Risk of death within 7 days of discharge from emergency departments with different organizational models.

OBJECTIVE: The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge. PATIENTS AND METHODS: We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis. RESULTS: In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59-0.92) for the Independent model and 0.75 (95% confidence interval: 0.61-0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score. CONCLUSION: Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.

Linking the severity of illness and the weekend effect: a cohort study examining emergency department visits.

BACKGROUND: Despite extensive research on the "weekend effect" i.e., the increased mortality associated with hospital admission during weekend, knowledge about disease severity in previous studies is limited. The aim of this study is to examine patient characteristics, including disease severity, 30-day mortality, and length of stay (LOS), according to time of admission to an emergency department. METHODS: Our study encompassed all patients admitted to a Danish emergency department in 2014-2015. Using data from electronic patient records, this study examines patient characteristics including age, gender, Charlson Comorbidity Index score, triage score, and primary diagnosis. Triage score and transfer to intensive care unit (ICU) were used as indicators of disease severity. LOS within the department and within the hospital was examined. Age- and sex-standardized 30-day mortality rates comparing patients with the same triage score admitted at daytime, evening, and nighttime on weekdays and on weekends were computed. To test differences, a Cox regression analysis was added. RESULTS: We included 35,459 patient visits, of which 10,435 (32%) started on a weekend. There were no large differences in baseline characteristics between patients admitted on weekdays and those admitted on weekends. The relative risk (RR) for being triaged orange or red was 1.16 (95% confidence interval (CI) 1.06-1.28, P = 0.0017) for weekend admissions as compared with weekday admissions. Weekend admissions were twice as likely as weekday admissions to be transferred to the ICU (RR, 1.96; 95% CI 1.53-2.52, P = 0.0000). No significant changes were found in LOS. The 30-day mortality rate increased with disease severity regardless of time of admission. When comparing the 30-day mortality rate for patients with the same triage score, the trend was toward a higher mortality when admission occurred during the weekend. Increasing mortality rate was significant for patients admitted at evening on weekends with a hazard ratio of 1.32 (95% CI 1.03-1.70, P = 0.027) when compared with patients admitted on daytime on weekdays. CONCLUSIONS: When comparing weekday and weekend admissions, the 30-day mortality rate increased for patients admitted at evening on weekends after adjusting for comorbidity and triage score, indicating that the weekend effect was independent of changes in illness severity.

Readmission and mortality in patients discharged with a diagnosis of medical observation and evaluation (Z03*-codes) from an acute admission unit in Denmark: a prospective cohort study.

BACKGROUND: We assessed the 30-day risk of readmission and mortality among patients receiving an International Classification of Diseases 10th edition diagnosis of medical observation and evaluation (Z03*) following admission to an acute medical admission unit (AMAU), stratified on any further specification of diagnosis during hospital stay. METHODS: We used Central Denmark's (Midt)-Electronic Patient Journal to identify patients with a Z03*-diagnosis among patients admitted to the AMAU, Aarhus University Hospital Nørrebrogade from April 2012 to March 2013, and noted any specification of diagnosis. Patients were followed from hospital discharge until death, emigration, or completion of 30 days follow-up. RESULTS: Of 409 patients with an initial Z03* diagnosis at the AMAU, 55% (n = 226) received a more specific discharge diagnosis after transferral to other departments. Among patients discharged to home with a Z03*-diagnosis, 30% were readmitted within 30 days, while the corresponding figure was 23% for patients receiving a specific diagnosis (p = 0.06). In contrast, corresponding figures for 30-day mortality were 3% for Z03*-diagnosed patients and 10% for those who obtained a specific diagnosis (p = 0.003). CONCLUSIONS: Patients diagnosed with Z03* at hospital discharge have a substantially lower 30-day mortality, but a higher readmission-rate, compared to patients who obtain a specific diagnosis during the entire hospital stay.

Out-of-hours and weekend admissions to Danish medical departments: admission rates and 30-day mortality for 20 common medical conditions.

OBJECTIVES: Knowledge on timing of admissions and mortality for acute medical patients is limited. The aim of the study was to examine hospital admission rates and mortality rates for patients with common medical conditions according to time of admission. DESIGN: Nationwide population-based cohort study. SETTING: Population of Denmark. PARTICIPANTS: Using the Danish National Registry of Patients covering all Danish hospitals, we identified all adults with the first acute admission to a medical department in Denmark during 2010. PRIMARY AND SECONDARY OUTCOME MEASURES: Hourly admission rates and age-standardised and sex-standardised 30-day mortality rates comparing weekday office hours, weekday out of hours, weekend daytime hours and weekend night-time hours. RESULTS: In total, 174,192 acute medical patients were included in the study. The admission rates (patients per hour) were 38.7 (95% CI 38.4 to 38.9) during weekday office hours, 13.3 (95% CI 13.2 to 13.5) during weekday out of hours, 19.8 (95% CI 19.6 to 20.1) during weekend daytime hours and 7.9 (95% CI 7.8 to 8.0) during weekend night-time hours. Admission rates varied between medical conditions. The proportion of patients admitted to an intensive care unit (ICU) increased outside of office hours. The age-standardised and sex-standardised 30-day mortality rate was 5.1% (95% CI 5.0% to 5.3%) after admission during weekday office hours, 5.7% (95% CI 5.5% to 6.0%) after admission during weekday out of hours, 6.4% (95% CI 6.1% to 6.7%) after admission during weekend daytime hours and 6.3% (95% CI 5.9% to 6.8%) after admission during weekend night-time hours. For the majority of the medical conditions examined, weekend admission was associated with highest mortality. CONCLUSIONS: While admission rates decreased from office hours to weekend hours there was an observed increase in mortality. This may reflect differences in severity of illness as the proportion admitted to an ICU increased during the weekend.

Acute admissions to medical departments in Denmark: diagnoses and patient characteristics.

BACKGROUND: Despite extensive research on individual diseases, population-based knowledge about reasons for acute medical admissions remains limited. Our aim was to examine primary diagnoses, Charlson Comorbidity Index (CCI) score, age, and gender among patients admitted acutely to medical departments in Denmark. METHODS: In this population-based observational study, 264,265 acute medical patients admitted during 2010 were identified in the Danish National Registry of Patients (DNRP), covering all hospitals in Denmark. Reasons for acute admissions were assessed by primary diagnoses, grouped according to the International Classification of Diseases 10th edition. Additionally, the CCI score, age and gender were presented according to each diagnostic group. RESULTS: Two-thirds of the patients had one of the four following reasons for admission: cardiovascular diseases (19.3%), non-specific Z-diagnoses ("Factors influencing health status and contact with health services") (16.9%), infectious diseases (15.5%), and non-specific R-diagnoses ("Symptoms and abnormal findings, not elsewhere classified") (11.8%). In total, 45% of the patients had a CCI score of one or more and there was a considerable overlap between the patients' chronic diseases and the reason for admission. The median age of the study population was 64 years (IQR 47-77 years), ranging from 46 years (IQR 27-66) for injury and poisoning to 74 years (IQR 60-83) for hematological diseases. Gender representation varied considerably within the diagnostic groups, for example with male predominance in mental disorders (59.0%) and female predominance in diseases of the musculoskeletal system (57.8%). CONCLUSION: Our study identifies that acute medical patients often present with non-specific symptoms or complications related to their chronic diseases.

Registration of acute medical hospital admissions in the Danish National Patient Registry: a validation study.

BACKGROUND: In recent years, the number of acute hospital admissions has increased and this has imposed both organizational and financial strains on the health care system. Consequently, it is of crucial importance that we have valid data on admission types in the administrative databases in order to provide data for health care planning and research. OBJECTIVE: To examine the validity of registration of acute admissions among medical patients in the Danish National Patient Registry (DNPR) using medical record reviews as the reference standard. METHODS: We used the nationwide DNPR to identify a sample of 160 medical patients admitted to a hospital in the North Denmark Region during 2009. Data on admission type was obtained from the DNPR and confirmed by a medical record review. We computed positive predictive values, sensitivity, and specificity including 95% confidence intervals (CI) using the medical record review as the reference standard. RESULTS: Among the 160 medical inpatients identified in the DNPR, 128 were registered with an acute admission, and 32 were registered with a nonacute admission. Two medical records could not be located. Thus, the analyses included 158 medical patients. Among the 127 patients registered with acute admission, 124 were confirmed to be correctly classified. Correspondingly, 28 of the 31 patients with a registered nonacute admission were confirmed to be correctly classified. The overall positive predictive value of the acute admissions among medical patients was 97.6% (95% CI, 93.8%-99.3%). Sensitivity was 97.6% (95% CI, 93.8%-99.3%) and specificity was 90.3% (95% CI, 76.4%-97.2%). CONCLUSION: The registration of acute admission among medical patients in the DNPR has high validity.