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Original research
Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust
  1. Jianxia Sun1,
  2. Alan J Girling2,
  3. Cassie Aldridge2,
  4. Felicity Evison1,
  5. Chris Beet3,
  6. Amunpreet Boyal4,
  7. Gavin Rudge2,
  8. Richard J Lilford5,
  9. Julian Bion6
  1. 1 Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  2. 2 Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  3. 3 Intensive Care, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
  4. 4 Research & Development, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  5. 5 Public Health, University of Warwick, Coventry, UK
  6. 6 Intensive Care Medicine, University of Birmingham, Birmingham, UK
  1. Correspondence to Professor Julian Bion, Intensive Care Medicine, University of Birmingham, Birmingham, B15 2TT, UK; J.F.Bion{at}bham.ac.uk

Abstract

Objective To determine whether the higher weekend admission mortality risk is attributable to increased severity of illness.

Design Retrospective analysis of 4 years weekend and weekday adult emergency admissions to a university teaching hospital in England.

Outcome measures 30-day postadmission weekend:weekday mortality ratios adjusted for severity of illness (baseline National Early Warning Score (NEWS)), routes of admission to hospital, transfer to the intensive care unit (ICU) and demographics.

Results Despite similar emergency department daily attendance rates, fewer patients were admitted on weekends (mean admission rate 91/day vs 120/day) because of fewer general practitioner referrals. Weekend admissions were sicker than weekday (mean NEWS 1.8 vs 1.7, p=0.008), more likely to undergo transfer to ICU within 24 hours (4.2% vs 3.0%), spent longer in hospital (median 3 days vs 2 days) and less likely to experience same-day discharge (17.2% vs 21.9%) (all p values <0.001).

The crude 30-day postadmission mortality ratio for weekend admission (OR=1.13; 95% CI 1.08 to 1.19) was attenuated using standard adjustment (OR=1.11; 95% CI 1.05 to 1.17). In patients for whom NEWS values were available (90%), the crude OR (1.07; 95% CI 1.01 to 1.13) was not affected with standard adjustment. Adjustment using NEWS alone nullified the weekend effect (OR=1.02; 0.96–1.08).

NEWS completion rates were higher on weekends (91.7%) than weekdays (89.5%). Missing NEWS was associated with direct transfer to intensive care bypassing electronic data capture. Missing NEWS in non-ICU weekend patients was associated with a higher mortality and fewer same-day discharges than weekdays.

Conclusions Patients admitted to hospital on weekends are sicker than those admitted on weekdays. The cause of the weekend effect may lie in community services.

  • mortality (standardized mortality ratios)
  • patient safety
  • duty hours/work hours
  • emergency department
  • hospital medicine

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: http://creativecommons.org/licenses/by/4.0/

http://dx.doi.org/10.1136/bmjqs-2018-008219

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    Footnotes

    • Contributors JB developed the initial study idea and is the guarantor. JS undertook data extraction and analysis. AJG supervised the statistical analysis. CA, AJG, FE, CB, AB, GR and RJL informed the methodology. All authors contributed to writing the final report and approved the final version.

    • Funding This project was funded by the National Institute for Health Research, Health Services and Delivery Research Programme (project number 12/128/17). RJL, GR and AJG are also funded by the NIHR Collaboration for Leadership in Applied Health Research and Care, West Midlands.

    • Disclaimer The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR, NIHR, NHS or the Department of Health.

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval South West Wales REC.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The data guardian is the University Hospital Birmingham NHS Foundation Trust.