Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study

Abstract

BackgroundInternationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events.ObjectiveTo describe IHCA demographics during three day/time periods—weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)—and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care.MethodsWe performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals.ResultsRisk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses.ConclusionsIHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.

Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry

“…Variations in care by time of day are common in hospitals, with nighttime hours often associated with decreased staffing and the availability of diagnostic tests or procedures (1–5). These discrepancies have been associated with treatment delays and worse outcomes at night for many conditions including maternal outcomes after childbirth (1), stroke (2), myocardial infarction (3), and in-hospital cardiac arrest (4,5).…”

“…These discrepancies have been associated with treatment delays and worse outcomes at night for many conditions including maternal outcomes after childbirth (1), stroke (2), myocardial infarction (3), and in-hospital cardiac arrest (4,5). Of note, the disparity in outcome by time of day is most pronounced in lower acuity settings such as unmonitored units, as opposed to intensive care units (ICUs), which are more likely to maintain higher levels of support at all hours (6).…”

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

“…This is an important omission, as it is likely that if reduced service availability at weekends adversely impact on outcomes, there is also an increased likelihood of adverse outcomes for patients admitted at night, when services are also reduced. Some studies have utilised specialist data to address this issue; for example, finding that at night there is an increased risk of mortality following in-hospital cardiac arrest 36 or coronary artery bypass grafting, 37 and a reduced chance of receiving timely intervention following stroke.…”

“…We checked that our results were robust to using an alternative definition of daytime and night-time (08.00-19.59 hours and 20.00-07.59 hours the following day), as has been used in a previous study (Table 17). 36 Previous studies have been constrained by the absence of information on patients' time of arrival at hospital and have been forced to classify the weekend crudely by dates as 00.00 hours Saturday to 23.59 hours Sunday and have been unable to adjust for patient severity of illness. Including arrival mode in the risk adjustment accounted for most of the differences in mortality between different days and different times, leaving Sunday daytime as the only period associated with a higher risk of death.…”

Balancing quality of care and resource utilisation in acute care hospitals

“…An analysis from a large cohort of inpatients in acute care hospitals in the UK suggests that outcomes after cardiac arrest are better during daytime working hours compared with night-time and weekends 11. This is important information that policy makers may use to shape future healthcare delivery by demanding increases in out-of-hours staffing in an attempt to improve these outcomes.…”