The Effect of Out of Hours Presentation with Acute Stroke on Processes of Care and Outcomes: Analysis of Data from the Stroke Improvement National Audit Programme (SINAP)

Abstract

BackgroundThere is inconsistent evidence that patients with stroke admitted to hospital out of regular working hours (such as weekends) experience worse outcomes. We aimed to identify if inequalities in the quality of care and mortality exist in contemporary stroke care in England.MethodsSINAP is a prospective database of acute stroke patients, documenting details of processes of care over the first 72 hours. We compared quality of care indicators and mortality at 72 hours, 7 days and 30 days, for patients who arrived within normal hours (Monday–Friday 8am to 6pm) and for those who arrived out of hours, using multivariable logistic and Cox proportional hazard models. Quality of care was defined according to time from arrival at hospital to interventions (e.g., brain scan), and whether the patient received therapeutic interventions (such as thrombolysis).Results45,726 stroke patients were admitted to 130 hospitals in England between 1 April 2010 and 31 January 2012. Patients admitted out of hours (n = 23779) had more features indicative of worse prognosis (haemorrhagic stroke, reduced consciousness, pre stroke dependency). Out of hours admission was significantly associated with longer delays in receiving a CT scan or being admitted to a stroke unit, and reduced odds of receiving thrombolysis. After adjusting for casemix, there was no consistent evidence of higher mortality for patients admitted out of hours, but patients admitted at the weekends had a higher risk of 30 day mortality (OR 1.14, 95% CI 1.06–1.21)ConclusionInequalities in the provision of stroke care for people admitted out of regular hours persist in contemporary stroke in England. The association with mortality is small and largely attributable to higher illness severity in patients admitted out of hours.

Strokes happen round the clock, but why is stroke care worse on weekends and overnight?

“…The study by Turner et al 4 adds to this body of literature, describing quality of care and outcomes in a large cohort of patients with stroke in Scotland. As previous studies have observed,5 they found that patients admitted on weekends and overnight were generally sicker than those admitted during weekends, with a higher prevalence of haemorrhagic stroke and markers of poor prognosis. Quality was poorer overnight and on weekends for some processes of care (swallow screening, thrombolysis) but not for others (brain scanning, administration of aspirin).…”

Off-Hour Admission and Outcomes in Patients with Acute Intracerebral Hemorrhage in the INTERACT2 Trial

“…However, analysis of 10,987 ICH patients from the Canadian Hospital Discharge Database showed no significant difference of in-hospital mortality between weekend and weekday admission [16] . Discrepancies across studies may be attributable to differences in the availability of organized specialist stroke care, defined by the use of stroke units [20,21] , quality of care checklists [5] , and patient-staff ratio [3] during off-hours. In the present analysis of INTERACT2, where all participants received a standardized treatment protocol and background management according to best practice acute stroke care [17,18] , there was no difference in outcome between off-and on-hour admission.…”

Recommendations for Endovascular Care of Stroke Patients

“…Different staffing models are seen for “regular” working hours compared to “off-hours.” The so-called weekend effect, in addition to admission during off hours such as nights and holidays, can negatively impact mortality and outcome for stroke patients [16,17,18,19,20,21]. Several studies have been published which look at the effect staffing has on the mortality and functional outcome of stroke patients.…”

“…Several studies have been published which look at the effect staffing has on the mortality and functional outcome of stroke patients. During off-hours, patients are noted to wait longer for diagnostic imaging and admission [17,18]. An increase in the number of patients eligible for IV alteplase is often seen on the weekend - however, there are decreased odds of receiving the medication on the weekend [16,17,18].…”

“…During off-hours, patients are noted to wait longer for diagnostic imaging and admission [17,18]. An increase in the number of patients eligible for IV alteplase is often seen on the weekend - however, there are decreased odds of receiving the medication on the weekend [16,17,18]. Even with telemedicine, there is a technological delay when the physician is off site [20].…”