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Todd Fraser wrote 03-29-2011 05:33:02 pm
Its very interesting that these quite stunning findings are heavily influenced by "Elective Surgical Admissions" that occur after hours. If "staffing" is the issue, I would have expected that the impact would be across medical and emergency surgery as well. One wonders if this truly represents 'elective' cases.

If we hold these findings to be true, the impacts could be profound. The factors that impact on SMR are well known to include those not related to ICU practice - factors such as lead time bias and the performance of other specialties within the hospital. Nonetheless, it seems to indicate that the system performs worse at these times, and a response is necessary. Whether or not the presence of increased seniority at the bedside can influence outcomes is of course unknown, but are we heading for a time, not too far down the track, where ED, theatre and ICU are 24-hour consultant services?

James Doyle wrote 03-31-2011 04:59:03 pm
An interesting paper - but before we have the consultants attend all admissions with healing hands may I question a few points!

Whilst the significance of increased mortality with after hour admissions 1800-0559 is clearly robust - the SMR as calculated from APACHE III-j scores show that not only are they highest from 0800-1000 but also the actual mortality is closest to the SMR during this time interval (best seen in figure 4). The authors themselves state that there was an increased incidence of high SMR between 0600-1000 but state that this was a relatively small group of elective surgical patients, they do not comment on this period of time also reflecting the relevant worsening of performance. (Maybe handover is causal to an increase in mortality)

If I have misread this or it is simply not significant, what about the recent publication in archives of surgery March 21, 2011 titled; Weekend and Night Outcomes in a Statewide Trauma System. This retrospective study of over 90000 patients demonstrated that patients presenting on weekends were less likely to die that those presenting on weekdays (OR 0.89, CI 0.81-0.97), it also reported comparable mortality to those presenting on weeknights and weekdays.

So what are we getting right with trauma that we are not with elective surgery?

wrote 04-01-2011 04:14:56 pm

Geoff Gordon wrote 04-06-2011 03:19:46 pm
The data source and numbers are robust. Interestingly an article about the same time failed to support this MJA paper. I need to go through it a bit more closely as on face value, the increased mortality was seemingly related to the increased illness severity. Accepting that the majority of patients in the registry are from big units (units with big elective operation numbers, hearts, heads vascular etc), I think the bottom line may be suspect. I would like to see them tease out the daytime admissions and outcomes, but only for the patients staying in the unit longer than 48 hours (real ICU patients) I suspect the differences will go away. Are we merely looking at the effect of a lot of low acuity elective type ICU admissions on overall figures; ie a mathematical curiosity? I think so.

Oliver Arkell wrote 06-08-2011 10:29:01 pm
Is there really any chance that consultants will be working around the clock doing shift work in ED, ICU etc? Seems highly unlikely to me, and to be quite frank, after a decade of post graduate training, I'm not that keen to go back to night shift again...

Todd Fraser wrote 06-09-2011 02:36:13 pm
Thanks Oliver,

Yes, I agree, I can't imagine going back to rostered night shifts now. It won't happen in the vast majority of hospitals though, as there simply aren't the numbers, nor the cash, to pay for them.

I know some hospitals have tried ED physicians over night, and some that have had anaesthetists rostered to nights only. I have heard that these have been gradually phased out again.

Is anyone aware of consultant rostering (in house, not on call) in ICU over night?