Objective To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction.Data sources Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013.Study selection Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included.Data extraction Studies' characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I .Results 48 studies with fair quality, enrolling 1 896 859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1 892 424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70 534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity. ConclusionThis systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility. IntroductionAcute myocardial infarction remains a leading cause of death worldwide.1 Every year, approximately one million people in the United States have an acute myocardial infarction and 400 000 die from coronary heart disease.2 Previous studies have suggested that patients with acute myocardial infarction who present to the hospital during off-hours (weekends and nights) may have higher mortality. [3][4][5][6] Higher mortality during off-hours may be attributed to a lower likelihood of receiving evidence based treatment or timely reperfusion therapies.6 7 Furthermore, the number of hospital staff and their level of expertise may contribute to gaps in the quality of care during off-hours. 4 8 9Because of the high incidence and case fatality of acute myocardial infarction, small increases in the relative risk of mortality during off-hours can translate to important effects in the population.Using data from the National Re...

Intravascular catheters required for the care of many hospitalized patients can give rise to bloodstream infection, a complication of care that has occurred most frequently in intensive care unit (ICU) settings. Elucidation of the pathogenesis of catheter-related bloodstream infections (CRBSIs) has guided development of effective diagnostic, management, and prevention strategies. When CRBSIs occur in the ICU, physicians must be prepared to recognize and treat them. Prevention of these infections requires careful attention to optimal catheter selection, insertion and maintenance, and to removal of catheters when they are no longer needed. This review provides a succinct summary of the epidemiology, pathogenesis, and microbiology of CRBSIs and a review of current guidance for the diagnosis, management, and prevention of these infections.

Effective quality improvement (QI) education should improve patient care, but many curriculum studies do not include clinical measures. The research team evaluated the prevalence of QI curricula with clinical measures and their association with several curricular features. MEDLINE, Embase, CINAHL, and ERIC were searched through December 31, 2013. Study selection and data extraction were completed by pairs of reviewers. Of 99 included studies, 11% were randomized, and 53% evaluated clinically relevant measures; 85% were from the United States. The team found that 49% targeted 2 or more health professions, 80% required a QI project, and 65% included coaching. Studies involving interprofessional learners (odds ratio [OR] = 6.55; 95% confidence interval [CI] = 2.71-15.82), QI projects (OR = 13.60; 95% CI = 2.92-63.29), or coaching (OR = 4.38; 95% CI = 1.79-10.74) were more likely to report clinical measures. A little more than half of the published QI curricula studies included clinical measures; they were more likely to include interprofessional learners, QI projects, and coaching.