ObjectivePatients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.MethodRetrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.ResultsSimilar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010).Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054).The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.ConclusionsThere are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.

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BackgroundStudies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance—a marker of illness severity—were associated with in-hospital mortality by day and time of attendance.MethodsRetrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression.ResultsOver the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points).ConclusionUsing conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times.