allocation envelopes. Due to the nature of the intervention, masking was not feasible. Between 24-48 h after mifepristone 200 mg, the participants administered 800 μg of misoprostol either at home 2 h before admission to hospital or in hospital. The primary outcome was the proportion of day-care procedures (defined as abortion completed in <9 h). The intention-to-treat analysis included all participants randomly assigned to receive the study drug and who had known results for the primary outcome. Individuals who received any treatment were included in the safety analyses. This trial is registered at ClinicalTrials.gov, NTC03600857, and EudraCT, 2018-000964-27. Between Jan 8, 2019, and Dec 21, 2022, 457 participants were randomly assigned to treatment groups. In the intention-to-treat-population, 220 participants were assigned to the home group and 215 to the hospital group. In the home group, 156 (71%) of 220 participants completed the abortion as day-care patients, compared with 99 (46%) of 215 in the hospital group (difference 24·9%, 95% CI 15·4-34·3; p<0·0001). In total, 97 (22%) of 444 participants in the safety analysis had an adverse event. Seven (2%) of 444 participants aborted after mifepristone only. Two (1%) of 220 in the home group aborted after the first dose of misoprostol, before hospital admission. Home administration of misoprostol significantly increases the proportion of day-care procedures in medical abortion after 12 gestational weeks, offering a safe and effective alternative to in-clinic protocols. Region Västra Götaland, Hjalmar Svensson's Fund, the Gothenburg Society of Medicine, Karolinska Institutet-Region Stockholm, and The Swedish Research Council.

Improving residential care amid COVID-19: The link between risk factors and hospitalization.

This study was conducted to investigate the relationship between the hospitalizations and backgrounds of patients with coronavirus disease 2019 to identify specific risk factors. This retrospective study used health observation records to analyze the relationship between certain risk factors and the subsequent hospitalization of 321 patients who were discharged from a residential care facility between January 16 and February 8, 2021. The usefulness of a hospitalization prediction score, created based on the presence of comorbidities and sex, was examined. Being older, male, and having a history of high blood pressure or vascular disease were all risk factors. A multivariate analysis with age and hospitalization predictive score as independent variables and hospitalization as the dependent variable showed that age (odds ratio: 1.07, 95 percent confidence interval: 1.03-1.11, p < 0.01) significantly increased hospitalization risk by 7 percent for every 1-year age increase. The median time from illness onset to hospitalization for all patients was 9 days (interquartile range: 8-10). Hypoxia was the most common cause of hospitalization. However, hypoxia and other symptoms, such as cough and dyspnea, were not correlated. Given the pandemic, there may come another time when hospitals are not able to accommodate all patients who require care. In such instances, age, sex, the presence of comorbidities, and checking oxygen saturation regularly using a pulse oximeter around 9 days after the onset of the disease should all be considered important, as it may lead to improved and safer operation of overnight care facilities.

Decentralization of OPDs of Basic and Rural Healthcare Units of Punjab, Pakistan

Decentralization is associated with political administration and historical development, and varies according to region and implementation factors. In the 1980s, the IMF (International Monetary Fund) and World Bank demonstrated that corruption and bad administration in society are due to centralization policies which concentrate authority and power in the hands of the elite upper class. This criticism was an initial point to start the period of structural decentralization adjustment. Decentralization is a substantial process for equal distribution of healthcare service delivery in the community. The outdoor patient department (OPD) is one of the most important parts of any health care unit to diagnose and treat patients who do not require overnight care or stay in hospitals. The main purpose of this research was to analyze the effect of decentralization and improvements in health services for OPD by analyzing the number of patients in Primary Healthcare Centers (Basic Health Unit (BHU) and Rural Health Centers (RHCs)) in Punjab before and after de-centralization. Non-probability convenient and simple random sampling technique was employed, and patients visiting PHCs (primary healthcare centers) OPD were included in the study population. OPD patients of rural and basic healthcare units were categorized into three pairs OPD 1, 2 and 3, and the means and other statistical parameters were calculated using SPSS. The average mean of all groups of OPD patients of RHCs were 119441.1111, 192536.5185 and 153487.1358, respectively. The average mean of all groups of BHU was 94818.5062, 109331.7160, and 124231.0123, respectively. The results showed that the number of patients in the OPD increased after decentralization due to more health facilities.

Exploring overnight social care for older adults: a scoping review

PurposeDemand for care at home is growing because of the increase in life expectancy, an ageing population and the chronic conditions that often accompany longevity. Daytime care at home services have been widely reported on, but less is known about overnight care at home. This paper aims to gather evidence about overnight social care for older adults in their homes.Design/methodology/approachRecent studies were identified through searches in three electronic databases. Studies published in English between January 2016 and June 2022 exploring overnight care at home for older adults were eligible for inclusion. An additional Google search identified home care services within the UK currently providing overnight support.FindingsThe review retrieved five relevant papers, highlighting the paucity of research in this area. A narrative review of the literature identified common themes that suggested domiciliary night care staff play an integral role in meeting the overnight care and support needs of older adults who wish to be cared for at home. Despite the limited evidence base in this area, the Google search for UK domiciliary services who provide overnight support identified several active programmes.Originality/valueTo the best of our knowledge, this is the first scoping review exploring the provision of overnight social care to older adults in their own homes. The review highlights the need for further research to inform commissioning and practice development.

“Linton had a Very Restless Night”: Sleeplessness in the Sickroom, 1783

ABSTRACT On 11 May 1783, Lady Mary Traquair “went to Bed for ye first night, had not been in Bed for 12 nights before,” because she had been nursing her son, Charles, Lord Linton, who was inoculated against smallpox in late April. In this anxious period, Lady Traquair quarrelled with the inoculator; adapted prescribed drug regimens; lost the little trust she had in the nursemaid; and tracked Linton’s sleep meticulously. Lady Traquair paid attention to all of the Galenic six non-naturals, but she became focussed on Linton’s sleep, which was badly disturbed. Her anxiety was heightened by mistrust of some of the attendants hired to care for her son. Even after his recovery, her habit of monitoring his sleep remained as shorthand for Linton’s wellbeing. While Linton’s illness did worry his mother, her record of his overnight care illuminates other facets of women’s experiences of illness and nursing. Examining how Lady Traquair intervened in Linton’s sleep illuminates her relationships with his attendants, her medical judgement, and the role she gave herself as a dutiful, unsentimental, but caring mother.

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit.

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight. What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being? A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction. Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education. As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Transition to an In-House Night Float System for Critical Care Fellows: Resident Experience, Morbidity, and Mortality in a Rural Academic Hospital.

BackgroundIn-house night call systems for ICUs are frequently implemented to enable hands-on patient care and provide direct supervision of resident physicians at night. Previous studies have highlighted the benefits of an in-house night float (NF) such as minimized time to intervention but failed to consistently demonstrate an improvement in patient outcomes. This study aimed to evaluate the impact of an in-house critical care fellow at night on the resident experience and assess for impact on patient morbidity and mortality.MethodsAn in-house overnight critical care fellow shift was implemented at West Virginia University Hospital in 2018. Resident physicians rotating overnight in the medical ICU (MICU) for six-month periods before and after the intervention were anonymously surveyed. A retrospective chart review of 300 patients admitted overnight to the MICU was performed. Multiple patient outcomes from the pre (2017) and post (2018) intervention periods were collected and compared using a two-sample t-test.ResultsIn the post-intervention survey, nearly every element of resident experience improved (availability of support, comfort in performing invasive procedures, and input in treatment plans), and far fewer residents felt overwhelmed relative to the pre-intervention survey. The resident experience markedly improved with the addition of an in-house critical care fellow.For the retrospective chart review, both groups had similar severity of illness and there was no change in ICU or hospital length of stay. No difference in mortality was found, though the study was underpowered for this outcome. For secondary measures, there was no difference in mechanical ventilation or use days, though more procedures performed were overnight compared to the former staffing model.ConclusionsImplementation of an in-house overnight critical care fellow shift in the MICU positively impacted resident experience without worsening patient outcomes. The intervention did not worsen measures of morbidity or mortality but did lead to an increased number of procedures performed overnight. The model of in-house NF coverage continues to be preferred by clinicians.

Learning From Strengths: Improving Care by Comparing Perinatal Approaches Between Japan and Canada and Identifying Future Research Priorities.

Preterm birth (PTB) is the leading cause of infant morbidity and mortality worldwide. Canada and Japan each have strengths that can inform clinical decision-making, research, and health care policy regarding the prevention of PTB and its sequelae. Our objectives were to: 1) compare PTB rates, risk factors, management, and outcomes between Japan and Canada; 2) establish research priorities while fostering future collaborative opportunities; and 3) undertake knowledge translation of these findings. We conducted a literature review to identify publications that examined PTB rates, risk factors, prevention and management techniques, and outcomes in Japan and Canada. We conducted site visits at 4 Japanese tertiary centres and held a collaborative stakeholder meeting of parents, neonatologists, maternal-fetal medicine specialists, and researchers. Japan reports lower rates of PTB, neonatal mortality, and several PTB risk factors than Canada. However, Canadian PTB data is population-based, whereas, in Japan, the rate of PTB is population-based, but outcomes are not. Rates of severe neurologic injury and necrotizing enterocolitis were lower in Japan, while Canada's rates of bronchopulmonary dysplasia and retinopathy of prematurity were lower. PTB prevention approaches differed, with less progesterone use in Japan and more long-term tocolysis. In Japan, there were lower rates of neonatal transfers and non-faculty overnight care, but also less use of antenatal corticosteroids and deferred cord clamping. Research priorities identified through the stakeholder meeting included early skin-to-skin contact, parental well-being after PTB, and transitions in care for the child. We identified key differences between Japan and Canada in the factors affecting PTB management and patient outcomes, which can inform future research efforts.

Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers

Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.

Experiential learning of overnight home care by medical trainees for professional development: an exploratory study.

ObjectivesIn an ageing society, community-based medical education in a home care setting needs to be developed. Drawing on Kolb's experiential learning theory, this study aimed to explore the learning processes in overnight home care by medical trainees in terms of their understanding of terminally ill patients and their conceptualization of themselves as future physicians.MethodsAn overnight home care program in which a trainee had to take care of terminally ill patients on his/her own under the supervision of a healthcare team was conducted. Nineteen trainees, including eight medical students and 11 residents, participated in this study. Text data of reflective reports written after the overnight care were collected and thematically analyzed.ResultsThe trainees' learning experiences in the program were categorized into four stages: predeparture, concrete experience, reflective observation and abstract conceptualization. Although they had mixed feelings, including anxiety, fear and expectations, at the predeparture stage, they could be actively involved in providing medical care and daily life support and in taking care of dying patients at the patients' homes overnight. By reflecting on their experiences, they gained a sense of achievement and identified the aspects upon which they should improve as future physicians. Subsequently, based on their reflective observation, they conceptualized their approaches to home care and the roles/responsibilities of physicians as healers, which led to professional identity formation. ConclusionsOvernight home care by medical trainees has the potential as an educational strategy to promote their realistic understanding of home care and facilitate professional identity formation.

Routine postoperative intensive care unit admission after colorectal cancer surgery for the elderly patient reduces postoperative morbidity and mortality.

Older colorectal cancer (CRC) patients are at increased risk of postoperative morbidity and mortality. Routine postoperative overnight intensive care unit (ICU) admission might reduce this risk. This study aimed to examine the effect of routine overnight ICU admission after CRC surgery on postoperative adverse outcomes and costs in patients aged 80years or older. Patients aged 80years or older who underwent CRC surgery in our centre were included in this observational cohort study. All patients in the period 2014-2017 with routine overnight ICU admission were assigned to the ICU cohort; all patients in the period 2009-2013 were assigned to the non-ICU cohort. Multivariable logistic regression was performed to compare the primary composite end-point (30-day mortality, serious complications and readmission) between the groups. Cost data from the literature were used to perform a cost analysis. A total of 242 patients were included, 125 in the ICU cohort and 117 in the non-ICU cohort. Routine overnight ICU admission was associated with a reduced risk of the composite end-point (OR 0.44, 95% CI0.22-0.87, P=0.02) after adjusting for important confounders. In the ICU cohort 28% of patients experienced ICU events requiring intervention; this was not associated with postoperative morbidity or mortality. The 9% reduction in the incidence of serious complications in the ICU cohort is sufficient to offset the additional costs of routine overnight ICU admission. Routine overnight ICU admission after CRC surgery in patients aged 80years and older is associated with reduced risk of postoperative mortality and morbidity and seems to be cost-effective.

Feasibility of a hospital outpatient day procedure for medication abortion at 13–18 weeks gestation: Findings from Nepal,

ObjectivesTo evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13–18 weeks. Study designOpen-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24–48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects. ResultsWe enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75–92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0–4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5). ConclusionsFor gestations 13–18 weeks, an outpatient day process for medication abortion is safe, effective and feasible. ImplicationsMedication abortion in 13 – 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service.

Effect on nurse and patient experience: overnight use of blue-depleted illumination

BackgroundTypical hospital lighting is rich in blue-wavelength emission, which can create unwanted circadian disruption in patients when exposed at night. Despite a growing body of evidence regarding the effects of...

Description, Implementation Integrity, and Social Validity of a Computer-Assisted Sleep Monitoring System among Residential Care Providers of Students with Autism Spectrum Disorder

Several subjective and direct methods have been used to measure and assess sleep patterns and problems among children and youth with autism spectrum disorder (ASD). In this paper, we describe the design, operating functions, and application of a computer-assisted system of sleep monitoring and data recording to improve measurement integrity of overnight care providers at a residential school. Descriptive and longitudinal evaluation conducted over a four-year evaluation period revealed that care providers averaged 91% implementation integrity with the system. A subsequent social validity assessment through survey questionnaire found that care providers uniformly rated the system as easy to learn, understand, and implement. We discuss the advantages of the system for sleep measurement and assessment of children and youth who have ASD and receive services in residential-care settings.

63. THE NEXT MORNING: MODIFICATIONS MADE ON ROUNDS TO ORDERS PLACED BY OVERNIGHT ADMITTING RESIDENTS

Background An increased focus on quality and safety has resulted in increased resident supervision by attending physicians. At our large pediatric academic medical center, the overnight shift is when residents admit general pediatrics patients without immediate attending supervision. As such, admission orders are not evaluated by an attending until morning rounds. To the authors’ knowledge these orders have not been previously evaluated in the academic literature. Objectives To categorize orders placed by residents overnight that were subsequently discontinued on medical rounds the next morning and to examine the reasons for those changes. Methods We utilized our hospital's Enterprise Data Warehouse to generate a report of all orders placed on newly admitted patients by residents on the general pediatrics night shift over a 12-month period that were subsequently discontinued the following morning on rounds. All charts were reviewed by two independent reviewers. Orders were categorized by type of order and perceived reason for discontinuation. Disagreements on categorization were discussed with the research team until consensus was achieved. Results 290 discontinued patient orders were included in the analysis. Inter-rater agreement was very good with a kappa of 0.91. 66% of orders were medicines, 11% were diets, 4% were diagnostic testing, and 19% were for patient care. Within medication orders, 29% were antibiotics, 17% were antiasthmatics, and 10% were non-narcotic analgesics. The reason for order discontinuation was due to a change in clinical trajectory in 44% of cases (98% of which was patient improvement), primary attending decision in 11% of cases, and due to medical errors in 8% of cases. The most common medical error was a duplicate order (37.5%). Conclusions This study suggests that admission orders placed by pediatrics residents overnight are clinically appropriate. Medical errors were most commonly duplicate orders. This pilot identifies the need for further study to better understand the overnight care delivered by residents and to identify areas for increased resident autonomy.

Parental Gatekeeping and Child Custody Evaluation: Part III: Protective Gatekeeping and the Overnights “Conundrum”

ABSTRACTThe concept of parental gatekeeping and the forensic evaluation model for child custody disputes is described and applied to the context of considering overnight care by fathers for infants and toddlers. The forensic model is briefly described: facilitative, restrictive, and protective gatekeeping. The gatekeeping continuum is described, ranging from extreme restrictive to very facilitative and inclusive. Gatekeeping is isomorphic with a common best interest statutory factor on support for the other parent–child relationships. The limited research on overnights and child outcomes is briefly reviewed and discussed in the context of attachment theory. The concept of social capital is introduced as an explanatory concept for research that shows the benefit of joint parental involvement and shared parenting, including overnight care by fathers. Attachment and social capital are presented as complementary, explanatory concepts for understanding the gatekeeping and overnights issues. The conservative school of thought on overnight care by fathers is discussed in terms of a justification analysis as part of the gatekeeping model. Mothers opposing overnights need to show with behavioral specificity how overnights would be harmful to the child and then how the father can still be afforded substantial involvement in the present and future.

Aneurysmal Subarachnoid Hemorrhage Mortality After Implementation of Nocturnist Advanced Practice Provider Coverage.

We hypothesized that a nocturnist advanced practice provider (APP) model compared with overnight neurocritical care coverage with general critical care physicians and neurology residents would provide similar patient outcomes, as measured by patient mortality. This study is a retrospective review of healthcare outcomes of aneurysmal subarachnoid hemorrhage (aSAH) patients from 2013 and 2016, after implementation of specialty-trained neurocritical care nocturnist APPs. In 2013, overnight hours were covered by the general intensive care unit team and a junior neurology resident. In 2016, these patients were cared for by APPs overnight. The primary outcome measured was comparison of mortality before and after this change of overnight coverage because the daytime coverage remained similar between years. In 2013, 58 patients were admitted to the neurocritical care unit with aSAH. In 2016, 19 aSAH patients were admitted to the neurocritical care unit. The mean modified Fisher grade was 3.36 in 2013, with 14 of 58 deaths (mortality rate, 24%). In 2016, the mean modified Fisher grade was 3.4. Three patients died (mortality rate, 15.7%). The active nocturnist APP model was associated with an approximately 10% reduction in SAH mortality (P = .54). This supports the hypothesis that APPs can provide noninferior care as the previous model. Further studies are needed to demonstrate the effects of both nocturnist and APP-driven models.

Early Warning Scores to Predict Noncritical Events Overnight in Hospitalized Medical Patients: A Prospective Case Cohort Study.

Physicians are often called to evaluate patients overnight with varying levels of clinical deterioration. Early warning scores predict critical clinical deterioration in patients; however, it is unknown whether they are able to reliably predict which patients will need to be seen overnight and whether these patients will require further resource use. A prospective case cohort study of 522 patient nights in a single tertiary care hospital in Vancouver, British Columbia, Canada, was conducted to assess the ability of Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) to predict patients who will need to be seen overnight by physicians and will require other healthcare resources. Prediction ability was assessed using area under the receiver operating characteristic curve and logistic regression models. The MEWS and NEWS both significantly predicted which patients needed to be seen overnight, and area under the receiver operating characteristic curves (95% confidence interval) for MEWS and NEWS were 0.72 (0.66-0.78) and 0.69 (0.63-0.76), respectively. Odds ratios (95% confidence interval) for MEWS and NEWS predicting need to be seen overnight were 1.52 (1.34-1.73) and 1.22 (1.14-1.31), respectively. Both MEWS and NEWS have fair ability to predict patients who will need to be seen overnight. This may be useful for improving handover and resource allocation for overnight care.

Patients’ experiences of a multidisciplinary team-led community case management programme: a qualitative study

ObjectivesTo explore the views and experiences of patients on the care they have received while enrolled on the Northumberland High Risk Patient Programme (NHRPP). This programme involved case finding of...

Socioeconomic determinants of overnight and weekend emergency department use for acute rhinosinusitis.

Prior work has shown Medicaid and self-pay insurance status is associated with emergency department (ED), rather than outpatient clinic, presentation for uncomplicated acute rhinosinusitis (ARS). We investigate whether the disparate use of ED resources for this nonemergent condition by patients with Medicaid and self-pay insurance can be attributed to presentation overnight or on weekends. Cross-sectional survey of 990,849 patients from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey presenting to EDs with uncomplicated ARS. Patients with orbital and intracranial complications of ARS were excluded. Univariate and multivariate associations identified demographic and socioeconomic characteristics, including insurance status, which were independently associated with overnight (between 5 pm and 7 am) or daytime weekend ED presentation for uncomplicated ARS. Medicaid or self-pay insurance status was associated with evening/overnight ED presentation (odds ratio=1.88, P=.018) in comparison to private or Medicare insurance. However, weekend daytime ED presentation was not associated with Medicaid or self-pay insurance statuses (P=.144). Income and education levels of patients' zip codes, taken as markers of socioeconomic status, were not associated with either evening/overnight or daytime weekend ED presentation for uncomplicated ARS (P>.05). ARS patients with Medicaid or self-pay status, previously shown to preferentially use EDs for uncomplicated ARS, were more likely to present for overnight ED care compared to patients with private insurance or Medicare. These findings suggest a potential lack of access to extended-hours primary care during evenings and nights for Medicaid patients. 4.