The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study

Abstract

BackgroundBecause most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours.MethodsThis was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002–2005, 2006–2009, and 2010–2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models.ResultsOf the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1–2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours.ConclusionsAt a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.

Night admission is an independent risk factor for mortality in trauma patients - a systemic error approach

“…This fact points to the idea that the various adverse conditions (holes in the barriers) can and should be neutralized through critical analysis of the context of each service and higher organizational level. These studies suggest that the relationship between level of organization and higher mortality in the periods "off hours" should be recognized and used as an important indicator to improve care processes as well as the reformulation of these processes over the years 3,4 .…”

“…and referral to medical specialists is hampered due to fewer professionals, providing a smaller number diagnostic investigations and therapeutic procedures based on evidence [3][4][5][6]10,[14][15][16] . Another factor that may have important association is related to the fatigue of professionals at night, and these are often the same professionals who worked during the day and stay at night, or who may already have come from other working hours; furthermore, the inversion of sleep-wake cycle can change and attention influence the procedures adopted 3,[17][18][19][20] . This study, performed in a major hospital in the emergency area, is consistent with data in the literature regarding the morbidity and mortality of patients admitted in different shifts and in the middle or end of the week, showing a higher mortality in patients admitted in the "off- Table 2 -Table 2 -Table 2 -Table 2 -Table 2 Barbosa Barbosa Barbosa Barbosa Barbosa Admissão noturna é fator de risco independente para mortalidade em pacientes vítimas de trauma -uma abordagem ao erro sistêmico hours" period 8,9,21 .…”

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“…This fact points to the idea that the various adverse conditions (holes in the barriers) can and should be neutralized through critical analysis of the context of each service and higher organizational level. These studies suggest that the relationship between level of organization and higher mortality in the periods "off hours" should be recognized and used as an important indicator to improve care processes as well as the reformulation of these processes over the years 3,4 .Although well known for aviation and other business sectors, the Swiss cheese model is misunderstood and poorly put into practice in health care 24 . It is important to understand that the period "off hours" has its organizational peculiarities and should be managed in order to solve these peculiarities, not similar to daytime shift so there is the improvement of services.…”

“…Such situations, also added to the circadian rhythm and dynamics of abnormal operating changes can be crucial factors for the worst performance in these periods. The cumulative presence of a number of unfavorable conditions is remarkable and very common in these periods, situations that favor and increase vulnerability to error [1][2][3][4][5][6][7][8][9][10] . Specific studies in patients with acute myocardial infarction, ischemic stroke and the Intensive Care Units showed higher rate of clinical complications and hospital mortality in the "off-hours" periods (nighttime or weekends) [4][5][6][7][8][9][10][11][12] .…”