The Hospital Mortality of Patients Admitted to the ICU on Weekends

doi:10.1378/chest.126.4.1292

Chest

Volume 126, Issue 4, October 2004, Pages 1292-1298

https://doi.org/10.1378/chest.126.4.1292 Get rights and content

Study objectives:

Previous studies have suggested that patients are more likely to die in the hospital if they are admitted on a weekend than on a weekday. This study was conducted to determine whether weekend admission to the ICU increases the risk of dying in the hospital.

Design:

Retrospective cohort study.

Setting:

ICU of a single tertiary care medical center.

Patients:

A total of 29,084 patients admitted to medical, surgical, and multispecialty ICUs from October 1994 through September 2002.

Interventions:

None.

Measurements and results:

The weekend ICU admissions comprised 27.9% of all ICU admissions (8,108 ICU admissions). The overall hospital mortality rate was 8.2% (2,385 deaths). Weekend ICU admission was associated with a higher unadjusted hospital mortality rate than that for weekday ICU admission (11.3% vs 7.0%, respectively; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.55 to 1.85). In multivariable analyses controlling for the factors associated with mortality such as APACHE (acute physiology and chronic health evaluation) III predicted mortality rate, ICU admission source, and intensity of treatment, no statistically significant difference in hospital mortality was found between weekend and weekday admissions in the overall study population (OR, 1.06; 95% CI, 0.95 to 1.17). For weekend ICU admissions, the observed hospital mortality rates of the medical, multispecialty, and surgical ICUs were 15.2%, 17.2%, and 6.4%, respectively, and for weekday ICU admissions the rates were 16.3%, 10.1%, and 3.5%, respectively. Subgroup analyses showed that weekend ICU admission was associated with higher adjusted hospital mortality rates than was weekday ICU admission in the surgical ICU (OR, 1.23; 95% CI, 1.03 to 1.48), but not in the medical or multispecialty ICUs.

Conclusions:

The overall adjusted hospital mortality rate of patients admitted to the ICU on a weekend was not higher than that of patients admitted on a weekday. However, weekend ICU admission to the surgical ICU was associated with an increased hospital mortality rate.

Section snippets

Materials and Methods

In this cohort study, we reviewed the prospectively collected APACHE (acute physiology and chronic health evaluation) III database of patients admitted to some of the ICUs of the Mayo Clinic (Rochester, MN) from October 1994 through September 2002. The Mayo Foundation Institutional Review Board approved the study.

Results

There were 41,197 ICU admissions during the study period, of which 30,234 were first admissions. Excluding 1,150 patients who did not authorize their medical records to be reviewed for research, 29,084 patients were included in the study. Patients were predominantly white (95.5%). The weekend ICU admissions comprised 27.9% of the study population (8,108 patients). Of the 15,705 ICU admissions through 1998, 4,019 patients (25.6%) had been admitted on weekends, compared to 4,089 of 13,379

Discussion

This study examined whether weekend ICU admission is an independent risk factor for mortality in > 29,000 patients who had been admitted to an academic medical center. Using the APACHE III prognostic system for measuring severity of illness and adjusting for variables that may influence hospital mortality, our results showed that weekend ICU admission was not associated with an overall increased risk of hospital death. However, weekend ICU admission was associated with increased hospital

Conclusion

The current study shows that weekend ICU admission is not significantly associated with overall increased adjusted hospital mortality. As long as adequate staffing is maintained, and necessary diagnostic and therapeutic modalities are available, weekend ICU admission need not be associated with poor patient outcome. However, with the anticipated shortage of critical care physicians, registered nurses, and other health-care providers, and with the pressure on medical centers to cut costs,

References (31)

JE Zimmerman et al.
The use of risk predictions to identify candidates for intermediate care units: implications for intensive care utilization and cost
Chest
(1995)
WA Knaus et al.
The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults
Chest
(1991)
WO Tarnow-Mordi et al.
Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit
Lancet
(2000)
D Dang et al.
Postoperative complications: does intensive care unit staff nursing make a difference?
Heart Lung
(2002)
CM Bell et al.
Mortality among patients admitted to hospitals on weekends as compared with weekdays
N Engl J Med
(2001)
WD Mangold
Neonatal mortality by the day of the week in the 1974–75 Arkansas live birth cohort
Am J Public Health
(1981)
RA Hendry
The weekend: a dangerous time to be born?
Br J Obstet Gynaecol
(1981)
EA Halm et al.
Why do hospital death rates vary?
N Engl J Med
(2001)
C Tanio
Weekend work: balancing competing interests
J Gen Intern Med
(1999)
MJ Barnett et al.
Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation
Med Care
(2002)

DJ Cullen et al.

Therapeutic intervention scoring system: a method for quantitative comparison of patient care

Crit Care Med

(1974)

AR Keene et al.

Therapeutic Intervention Scoring System: update 1983

Crit Care Med

(1983)

WA Knaus et al.

The range of intensive care services today

JAMA

(1981)

RE Park et al.

Explaining variations in hospital death rates: randomness, severity of illness, quality of care

JAMA

(1990)

S Carmel et al.

Variation in intensive care unit outcomes: a search for the evidence on organizational factors

Curr Opin Crit Care

(2001)

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2023, Medicina Clinica Practica
Poor sleep hygiene and the hour of changing shifts are among the most important factors which affect the quality of services in the intensive care unit. The present study aimed to investigate the demographic properties of patients who died in the intensive care unit and their association with their death hour.
As a cross-sectional study, this study was performed by referring to the Statistics Center of Hazrat Rasool Akram Hospital and collecting the demographic information of dead patients at 12 intensive care units in this hospital. This information includes age, sex, the cause of death, and the exact time of death of these patients.
In this study, the rate of mortality in intensive care units was assessed as follows; from 12 pm to 2 am (14.48%), from 2 am to 4 (5.49%), from 4 to 6 am (8.99%), from 6 to 8 am (11.32%), from 8 to 10 am (6.79%), from 10 am to 12 noon (8.03%), from 12 to 14 (6.04%), from 14 to 16 (6.93%), from 16 to 18 (7.41%), from 18 to 20 (9.47%), from 20 to 22 (8.1%), and from 22 to 24 hours (6.93%). The highest rate of mortality was between 12–2 AM and then 6–8 AM. In this study, a significant rate of deaths occurred during the night and the lowest rate was during normal work hours and in fact during the morning hours of visiting patients.
Since the highest rate of mortality was during night hours, during the hours of changing shifts, and at the beginning of midnight, the mortality rate could be decreased with the decrement in staff's working hours and paying more attention to patients during these hours, the overall mortality rate of patients could be decreased in ICU units.
La mala higiene del sueño y el horario de cambio de turno se encuentran entre los factores más importantes que afectan la calidad de los servicios en la unidad de cuidados intensivos. El presente estudio tuvo como objetivo investigar las propiedades demográficas de los pacientes que fallecieron en la unidad de cuidados intensivos y su asociación con la hora de su muerte.
Como estudio transversal, este estudio se realizó remitiendo al Centro de Estadísticas del Hospital Hazrat Rasool Akram y recopilando la información demográfica de los pacientes fallecidos en 12 unidades de cuidados intensivos de este hospital. Esta información incluye la edad, el sexo, la causa de la muerte y la hora exacta de la muerte de estos pacientes.
En este estudio, la tasa de mortalidad en las unidades de cuidados intensivos se evaluó de la siguiente manera; de 12 a 2 am (14,48%), de 2 a 4 am (5,49%), de 4 a 6 am (8,99%), de 6 a 8 am (11,32%), de 8 a 10 am (6,79%), de 10 a 12 horas (8,03%), de 12 a 14 (6,04%), de 14 a 16 (6,93%), de 16 a 18 (7,41%), de 18 a 20 (9,47%), de 20 a 22 (8,1%), y de 22 a 24 horas (6,93%). La tasa más alta de mortalidad fue entre las 12 y las 2 de la mañana y luego entre las 6 y las 8 de la mañana. En este estudio, una tasa significativa de muertes ocurrió durante la noche y la tasa más baja fue durante las horas normales de trabajo y, de hecho, durante las horas de la mañana de visita a los pacientes.
Étant donné que le taux de mortalité le plus élevé était pendant les heures de nuit, pendant les heures de changement de poste et au début de minuit, le taux de mortalité pourrait être diminué avec la diminution des heures de travail du personnel et en accordant plus d'attention aux patients pendant ces heures, l'ensemble le taux de mortalité des patients pourrait être diminué dans les unités de soins intensifs.
Analysis of the Weekend Effect at a High-Volume Center for the Treatment of Intracranial Aneurysms
2023, World Neurosurgery
The “weekend effect” is the negative effect on disease course and treatment resulting from being admitted to the hospital during a weekend. Whether the weekend effect is associated with worse outcomes for patients treated for aneurysmal subarachnoid hemorrhage (aSAH) is unknown. We assessed neurologic outcomes of patients with aSAH admitted during the weekend versus during the week.
A retrospective database was reviewed to identify all patients with aSAH who received open or endovascular treatment from August 1, 2007, to July 31, 2019, at a quaternary center. The primary outcome was a poor neurologic outcome (modified Rankin Scale score >2). Propensity adjustment included age, sex, treatment type, Hunt and Hess grade, and Charlson Comorbidity Index.
A total of 1014 patients (women, 703 [69.3%]; men, 311 [30.7%]; mean age, 56 [standard deviation, 14]) met inclusion criteria; 726 (71.6%) had weekday admissions, and 288 (28.4%) had weekend admissions. There was no significant difference between patients with a weekday versus a weekend admission in mean (standard deviation) time to treatment (0.85 [1.29] vs. 0.93 [1.30] days, P = 0.10) or length of stay (19 [9] vs. 19 [9] days, P = 0.04). Total cost and rates of delayed cerebral ischemia and vasospasm were similar between the admission groups, both overall and within the open and endovascular treatment cohorts. After propensity adjustment, weekend admission was not a significant predictor of a modified Rankin Scale score greater than 2 (odds ratio [95% confidence interval]; 1.12 [0.85–1.49]; P = 0.4).
No difference in neurologic outcomes was associated with weekend admission among this cohort of patients with aSAH.
GAM feature selection to discover predominant factors for mortality of weekend and weekday admission to the ICUs
2020, Smart Health
“Weekend effect” on mortality is a common controversial topic among many hospitals. Although the mortality of patients associated with weekend Intensive Care Units (ICUs) admission has been demonstrated slightly higher than that of patients admitted on weekdays in many studies, the underlying causal mechanisms and the potential factors are not clear at present. In this study, we extract medical record features from the database and propose a Generalized Additive Model(GAM) feature selection method to identify the main contribution features for analyzing this issue. The GAM feature selection system could rank candidate features by its importance, which turns out to be effective in reducing the complexity of a medical issue. The best lists of features are acquired by the weekday GAM model and the weekend GAM model separately. Fourteen out of forty-one features are identified for the reduced list of features. Both models’ reduced lists of features have ten identical characteristics, and the other four are different. The prediction accuracy with the reduced list of features is 79.90% for the weekday model and 78.56% for the weekend model. The contrast experiment has validated the feature ranking results. Furthermore, variables of the same feature classes are also different from weekday admission to weekend admission. We expect that the proposed GAM feature selection method could contribute to solving more medical issues in the future.
Unplanned Admission to the ICU: A Qualitative Study Examining Family Member Experiences
2020, Chest
Transfers to the ICU from acute care are common, and it is essential to understand how family members of critically ill patients experience these transitions of care.
Can we enhance our understanding of family members’ experiences during hospital stays complicated by a patient’s unplanned admission to the ICU?
Qualitative interviews were conducted with family members of patients were transferred from acute care to the ICU at a level I trauma center in Seattle, WA (n = 17). To organize data, we used thematic analysis, coupled with a validated conceptual model of clinician-surrogate communication.
Drawing from a validated conceptual model, we used two domains to frame our coding: “information processing” and “relationship building.” Within information processing, we coded information disclosure, sensemaking, and expectations; within relationship building, we coded emotional support, trust, and consensus and conflict. Family members wanted timely, accurate information about the patient’s condition both during and after transfer. An unplanned ICU admission was a stressful event for family members, who looked to clinicians for emotional support. Developing trust was challenging, because family members struggled to feel like integrated members of the medical team when patients transitioned from one setting to another.
Family of patients who experience an unplanned ICU admission want high-quality communication both during and after a patient’s transfer to the ICU. This communication should help family members make sense of the situation, address unmet expectations, and provide emotional support. In addition, interventions that foster family-clinician trust can help family members feel like integrated members of the care team as they face the challenge of navigating multiple different environments within the hospital.
Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome
2019, Resuscitation
Acute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20–40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency.
Using the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event.
Of 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11–1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend.
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View all citing articles on Scopus

: This research was supported by the Anesthesia Clinical Research Unit and by the Pulmonary and Critical Care Division Research Fund, Mayo Clinic and Foundation.

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Chest

Clinical Investigations in Critical CareThe Hospital Mortality of Patients Admitted to the ICU on Weekends

Study objectives:

Design:

Setting:

Patients:

Interventions:

Measurements and results:

Conclusions:

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Chest

Chest

Lancet

Heart Lung

Mortality among patients admitted to hospitals on weekends as compared with weekdays

N Engl J Med

Neonatal mortality by the day of the week in the 1974–75 Arkansas live birth cohort

Am J Public Health

The weekend: a dangerous time to be born?

Br J Obstet Gynaecol

Why do hospital death rates vary?

N Engl J Med

Weekend work: balancing competing interests

J Gen Intern Med

Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation

Med Care

Therapeutic intervention scoring system: a method for quantitative comparison of patient care

Crit Care Med

Therapeutic Intervention Scoring System: update 1983

Crit Care Med

The range of intensive care services today

JAMA

Explaining variations in hospital death rates: randomness, severity of illness, quality of care

JAMA

Variation in intensive care unit outcomes: a search for the evidence on organizational factors

Curr Opin Crit Care

Clinical Investigations in Critical Care
The Hospital Mortality of Patients Admitted to the ICU on Weekends