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In-hospital mortality from trauma linked to late-night arrival time
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A retrospective study of more than 600,000 patients found that those with trauma were most likely to die if their arrival time at a hospital emergency room was between midnight and 6 a.m. Patients admitted between 6 p.m. and midnight also experienced relatively high mortality rates in comparison to other time periods.
“Across all trauma levels, we found that an admission time of after 6 p.m. until 6 a.m. had a significantly higher mortality risk in contrast to being admitted during the other 12 hours of the day,” said principal study author Anthony M. Tolisano, a third-year medical student at New York University School of Medicine.
National Trauma Data Bank (NTDB) data were compiled. Generalized linear modeling determined the relative risk of mortality associated with one of four patient arrival times: morning (6 a.m. to noon); afternoon (noon to 6 p.m.); evening (6 p.m. to midnight); and late night (midnight to 6 a.m.). Trauma level (I – IV) was factored in. In addition, data were adjusted for patient demographics such as age, gender and race; health; injury assessed by the Injury Severity Score (ISS); and general factors such as region of country and year of admission.
A total of 601,388 patients met study inclusion and exclusion criteria. And although injuries were fairly similar clinically across the entire 24-hour time period, the mortality risk for late-night arrivals was 26% higher than for afternoon arrivals. There was also a 9% higher mortality risk for those patients admitted late night vs. evening, and a 21% higher mortality risk with late night admission as opposed to those admitted in the morning.
Trauma focus
He presented their outcomes at the annual meeting of the American Academy of Orthopaedic Surgeons.
One of the findings, in particular, surprised the authors. “It turned out that level I trauma centers had higher mortality rates than lower trauma center levels … even after adjustment for a number of variables, including severity of injury,” Tolisano told Orthopedics Today. “This was confusing to us because it does not mesh with the rest of the published material.”
The discrepancy may be due to the fact that there were relatively few patients presenting at level III and IV trauma centers. “In fact, we had to combine those two levels to make meaningful relationships relative to the level I trauma centers,” Tolisano said. He also noted that NTDB is a voluntary database and perhaps level I trauma centers are better at inputting data, considering the amount of data they had on them.”
Fatigue
Staff fatigue may contribute to the higher level of mortality at night, Tolisano speculated, although there are conflicting studies. “Hospitals may be understaffed at night,” he said. “The greatest number of admissions occurs around 7 p.m., yet the majority of hospitals have increased staffing in the morning. Therefore, it makes sense to redistribute staff throughout the 24 hours. But we found low mortality rates in general, ranging between 4.6% and 4.9%.”
He also pointed out that although level I trauma centers had higher mortality rates overall, these centers had lower mortality rates at night compared to day time vs. lower-level trauma centers. – by Bob Kronemyer
Reference:
- Tolisano, AM; Egol, KA; Spratt, KF; et al. Does time of day of hospital arrival affect outcome following trauma? Paper 121. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13. New Orleans.
Anthony M. Tolisano can be reached at 860-967-7563; e-mail: anthony.tolisano@nyumc.org
