Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2015

Open Access 01-12-2015 | Original research

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

Authors: Yuko Ono, Tokiya Ishida, Yudai Iwasaki, Yutaka Kawakami, Ryota Inokuchi, Choichiro Tase, Kazuaki Shinohara

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2015

Login to get access

Abstract

Background

Because 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.

Methods

This 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.

Results

Of 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.

Conclusions

At 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.
Literature
1.
Saposnik G, Baibergenova A, Bayer N, Hachinski V. Weekends: a dangerous time for having a stroke? Stroke. 2007;38:1211–5.CrossRefPubMed
2.
Johnson J. The increased incidence of anesthetic adverse events in late afternoon surgeries. AORN J. 2008;88:79–87.CrossRefPubMed
3.
Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005;12:629–34.CrossRefPubMed
4.
Buckley D, Bulger D. Trends and weekly and seasonal cycles in the rate of errors in the clinical management of hospitalized patients. Chronobiol Int. 2012;29:947–54.CrossRefPubMed
5.
Bendavid E, Kaganova Y, Needleman J, Gruenberg L, Weissman JS. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120:422–8.CrossRefPubMed
6.
Peberdy MA, Ornato JP, Larkin GL, Braithwaite RS, Kashner TM, Carey SM, et al. National registry of cardiopulmonary resuscitation investigators survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785–92.CrossRefPubMed
7.
Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE. Myocardial Infarction Data Acquisition System (MIDAS 10) study group weekend versus weekday admission and mortality from myocardial infarction. N Engl J Med. 2007;356:1099–109.CrossRefPubMed
8.
Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663–8.CrossRefPubMed
9.
Arbabi S, Jurkovich GJ, Wahl WL, Kim HM, Maier RV. Effect of patient load on trauma outcomes in a Level I trauma center. J Trauma. 2005;59:815–8.CrossRefPubMed
10.
Helling TS, Nelson PW, Shook JW, Lainhart K, Kintigh D. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma. 2003;5:20–5.CrossRef
11.
Carr BG, Jenkins P, Branas CC, Wiebe DJ, Kim P, Schwab CW, et al. Does the trauma system protect against the weekend effect? J Trauma. 2010;69:1042–7.CrossRefPubMed
12.
Carmody IC, Romero J, Velmahos GC. Day for night: should we staff a trauma center like a nightclub? Am Surgeon. 2002;68:1048–51.PubMed
13.
Busse JW, Bhandari M, Devereaux PJ. The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery. Acta Orthop Scand. 2004;75:333–8.CrossRefPubMed
14.
Parsch W, Loibl M, Schmucker U, Hilber F, Nerlich M, Ernstberger A. Trauma care inside and outside business hours: comparison of process quality and outcome indicators in a German level-1 trauma center. Scand J Trauma Resusc Emerg Med. 2014;22:62. doi:10.1186/s13049-014-0062-2.CrossRefPubMedCentralPubMed
15.
16.
Inokuchi R, Sato H, Nakamura K, Aoki Y, Shinohara K, Gunshin M, et al. Motivations and barriers to implementing electronic health records and ED information systems in Japan. Am J Emerg Med. 2014;32:725–30.CrossRefPubMed
17.
Inokuchi R, Sato H, Nakajima S, Shinohara K, Nakamura K, Gunshin M, et al. Development of information systems and clinical decision support systems for emergency departments: a long road ahead for Japan. Emerg Med J. 2013;30:914–7.CrossRefPubMed
18.
Baker SP, O’Neill B, Haddon Jr W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.CrossRefPubMed
19.
20.
Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med. 1981;9:672–6.CrossRefPubMed
21.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score. J Trauma. 1989;29:623–9.CrossRefPubMed
22.
Champion HR, Sacco WJ, Hunt TK. Trauma severity scoring to predict mortality. World J Surg. 1983;7:4–11.CrossRefPubMed
23.
Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method trauma score and the injury severity score. J Trauma. 1987;27:370–8.CrossRefPubMed
24.
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain Jr LW, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma. 1990;30:1356–65.CrossRefPubMed
25.
Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.CrossRefPubMed
26.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.CrossRefPubMed
27.
Hondo K, Shiraishi A, Fujie S, Saitoh D, Otomo Y. In-hospital trauma mortality has decreased in Japan possibly due to trauma education. J Am Coll Surg. 2013;217:850–7.CrossRefPubMed
28.
Cowley RA, Hudson F, Scanlan E, Gill W, Lally RJ, Long W, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma. 1973;13:1029–38.CrossRefPubMed
29.
Henderson KI, Coats TJ, Hassan TB, Brohi K. Audit of time to emergency trauma laparotomy. Br J Surg. 2000;87:472–6.CrossRefPubMed
30.
Ono Y, Yokoyama H, Matsumoto A, Kumada Y, Shinohara K, Tase C. Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery? J Anesth. 2014;28:381–9.CrossRefPubMed
31.
Gonzalez RP, Cummings G, Mulekar M, Rodning CB. Increased mortality in rural vehicular trauma: identifying contributing factors through data linkage. J Trauma. 2006;61:404–9.CrossRefPubMed
32.
Feero S, Hedges JR, Simmons E, Irwin L. Does out-of-hospital EMS time affect trauma survival? Am J Emerg Med. 1995;13:133–5.CrossRefPubMed
33.
Bergeron E, Rossignol M, Osler T, Clas D, Lavoie A. Improving the TRISS methodology by restructuring age categories and adding comorbidities. J Trauma. 2004;56:760–7.CrossRefPubMed
34.
Fatovich DM, Phillips M, Jacobs IG. A comparison of major trauma patients transported to trauma centres vs. nontrauma centres in metropolitan Perth. Resuscitation. 2011;82:560–3.CrossRefPubMed
35.
Yang KC, Zhou MJ, Sperry JL, Rong L, Zhu XG, Geng L, et al. Significant sex-based outcome differences in severely injured Chinese trauma patients. Shock. 2014;42:11–5.CrossRefPubMed
36.
Sperry JL, Nathens AB, Frankel HL, Vanek SL, Moore EE, Maier RV. Inflammation and the host response to injury investigators. Characterization of the gender dimorphism after injury and hemorrhagic shock: are hormonal differences responsible? Crit Care Med. 2008;36:1838–45.CrossRefPubMed
37.
Angele MK, Frantz MC, Chaudry IH. Gender and sex hormones influence the response to trauma and sepsis: potential therapeutic approaches. Clinics (Sao Paulo). 2006;61:479–88.CrossRef
38.
Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson comorbidity Index useful for predicting trauma outcomes? Acad Emerg Med. 2005;12:318–21.CrossRefPubMed
39.
Moore L, Lavoie A, Le Sage N, Bergeron E, Emond M, Liberman M, et al. Using information on preexisting conditions to predict mortality from traumatic injury. Ann Emerg Med. 2008;52:356–64.CrossRefPubMed
40.
Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am. 1983;249:28–35.CrossRefPubMed
41.
Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg. 1980;140:144–50.CrossRefPubMed
42.
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65:748–54.CrossRefPubMed
43.
Di Bartolomeo S, Marino M, Ventura C, Trombetti S, De Palma R. A population based study on the night-time effect in trauma care. Emerg Med J. 2014;31:808–12.CrossRefPubMed
44.
Di Bartolomeo S. The ‘off-hour’ effect in trauma care: a possible quality indicator with appealing characteristics. Scand J Trauma Resusc Emerg Med. 2011;19:33. doi:10.1186/1757-7241-19-33.CrossRefPubMedCentralPubMed
45.
Thompson CT, Bickell WH, Siemens RA, Sacra JC. Community hospital level II trauma center outcome. J Trauma. 1992;32:336–41.CrossRefPubMed
46.
Barone JE, Ryan MC, Cayten CG, Murphy JG. Is 24-hour operating room staff absolutely necessary for level II trauma center designation? J Trauma. 1993;34:878–82.CrossRefPubMed
47.
Schwartz DA, Medina M, Cotton BA, Rahbar E, Wade CE, Cohen AM, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg. 2014;76:134–9.CrossRefPubMed
48.
Thorpe KE. House staff supervision and working hours. Implications of regulatory change in New York State. JAMA. 1990;263:3177–81.CrossRefPubMed
49.
McKee M, Black N. Does the current use of junior doctors in the United Kingdom affect the quality of medical care? Soc Sci Med. 1992;34:549–58.CrossRefPubMed
50.
De Knegt C, Meylaerts SA, Leenen LP. Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma. Injury. 2008;39:993–1000.CrossRefPubMed
51.
Carr BG, Reilly PM, Schwab CW, Branas CC, Geiger J, Wiebe DJ. Weekend and night outcomes in a statewide trauma system. Arch Surg. 2011;146:810–7.CrossRefPubMed
52.
Psoinos CM, Emhoff TA, Sweeney WB, Tseng JF, Santry HP. The dangers of being a “weekend warrior”: a new call for injury prevention efforts. J Trauma Acute Care Surg. 2012;73:469–73.CrossRefPubMedCentralPubMed
53.
McHugh EM. The new EMTALA regulations and the on-call physician shortage: in defense of the regulations. J Health Law. 2004;37:61–84.PubMed
Metadata
Title
The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study
Authors
Yuko Ono
Tokiya Ishida
Yudai Iwasaki
Yutaka Kawakami
Ryota Inokuchi
Choichiro Tase
Kazuaki Shinohara
Publication date
01-12-2015
Publisher
BioMed Central
DOI
https://doi.org/10.1186/s13049-015-0095-1

Other articles of this Issue 1/2015

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2015 Go to the issue

Original research

Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data

Original research

A mobile minimally invasive interventional shelter: a new answer to on-spot emergency treatment of large arterial injuries?

Original research

Cross-sectional survey on self-reported health of ambulance personnel

Review

Therapeutic hypothermia for acute brain injuries

Original research

The novel intubating laryngeal tube (iLTS-D) is comparable to the intubating laryngeal mask (Fastrach) – a prospective randomised manikin study

Original research

Implementation of a dispatch-instruction protocol for cardiopulmonary resuscitation according to various abnormal breathing patterns: a population-based study