Skip to main content

Advertisement

SpringerLink
Log in

Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study

  • Neurological Update
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Introduction

We aimed to disprove an in-hospital off-hour effect in stroke patients by adjusting for disease severity and poor prognostic findings on imaging.

Patients and methods

Our study included 5378 patients from a single center prospective stroke registry of a large teaching hospital in the Netherlands, admitted between January 2003 and June 2015. Patients were categorized by admission time, off-hours (OH) or working hours (WH). The in-hospital mortality, 7-day mortality, unfavorable functional outcome (modified Rankin scale > 2) and discharge to home were analyzed. Results were adjusted for age, sex, stroke severity (NIHSS score) and unfavorable findings on imaging of the brain (midline shift and dense vessel sign).

Results

Overall, 2796 patients (52%) were admitted during OH, which had a higher NIHSS score [3 (IQR 2–8) vs. 3 (IQR 2–6): p < 0.01] and had more often a dense vessel sign at admission (7.9% vs. 5.4%: p < 0.01). There was no difference in mortality between the OH-group and WH-group (6.2% vs. 6.0%; p = 0.87). The adjusted hazard ratio of in-hospital mortality during OH was 0.87 (95% CI: 0.70–1.08). Analysis of 7-day mortality showed similar results. Unadjusted, the OH-group had an unfavorable outcome [OR: 1.14 (95% CI: 1.02–1.27)] and could less frequently be discharged to home [OR: 1.16 (95% CI: 1.04–1.29)], which was no longer present after adjustment.

Discussion and conclusions

The overall outcome of stroke patients admitted to a large Dutch teaching hospital is not influenced by time of admission. When studying OH effects, adjustment for disease severity and poor prognostic findings on imaging is crucial before drawing conclusions on staffing and material.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA et al (2014) Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 383:245–254

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sorita A, Ahmed A, Starr SR, Thompson KM, Reed DA, Dabrh AM et al (2014) Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis. Eur J Intern Med 25:394–400

    Article  PubMed  Google Scholar 

  3. Saposnik G, Baibergenova A, Bayer N, Hachinski V (2007) Weekends: a dangerous time for having a stroke? Stroke 38:1211–1215

    Article  PubMed  Google Scholar 

  4. Palmer WL, Bottle A, Davie C, Vincent CA, Aylin P (2012) Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care. Arch Neurol 69:1–7

    Article  Google Scholar 

  5. Aylin P, Yunus A, Bottle A, Majeed A, Bell D (2010) Weekend mortality for emergency admissions. A large, multicentre study. Qual Saf Health Care 6:213–217

    Article  Google Scholar 

  6. Bell CM, Redelmeier D (2001) Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 345:663–668

    Article  CAS  PubMed  Google Scholar 

  7. Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week. BMJ Qual Saf 2015;492–504

  8. Albright KC, Raman R, Ernstrom K, Hallevi H, Martin-Schild S, Meyer BC et al (2009) Can comprehensive stroke centers erase the “Weekend effect”? Cerebrovasc Dis 27:107–113

    Article  PubMed  Google Scholar 

  9. Albright KC, Savitz SI, Raman R, Martin-Schild S, Broderick J, Ernstrom K et al (2012) Comprehensive stroke centers and the ‘weekend effect’: the SPOTRIAS experience. Cerebrovasc Dis 34:424–429

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jauss M, Oertel W, Allendoerfer J, Misselwitz B, Hamer H (2009) Bias in request for medical care and impact on outcome during office and non-office hours in stroke patients. Eur J Neurol 10:1165–1167

    Article  Google Scholar 

  11. Kamitani S, Nishimura K, Nakamura F, Kada A, Nakagawara J, Toyoda K et al (2014) Consciousness level and off-hour admission affect discharge outcome of acute stroke patients: a J-ASPECT study. J Am Heart Assoc 3:e001059

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kim SC, Hong KS, Hwang SI, Kim JE, Kim AR, Cho JY et al (2012) Weekend admission in patients with acute ischemic stroke is not associated with poor functional outcome than weekday admission. J Clin Neurol 8:265–270

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kim C, Jang MU, Oh MS, Park JH, Jung S, Lee JH et al (2014) Off-hour effect on 3-month functional outcome after acute ischemic stroke: a prospective multicenter registry. PLoS One 9:e105799

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kristiansen NS, Mainz J, Norgard BM, Bartels PD, Andersen G, Johnsen SP (2014) Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality. Stroke 45:3663–3669

    Article  PubMed  Google Scholar 

  15. Martínez-Martínez MM, Fernández-Travieso J, Fuentes B, Ruiz-Ares G, Martínez-Sánchez P, García RC et al (2012) Off-hour effects on stroke care and outcome in stroke centres. Eur J Neurol 08:1140–1145

    Article  Google Scholar 

  16. Streifler JY, Benderly M, Molshatzki N, Bornstein N, Tanne D (2012) Off-hours admission for acute stroke is not associated with worse outcome—a nationwide Israeli stroke project. Eur J Neurol 04:643–647

    Article  Google Scholar 

  17. Fang JS, Saposnik G, Silver FL, Kapral MK (2010) Investigators of the Registry of the Canadian Stroke Network. Association between weekend hospital presentation and stroke fatality. Neurology 75:1589–1596

    Article  PubMed  Google Scholar 

  18. Hasegawa Y, Yoneda Y, Okuda S, Hamada R, Toyota A, Gotoh G et al (2005) The effect of weekends and holidays on stroke outcome in acute stroke units. Cerebrovasc Dis 20:325–331

    Article  PubMed  Google Scholar 

  19. Lee J, Morishima T, Kunisawa S, Sasaki N, Otsubo T, Ikai H et al (2013) Derivation and validation of in-hospital mortality prediction models in ischaemic stroke patients using administrative data. Cerebrovasc Dis 35:73–80

    Article  PubMed  Google Scholar 

  20. Niewada M, Jezierska-Ostapczuk A, Skowronska M, Sarzynska-Dlugosz I, Czlonkowska A (2012) Weekend versus weekday admissions in polish stroke centres—could admission day affect prognosis in polish ischaemic stroke patients? Neurol Neurochir Pol 46:15–21

    Article  Google Scholar 

  21. Bray BD, Cloud GC, James MA, Hemingway H, Paley L, Stewart K et al (2016) Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care. Lancet 388(10040):170–177

    Article  PubMed  Google Scholar 

  22. Cho KH, Park EC, Nam CM, Choi Y, Shin J, Lee SG (2016) Effect of weekend admission on in-hospital mortality in patients with ischemic stroke: an analysis of Korean nationwide claims data from 2002 to 2013. J Stroke Cerebrovasc Dis 25(2):419–427

    Article  PubMed  Google Scholar 

  23. Turner M, Barber M, Dodds H, Dennis M, Langhorne P, Macleod MJ (2016) Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes. J Neurol Neurosurg Psychiatry 87(2):138–143

    PubMed  Google Scholar 

  24. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607

    Article  Google Scholar 

  25. Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR et al (1999) Baseline NIH stroke scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in acute stroke treatment (TOAST). Neurology 53:126–131

    Article  CAS  Google Scholar 

  26. Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N et al (2010) Predictors of early mortality after acute ischaemic stroke. Swiss Med Wkly 140:254–259

    PubMed  Google Scholar 

  27. Braga P, Ibarra A, Rega I, Ketzoian C, Pebet M, Servente L et al (2002) Prediction of early mortality after acute stroke. J Stroke Cerebrovasc Dis 11:15–22

    Article  PubMed  Google Scholar 

  28. Bakshi R, Mazziotta JC (1998) Acute middle cerebral artery thrombosis demonstrated by cranial computed tomography: the “dense MCA” sign. Arch Neurol 55:1577

    Article  CAS  PubMed  Google Scholar 

  29. Curtze S, Meretoja A, Mustanoja S, Putaala J, Lindberg T, Leppä M et al (2012) Does time of day or physician experience affect outcome of acute ischemic stroke patients treated with thrombolysis? A study from Finland. Int J Stroke 7:511–516

    Article  Google Scholar 

  30. Cram P, Hillis SL, Barnett M, Rosentahal GE (2004) Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med 117:151–157

    Article  PubMed  Google Scholar 

  31. McKinney JS, Deng Y, Kasner SE, Kostis JB (2011) Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality. Stroke 9:2403–2409

    Article  Google Scholar 

  32. Reeves MJ, Smith E, Fonarow G, Hernandez A, Pan W, Schwamm LH (2009) Off-hour admission and in-hospital stroke case fatality in the get with the guidelines—stroke program. Stroke 40:569–576

    Article  PubMed  Google Scholar 

  33. Tung YC, Chang GM, Chen YH (2009) Associations of physician volume and weekend admissions with ischemic stroke outcome in Taiwan: a nationwide population-based study. Med Care 09:1018–1025

    Article  Google Scholar 

  34. Ogbu UC, Westert GP, Slobbe LCJ, Stronks K, Arah OA (2011) A multifaceted look at time of admission and its impact on case-fatality among a cohort of ischaemic stroke patients. J Neurol Neurosurg Psychiatry 1:8–13

    Article  Google Scholar 

  35. Fang K, Churilov L, Weir L, Dong Q, Davis S, Yan B (2014) Thrombolysis for acute ischemic stroke: do patients treated out of hours have a worse outcome? J Stroke Cerebrovasc Dis 23(3):427–432

    Article  PubMed  Google Scholar 

  36. Nakajima M, Inatomi Y, Yonehara T, Watanabe M, Ando Y (2015) Outcome in patients admitted outside regular hospital working hours: does time until regular working hours matter? Int J Stroke 10:79–84

    Article  PubMed  Google Scholar 

  37. Hoh BL, Chi YY, Waters MF, Mocco J, Barker FG (2010) Effect of weekend compared with weekday stroke admission on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay in the nationwide inpatient sample database, 2002–2007. Stroke 41:2323–2328

    Article  PubMed  Google Scholar 

  38. Turin TC, Kita Y, Rumana N, Ichikawa M, Sugihara H, Morita Y et al (2008) Case fatality of stroke and day of the week: is the weekend effect an artifact? Takashima stroke registry, Japan (1988–2003). Cerebrovasc Dis 26:606–611

    Article  PubMed  Google Scholar 

  39. Ayanian JZ, Weissman JS (2002) Teaching hospitals and quality of care: a review of the literature. Milbank Q 80:569–593

    Article  PubMed  PubMed Central  Google Scholar 

  40. Saad A, Adil MM, Patel V, Owada K, Winningham MJ, Nahab F (2014) Clinical outcomes after thrombectomy for acute ischemic stroke on weekends versus weekdays. J Stroke Cerebrovasc Dis 23:2708–2713

    Article  PubMed  Google Scholar 

  41. Scholte op Reimer WJ, Dippel DW, Franke CL, van Oostenbrugge RJ, de Jong G, Hoeks S et al (2006) Quality of hospital and outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands. Stroke 37:1844–1849

    Article  PubMed  Google Scholar 

  42. Jungehulsing GJ, Rossnagel K, Nolte CH, Muller-Nordhorn J, Roll S, Klein M et al (2006) Emergency department delays in acute stroke—analysis of time between ED arrival and imaging. Eur J Neurol 13:225–232

    Article  CAS  PubMed  Google Scholar 

  43. Rose KM, Rosamond WD, Huston SL, Murphy CV, Tegeler CH (2008) Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry. Stroke 12:39:3262–3267

    Article  Google Scholar 

  44. Madej-Fermo OP, Staff I, Fortunato G, Abbott L, McCullough LD (2012) Impact of emergency department transitions of care on thrombolytic use in acute ischemic stroke. Stroke 43:1067–1074

    Article  PubMed  Google Scholar 

  45. Bodenant M, Leys D, Debette S, Cordonnier C, Dumont F, Henon H et al (2010) Intravenous thrombolysis for acute cerebral ischaemia: comparison of outcomes between patients treated at working versus nonworking hours. Cerebrovasc Dis 30:148–156

    Article  PubMed  Google Scholar 

  46. Crowley RW, Yeoh HK, Stukenborg GJ, Medel R, Kassell NF, Dumont AS (2009) Influence of weekend hospital admission on short-term mortality after intracerebral hemorrhage. Stroke 40:2387–2392

    Article  PubMed  Google Scholar 

  47. Kazley AS, Hillman DG, Johnston KC, Simpson KN (2010) Hospital care for patients experiencing weekend vs weekday stroke: a comparison of quality and aggressiveness of care. Arch Neurol 67:39–44

    Article  PubMed  Google Scholar 

  48. De Bruin A, De Bruin EL, Gast A, Kardaun JWPF, Sijl M, Verweij GCG (2003) Koppeling van LMR-en GBA gegevens: methode, resultanten en kwaliteitsonderzoek. CBS, Heerlen, The Netherlands

    Google Scholar 

  49. McCormick N, Bhole V, Lacaille D, Avina-Zubieta JA (2015) Validity of diagnostic codes for acute stroke in administrative databases: a systematic review. PLoS One 10:e0135834

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of neurology, Medisch Spectrum Twente, Koningsplein 1, 7512KZ, Enschede, The Netherlands

    M. P. Tuinman, E. G. A. van Golde, R. P. Portier, I. L. H. Knottnerus, H. M. den Hertog & P. J. A. M. Brouwers

  2. Department of epidemiology, Medisch Spectrum Twente, Koningsplein 1, 7512KZ, Enschede, The Netherlands

    J. van der Palen

Authors
  1. M. P. Tuinman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. G. A. van Golde
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. P. Portier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. I. L. H. Knottnerus
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. van der Palen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. H. M. den Hertog
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. J. A. M. Brouwers
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. P. Tuinman.

Ethics declarations

Conflicts of interest

The authors declare that there is no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical standard

Neither an ethical approval nor an informed consent was sought for this article because this study is a retrospective cohort study of anonymously collected data. This study was completed in accordance with the Helsinki Declaration as revised in 2013.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tuinman, M.P., van Golde, E.G.A., Portier, R.P. et al. Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study. J Neurol 266, 782–789 (2019). https://doi.org/10.1007/s00415-018-9079-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-018-9079-1

Keywords

Search

Navigation