Association of weekend effect with early mortality in severe sepsis patients over time

doi:10.1016/j.jinf.2016.12.009

Journal of Infection

Volume 74, Issue 4, April 2017, Pages 345-351

https://doi.org/10.1016/j.jinf.2016.12.009 Get rights and content

Highlights

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Severe sepsis patients may encounter the weekend effect.
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Especially among patients with non-ICU admission or patients with shock.
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Weekend admission was associated with increased short-term mortality.
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Especially when admitted on Saturday as compared to Sunday.

Summary

Background

The aim of this study is to investigate the “weekend effect” and early mortality of patients with severe sepsis.

Methods

Using the Taiwanese National Healthcare Insurance Research Database, all patients who were hospitalized for the first time with an episode of severe sepsis between January 2000 and December 2011 were identified and the short-term mortality of patients admitted on weekdays was compared to those admitted on weekends. The primary endpoint was 7-day mortality. The secondary endpoints were 14 and 28-day mortality.

Results

A total of 398,043 patients were identified to have had the diagnosis of severe sepsis. Compared with patients admitted on weekends, patients admitted on weekdays had a lower 7-day mortality rate (adjusted odds ratio [OR] 0.89, 95% confidential interval [CI] 0.87–0.91), 14-day mortality rate (adjusted OR 0.92, 95% CI 0.90–0.93), and 28-day mortality rate (adjusted OR 0.97, 95% CI 0.95–0.98). This “weekend effect” was maintained every year throughout the 11-year study period.

Conclusions

Patients with severe sepsis are more likely to die in the hospital if they were admitted on weekends than if they were admitted on weekdays.

Section snippets

Background

Severe sepsis is a life-threatening condition associated with acute organ dysfunction and high mortality.¹ Its annual incidence in the United States increased from 8.7% during the period 1979–2000 to 13.3% during the period of 2004–2009,² creating an increased economic burden.³ In Taiwan, severe sepsis is the eleventh leading cause of death and a major cause of hospital admission. The annual incidence rates increased by 1.6-fold with an annual percent increase of 3.9%.⁴ Along with international

Data source

The National Health Insurance Research Database (NHIRD) in Taiwan was used. The National Health Insurance (NHI) program was launched in 1995 and covers 99% of the 23 million residents. The NHI offers comprehensive medical care, including coverage for outpatient, inpatient, emergency, and dental care, traditional Chinese medicine services, and prescription drugs. The principal goals of NHI were to improve the efficiency of the Taiwanese healthcare system and to improve social equality by

Characteristics of the study population

We identified 398,043 patients who were hospitalized for severe sepsis and met the inclusion criteria between January 2000 and December 2011. There were 95,472 patients admitted on weekends and 302,571 patients admitted on weekdays. The mean age of the cohort was 70.4 years (standard deviation [SD], 15.3 years). Most of these patients were male (59.0%), and the mean CCI score was 6.1 (SD 3.5). Many patients developed two organ failure (45.8%), and most were diagnosed with respiratory infection

Discussion

In 2001, Bell et al. concluded that patients with serious medical conditions were more likely to die in the hospital if they were admitted on weekends than if they were admitted on weekdays.⁷ Barba et al. also found the risk of mortality within the first 48 h was higher for adult patients admitted on weekends than admitted on weekdays.⁸ A recent study showed patients admitted through the ED with sepsis on weekends had a greater likelihood of early mortality, but not overall mortality, when

Conclusions

The results of our study provide further support for the weekend effect and specifically for the impact of the weekend effect on the short-term mortality of severe sepsis patients. Just as the guideline suggested, routine screening of potentially infected seriously ill patients for severe sepsis to early identification and implementation of sepsis bundles should be used to improve patient outcomes. We hypothesize that the increase in short-term mortality of severe sepsis patients may be

Competing interests statement

The authors declare that they have no competing interests and they have no financial support.

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Estimar asociación entre temperatura corporal y mortalidad intrahospitalaria.
Estudio observacional analítico de cohortes prospectiva entre febrero y julio del 2017 en pacientes con diagnóstico de sepsis que ingresaron a un hospital de iv nivel; se tomó temperatura digital y el desenlace fue mortalidad intrahospitalaria.
La asociación entre temperatura corporal y mortalidad intrahospitalaria en sepsis es controvertida. Estudios denotan que la fiebre aumenta el consumo de oxígeno y empeora la disfunción multiorgánica y la contraparte, que esta ayuda al control de patógeno.
Ingresados a la Sala de reanimación de Méderi Hospital Universitario Mayor, con sepsis que ingresaron consecutivamente por 6 meses que cumplieron los criterios de inclusión y exclusión.
Se tomó la temperatura digital axilar al ingreso protocolizada (termómetro digital, único, avalado y con garantía de calibración).
El riesgo relativo para mortalidad intrahospitalaria en pacientes sépticos, según hipotermia vs. no hipotermia fue de 1,58, intervalo de confianza del 95%, 0,85-2,84, p = 0,056. La incidencia de muerte en los pacientes hipotérmicos fue de 4,2 por 100 días paciente hospitalizado comparada con una incidencia de muerte en los pacientes sin hipotermia de 2,6 por 100 días-paciente hospitalizado, no siendo estadísticamente significativo (p = 0,056).
En esta cohorte no se encontró asociación directa entre temperatura corporal y mortalidad intrahospitalaria, pero sí hay una tendencia, aunque no estadísticamente significativa, entre presentar hipotermia y mortalidad. En esta población los factores más asociados a mortalidad intrahospitalaria fueron foco pulmonar y shock séptico.
To estimate the relationship between body temperature on admission and hospital mortality.
Prospective analytical observational cohort study conducted between February and July 2017 on patients diagnosed with sepsis, and who were admitted to fourth level hospital. Digital temperature was taken, and the outcome was in-hospital mortality.
The association between body temperature and hospital mortality in sepsis is controversial. Studies show that fever increases oxygen consumption and worsens multi-organ dysfunction, and the counterpart is, that it helps control pathogens.
Patients admitted consecutively over a 6-month period to the Resuscitation room of Méderi Hospital Universitario Mayor with sepsis and met the inclusion and exclusion criteria.
The axillary digital temperature was taken upon admission, using a standardised digital thermometer, guaranteed and with a calibration guarantee).
The relative risk for in-hospital mortality in septic patients, according to hypothermia vs no-hypothermia was 1.58, 95%, confidence interval 0.85-2.84, P=.056. The incidence of death in hypothermic patients was 4.2 per 100 hospital admission days, compared to an incidence of death in non-hypothermic patients of 2.6 per 100 patient hospital admission days. This was not statistically significant (P=.056).
Although there is a non-statistically significant trend between presenting with hypothermia and mortality, there was no direct association in this cohort between body temperature and in-hospital mortality. In this population, the factors most associated with in-hospital mortality were pulmonary foci and septic shock.
Blood culture reports by infectious disease physicians can improve prognosis of bacteremia, including weekend-onset cases
2020, International Journal of Infectious Diseases
Citation Excerpt :
Multivariate logistic regression analyses were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for prognostic factors associated with 28-day mortality following adjustment for the following variables: age (≥65 years), sex, sepsis, weekend bacteremia onset, and intervention. Selection of these variables was based on previously published reports (Holmbom et al. 2016; Shih et al. 2017; Namikawa et al. 2019). P-values <0.05 were considered statistically significant.
Cases of positive blood cultures were previously reported by a microbiological technologist (MT) to an attending physician (AP), and the Antimicrobial Stewardship team provided medical assistance by grasping the situation at the morning meeting the next day. Since April 2018, MTs have reported positive blood cultures to an infectious disease physician (IDP), who proposes the management approach to the AP and provides weekend support. This study assessed the effectiveness of blood culture reports provided by IDPs to APs on outcomes of bacteremia, including weekend-onset cases.
Patient characteristics and prognoses before (October 2017 to March 2018) and after intervention (April to September 2018) were compared.
The pre-intervention and post-intervention groups comprised 134 and 161 patients, respectively. Patients were more likely to be older (>65 years) in the post-intervention group (p < 0.05). There were no significant between-group differences in infection severity. The rate of de-escalation significantly increased from 38.1%–57.8% (p = 0.001). The rates of 28-day and in-hospital mortality reduced following the intervention (21.3% vs. 8.2% and 32.8% vs. 10.6%; p = 0.004 and p < 0.001, respectively). In-hospital mortality for weekend-onset cases also reduced following the intervention (33.3% vs. 12.9%, p = 0.01). Sepsis was a poor prognostic factor (OR 8.070, 95% CI 3.320–19.600, p < 0.001) and intervention was a good prognostic factor (OR 0.311, 95% CI 0.142–0.680, p = 0.003) affecting 28-day mortality in multivariate analysis.
Changes to blood culture result reporting protocols can improve outcomes of bacteremia, including weekend-onset cases.
Assessment of the “Weekend Effect” in Lower Extremity Vascular Trauma
2020, Annals of Vascular Surgery
Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this “weekend effect.” The objective of this study was to determine if a weekend effect exists for LEVT.
The National and Nationwide Inpatient Sample Database (2005–2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models.
There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups.
This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.
Weekend effect among patients undergoing elective vascular surgery
2019, Journal of Vascular Surgery
Several studies have described a higher mortality among patients admitted or operated during the weekend for various diseases. However, pooled data on patients undergoing elective vascular surgery procedures are sparse.
The PubMed, Embase, Scopus, and Cochrane Library databases were systematically searched to identify eligible studies. Studies comparing short-term mortality (≤30 days) between patients undergoing elective vascular surgery during the weekend and working days were included. When studies included patients undergoing mixed types of surgery, only the vascular surgery subgroups were evaluated. Urgent/emergency vascular procedures were excluded according to certain definitions provided by each study. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd, Cambridge, UK).
Overall, four retrospective studies including 131,201 patients undergoing elective vascular surgery (on working days, n = 130,163; on the weekend, n = 1038) were evaluated. The pooled short-term mortality risk was higher among patients operated during the weekend compared with working days (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.58-3.67; P = .0004). This weekend effect was more evident among patients undergoing abdominal aortic aneurysm repair and carotid surgery (OR, 3.62 [95% CI, 1.49-8.82; P = .0046] and OR, 3.48 [95% CI, 1.15-10.54; P = .027], respectively). In the United States, the weekend effect was more evident among patients undergoing aortic aneurysm repair (OR, 3.61; 95% CI, 1.99-6.53; P < .0001). However, data from Canada originated from one study on patients undergoing carotid and peripheral arterial surgery only.
Elective vascular surgery is associated with a higher short-term mortality risk when conducted over the weekend. Improvement of perioperative management during these days may be necessary to improve outcomes.
Associations between early handoffs, length of stay and complications in internal medicine wards: A retrospective study
2019, European Journal of Internal Medicine
Citation Excerpt :
We used an effect modification analysis to explore the effect of weekday versus a weekend or holiday admissions on the association between early handoffs and LOS, as well as the association between early handoffs and MC. This finding contrasts with several prior handoff studies, which reported a “weekend effect,” with a significantly longer LOS and a higher mortality rate [21,22]. We propose several contributing factors for our findings.
In US healthcare system, handoffs are associated with an increase in medical error and in hospital length of stay. In non-US healthcare systems, this phenomenon has not been well studied. We studied the association between early handoffs (EH) in a non-US internal medicine ward with length of stay (LOS), use of resources, major complication (MC) and discharge to post-acute care (PAC) facility.
We conducted a retrospective cohort study on patients admitted to the general internal medicine division. Patients with EH (defined as a transfer of responsibility between primary teams within the first 72 h) were compared with patients without EH. The primary outcome was LOS in the general internal medicine division. Secondary outcomes were the use of resources, the incidence of MC (transfer to intensive care, to intermediate care or death) and discharge to a PAC facility.
We included 11,869 patients, 38% of whom were in the EH group. Patients were 67.7±16.6 years old and 53% were males. EH was independently associated with an increase of LOS (+6.4% [95% CI, 3.5%–9.5%], P < .001) and with an increased rate of MC (OR 1.3 [95% CI, 1.1–1.7], P = .012). In our subgroup analysis, the association between early handoff and LOS and MC rate were not statistically significant when the admission occurred on public holidays and weekends.
Among patients admitted in our general internal medicine division, early handoffs were associated with significantly higher length of stay and major complication rate, but not in patients admitted during week-ends.

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View full text

Association of weekend effect with early mortality in severe sepsis patients over time

Highlights

Summary

Background

Methods

Results

Conclusions

Section snippets

Background

Data source

Characteristics of the study population

Discussion

Conclusions

Competing interests statement

Chest

Eur J Intern Med

Am J Med

J Chronic Dis

J Emerg Med

Am J Emerg Med

J Emerg Nurs

Ann Emerg Med

Am J Emerg Med

J Emerg Med

Severe sepsis and septic shock

N Engl J Med

Benchmarking the incidence and mortality of severe sepsis in the United States

Crit Care Med

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007

Crit Care Med

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock

Crit Care Med

The surviving sepsis campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study)

Intensive Care Med

Mortality among patients admitted to hospitals on weekends as compared with weekdays

N Engl J Med