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Weekend & Night Outcomes in a Mature State Trauma
System
Brendan G. Carr, MD MS
Department of Emergency MedicineDepartment of Biostatistics and Epidemiology
University of Pennsylvania School of Medicine
Background
• Outcomes for time-sensitive medical conditions are dependent upon the existence of comprehensive systems of care
• Variability in outcomes has been demonstrated for a number of time-sensitive conditions including STEMI, cardiac arrest, and ischemic stroke
The New Jersey STEMI “system”
Background
• Trauma Care in the USVerification processDemonstrated survival benefitExplicit criteria required for:
– Structures (staffing, OR availability)– Processes (QI program, prehospital
notification)
Goals of the Investigation
• We sought to determine whether the probability of death or adverse clinical outcomes was higher among injured patients presenting at night or on the weekend.
Hypothesis
• We hypothesized that outcomes after trauma would be similar for patients presenting during nights or on the weekend.
Methods
• Retrospective cohort analysis• Five years of data (2004-2008)• Pennsylvania Statewide Trauma Registry
32 accredited trauma centersAdmitting diagnosis of injuryAge >18
Methods
• Main Outcomes: In-hospital mortality
• Secondary Outcomes: ICU length of stayHospital length of stayDelay of more than two hours to
laparotomy or craniotomy
Methods
• Exposure:Night presentation
– 11pm – 6:59am
Weekend presentation – 11pm Friday – 6:59am Monday– Saturday 12:01 am – Sunday 11:59pm
Methods - Power
• We calculated the detectable mortality difference given:
Known sample size2-tailed alpha of 0.05Power of 90%Effect size estimate (mortality
differences for night and weekend presentation based on pilot data)
Methods - Analysis
• Unadjusted Pearson’s chi-square, rank sum, T-test,
Logistic regression• Adjusted
Logistic regression Negative binomial regression (LOS)
Methods - Analysis
• Case Mix adjustmentModified Charlson
– 15 instead of 19 comorbid conditions
• Injury Severity adjustmentTRISS (Trauma – Injury Severity Score)
– Anatomic injury scoring system (ISS)– Physiological scoring system (Revised
Trauma Score)
Results - Power
• Night as compared to dayPowered to detect 0.63% mortality
difference• Weekend as compared to weekday
Powered to detect 0.53% mortality difference
Results – Demographics
Results - Demographics
Summary Results (Adjusted)
Night• Mortality
- Age < 55
- Severe injury - Blunt - Penetrating -
• Delay to laparotomy+
• Delay to craniotomy-
• ICU LOS
• Hospital LOS
Weekend• Mortality
Age < 55
Severe injury Blunt - Penetrating -
• Delay to laparotomy-
• Delay to craniotomy-
• ICU LOS-
• Hospital LOS
Limitations
• Retrospective data• Single state analysis• Negative findings raise power concerns • Inadequate injury severity adjustment• Inadequate case mix adjustment• Exclusion of transfer patients
Conclusions
• Patients presenting at night are no more likely to die than patients presenting during the day
• Patients presenting on the weekend are less likely to die than patients presenting on weekdays
Implications
• Explicit staffing and resource requirements for unplanned critical illness protect against the “weekend effect”
• The impact of similar systems based interventions should be tested for other time-sensitive conditions
Acknowledgments
• Co-authorsPat Reilly, MDC. William Schwab, MDCharles C. Branas, PhD Juliet Geiger, RN MSNDouglas J. Wiebe, PhD
• AHRQ K08HS017960• Pennsylvania Trauma System Foundation
Questions?
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