Association Between Time of Admission to the ICU and Mortality

Cavallazzi, Rodrigo; Marik, Paul E.; Hirani, Amyn; Pachinburavan, Monvasi; Vasu, Tajender S.; Leiby, Benjamin E.

doi:10.1378/chest.09-3018

Cited by 169 publications

(147 citation statements)

References 36 publications

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“…On the one hand, two studies did not show higher hospital mortality rate in patients admitted on WE or during off-hours in the United States and France, respectively [26,27] . On the other, an increased risk of death was found in patients admitted to an ICU over the weekend, but not during the nighttime, in the United States [28] . Finally, Singer et al [16] found that hospital mortality and LOS were associated with length of ED boarding (from 2.5% in patients boarded less than two hours to 4.5% in those boarding 12 hours or more).…”

Section: Discussionmentioning

confidence: 98%

In-hospital mortality and length-of-stay in a cohort of ED patients admitted to internistic units

Giorgi¹,

Fabbian²,

Ferro³

et al. 2013

JHA

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Background: Several life-threatening acute diseases exhibit precise preferred times of onset, during the day (morning), the month or season of the year (winter), and the day of the week (Monday). Moreover, admission to the hospital during nighttime and weekend (WE) is associated with increased risk of in-hospital mortality (IHM) and length-of-hospital stay (LOS). Since most of these data have been obtained in North American settings, the aim of this study was to verify also in an Italian setting whether some factors related to ED evaluation, including time of arrival, and disease's severity evaluated by a colour code, could be associated with IHM and LOS in ED patients admitted to internal medicine units. Methods:This study was conducted between January 1, 2010 and July 31, 2012, at the St Anna Hospital of Ferrara. We analyzed age, sex, time of arrival to the ED, ED boarding time, and triage colour code of all patients admitted to the Department of Medicine. Friday to midnight Sunday was considered as WE, and the nine main national festive days were always considered as Sunday-WE. Thus, the time period was classified into holidays (WE + festive days) and weekdays (WD), and daytime (8:00 am -8:00 pm) and nighttime (8:00 pm -8:00 am). IHM and LOS were assumed as primary and secondary objectives, respectively. Patients were classified into deceased and survivors, and LOS was classified depending on length lower or higher than the median (seven days). T-test, chi-squared test, U Mann-Whitney test, and logistic regression analysis were performed.Results: During the 18-month period, 13,237 consecutive patients visiting the ED (43.4% males, mean age 74.8 ± 13.6 years, 56.6% females, mean age 78.0 ± 13.3 years), were considered. IHM was related to: time of admission (daytime vs. nighttime, p = .015; WE vs. WD, p = .026, holidays vs. no holidays, p = .021), colour code (p < .001), and age (p < .001). Multivariate analysis showed an independent association with IHM for colour code (p < .001), and age (p < .001). LOS >7 days was related to: time of admission (daytime vs. nighttime, p < .001; WE or WD, p = .001; holidays vs. no holidays, p = .002). Furthermore, LOS >7 days depended on both colour code of admission (p < .001), and age (p < .001). Multivariate analysis showed a significant correlation with LOS >7 days for yellow colour code (p < .001), and age (p < .001). Conclusions:Although several factors, such as admission colour code and age, influence some parameters of clinical outcome, i.e., IHM and LOS, a striking weekend effect is not evident in a cohort of consecutive patients admitted to an Italian Medical Department, characterized by intermediate-high level of urgency.

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Section: Discussionmentioning

confidence: 98%

In-hospital mortality and length-of-stay in a cohort of ED patients admitted to internistic units

Giorgi¹,

Fabbian²,

Ferro³

et al. 2013

JHA

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“…A landmark article on mortality differences in ICU admissions found significant differences in mortality during weekends, but no difference by time of day (21.4% daytime mortality, 20.8% nighttime). 9 Studies that evaluated time of admission and mortality for specific diagnoses: AMI, PE, and UGIB found increased mortality with weekend admissions, but no differences overnight. [3][4][5][6] Thus, our highest priority should be improving care on weekends.…”

Section: Nights Versus Weekendsmentioning

confidence: 99%

“…In the report by Needleman et al, day and evening shifts were more likely to be below target staffing than night shifts. 9 Fifteen states have legislation that either guides or mandates levels of nurse staffing. In California, the minimum staffing levels for direct care nurses are mandated and thus must be consistent on weekends and nights, None of the cited studies demonstrating care disparities on nights and weekends were able to correlate outcome differences to staffing levels, whether for nurses or physician providers.…”

mentioning

confidence: 99%

“…In California, the minimum staffing levels for direct care nurses are mandated and thus must be consistent on weekends and nights, None of the cited studies demonstrating care disparities on nights and weekends were able to correlate outcome differences to staffing levels, whether for nurses or physician providers. [3][4][5][6]9 Pharmacists and therapists have been shown to improve care as part of multidisciplinary care teams, [12][13][14][15][16] though a relationship between ancillary staffing levels and patient outcomes has not been well studied. Other hospital personnel critical to the delivery of care such as radiology technicians may be more lightly staffed on weekends and nights, potentially delaying needed imaging and increasing the length of hospital stay.…”

mentioning

confidence: 99%

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Safe, High Quality Care Around the Clock: What will it Take to Get us There?

Mourad

Adler

2011

J GEN INTERN MED

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“…With respect to (1), while there is evidence that discharging patients from ICU at night can be harmful in some healthcare settings (with night used as a proxy either for premature ICU discharge and/or a period when staffing on the ward/floor is lower) [1], evidence of "harms" to patients who are admitted at night is conflicting [2] and for those who remain in the ICU overnight appears limited. Though not within the scope of this debate on patient outcomes, with respect to "harms" to family members, the evidence seems non-existent and with respect to "harms" to staff, there is some evidence that ICU physicians, working within a daytime-only model, may suffer cognitive fatigue and sleep deprivation and that this may impair performance.…”

mentioning

confidence: 99%

Nighttime physician staffing improves patient outcomes: we are not sure

2016

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The financial cost to implement dedicated nighttime senior physician staffing in intensive care units (ICUs) would not be inconsiderable to any healthcare system. Therefore, prior to embarking on such a financial outlay, there would need to be substantive evidence around two major areas: (1) evidence that there is a nighttime "problem" and (2) evidence that dedicated nighttime ICU senior physician staffing fixed/mitigated the nighttime "problem" and delivered benefits, including economic benefits, to offset the financial outlay.With respect to (1), while there is evidence that discharging patients from ICU at night can be harmful in some healthcare settings (with night used as a proxy either for premature ICU discharge and/or a period when staffing on the ward/floor is lower) [1], evidence of "harms" to patients who are admitted at night is conflicting [2] and for those who remain in the ICU overnight appears limited. Though not within the scope of this debate on patient outcomes, with respect to "harms" to family members, the evidence seems non-existent and with respect to "harms" to staff, there is some evidence that ICU physicians, working within a daytime-only model, may suffer cognitive fatigue and sleep deprivation and that this may impair performance. With regard to (2), while there is evidence that exposure to ICU physician staffing per se may improve patient outcomes (e.g. those treated in ICU physician-led or "closed" units) [3], the evidence that dedicated nighttime ICU senior physician staffing affords additional benefits to patients appears conflicting and limited.The pro debaters [4] consider the question of dedicated nighttime ICU senior physician staffing broadlyincluding not only the impact on patient outcomes (the scope of this debate) but also on daytime ICU physicians' workload and the cumulative role of fatigue and sleep deprivation on performance and burnout. The pro debaters suggest that, from both personal experience and the existing literature, there is ample evidence that dedicated nighttime ICU senior physician staffing improves outcomes for patients and for staff and that the difficulty lies only in teasing out from the existing evidence when, where and how outcomes are improved-given the important role played by context. The con debaters [5] suggest that while the premise of dedicated nighttime ICU senior physician staffing appears intuitively one that would seem to improve patient outcomes, the evidence does not support this. However, they accept a need to consider not only the patient outcomes studied to date (predominantly mortality and length of stay) but also other outcomes for patients (e.g. quality of care including end-of-life care, quality of life, etc.), for family members/caregivers (e.g. family satisfaction) and for payers (e.g. staff satisfaction, cost savings) and agree that this evidence is far from substantive. The con debaters conclude that, given the absence of direct evidence of benefit of dedicated nighttime ICU senior physician staffing on the patient outcomes th...

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Association Between Time of Admission to the ICU and Mortality

Cited by 169 publications

References 36 publications

In-hospital mortality and length-of-stay in a cohort of ED patients admitted to internistic units

In-hospital mortality and length-of-stay in a cohort of ED patients admitted to internistic units

Safe, High Quality Care Around the Clock: What will it Take to Get us There?

Nighttime physician staffing improves patient outcomes: we are not sure

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