The Weekend Effect and Readmissions in the Helsinki and Uusimaa Hospital District : Patient Safety in Secondary and Tertiary Health Care

Background: Patients admitted to the hospital during the weekend have been found to have a higher risk of mortality than those admitted during the week. This weekend effect phenomenon has been widely investigated and the reasons for it extensively discussed. The existence of the weekend effect was examined by specialty at the university hospital and six secondary hospitals in the greater Helsinki area during a 14-year period. The majority of ear, nose and throat (ENT), as well as orthopedic and hand (OHS), day surgery procedures are performed under local or regional anesthesia in Finland. However, this is not true of many other countries. Associations and background factors for overstay, readmission and contacts were investigated at Helsinki University Hospital. Methods: Data for all inpatients during the years 2000-2013 in the Helsinki and Uusimaa Hospital District were selected retrospectively: for the university hospital, all those treated at some point at the university hospital; for the secondary hospitals, those inpatients only treated in secondary hospitals. Urgency and specialty of care were used to group the weekend effect study population. Associations between variables were analyzed. Patients undergoing ENT (n=1,011) or OHS (n=542) day surgery from January 1 to March 31, 2015 were collected retrospectively from the hospital’s surgery database (GE Healthcare Centricity Opera OR Management Software). The 15 most common procedures were selected for both ENT and OHS day surgery. Data was collected on all-cause overstays, readmissions and contacts during the 30-day follow-up period. For ENT patients, American Society of Anesthesiologists (ASA) class, age, sex, type of procedure and anesthesia comprised the multivariable logistic regression model. For OHS patients, diverse factors related to patient characteristics and anesthesia were scrutinized for their effect on these outcomes using Pearson chi-square test, Fischer’s exact test and multivariate logistic regression. For OHS patients, anesthesia charts were also examined and associations between variables were studied using risk profiles. Results: For the university hospital, data for 1,542,230 inpatients were collected retrospectively for the weekend effect study. Of these, 853,268 were emergency patients. Deaths in hospital or within 30 days of discharge numbered 47,122. In in-hospital mortality, a significant weekend effect was found in 7 of 12 specialties for emergency admissions and 4 of 12 specialties for elective admissions. In 30-day post-discharge mortality, a significant weekend effect was found in 1 of 12 specialties for emergency admissions and 2 of 12 specialties for elective admissions. For the six secondary hospitals, data for 456,676 inpatients were selected retrospectively for the weekend effect study. Of these, 292,399 were emergency patients. Deaths in hospital or within 30 days of discharge numbered 17,231. In in-hospital mortality, a significant weekend effect was found in 1 of 7 specialties for emergency admissions and 4 of 8 specialties for elective admissions. In 30-day post-discharge mortality, a significant weekend effect was found in 1 of 7 specialties for emergency admissions and 3 of 8 specialties for elective admissions. The specialties most sensitive to the phenomenon in both the university and the secondary hospitals were surgery, internal medicine, and gynecology and obstetrics. In addition, neurology was also sensitive to the phenomenon in the university hospital. For ENT patients, sex, age and type of procedure proved to be significant factors on the study outcomes of overstay, readmission and contact. General anesthesia patients had an overstay or readmission 3.2% (n=23) of the time, while local anesthesia patients only 1.4% (n=4) of the time. The majority of study outcomes occurred in tonsil surgery, which was only carried out under general anesthesia. For OHS patients, statistically significant factors related to outcomes of overstay, readmission or contact were female sex, total amount of fentanyl, use of remifentanil, other pain medication during procedure and administration of antiemetic medication. General anesthesia and plexus block, total amount of oxycodone and postoperative pain medication emerged as borderline significant factors on outcome after day surgery. Combination analysis was then performed to find risk profiles for outcomes. Conclusion: In the university hospital, a weekend effect for many specialties for both emergency and elective admissions was observed. In the secondary hospitals, elective patients had a weekend effect for many specialties. Weekend elective procedures must be restricted to only those necessary to be performed on the weekend and guidelines for patient selection are needed. Before staffing is adjusted, more disease-specific research is needed to find which patients would benefit most. ASA class and type of anesthesia did not affect the risk of outcomes in ENT day surgery but sex, type of procedure and age did. Female OHS patients with procedures under general anesthesia and requiring greater amounts of opioids in conjunction with surgery were undoubtedly linked with study outcomes. As type of anesthesia had no effect on study outcomes in ENT and OHS day surgery, local and regional anesthesia should be used when medically and procedurally possible. Overstay, readmission and contact rates were the same, or lower, than other international studies.  Tausta: Hoidon laadun seuraaminen lääketieteessä on hyvin tärkeää. Potilasturvallisuusongelmia voidaan parantaa tutkimalla vältettävissä olevia sairaalakuolemia ja kehittämällä toimintatapoja. Sitä kautta saadaan vihiä organisaatiotason ongelmista. Suurin osa hoidon laatuongelmista ei kuitenkaan aiheuta kuolemaa eikä suurin osa kuolemista johdu epäonnistuneesta hoidosta. Kaikista sairaalassa olevista potilaista kuolee 5-10 % ja 95-98 % kuolemista johtuu sairauksien luonnollisesta kulusta. Sairaalakuolleisuuteen voi vaikuttaa jopa hoidon viikonpäivä, ns. viikonloppuilmiö (englanniksi weekend effect). Se tarkoittaa, että potilailla, jotka tulevat sairaalaan viikonloppuna, on suurempi kuolleisuus kuin arkipäivänä sisäänkirjoitetuilla. Suomessa on tutkittu viikonloppuilmiötä mm. tehohoitopotilailla, joilla esiintyi selvä viikonloppuilmiö, kun taas aivoinfarktipotilaiden liuotushoidossa tätä ei ole havaittu. Sairaalakuolleisuuteen liittyviä tekijöitä ei ole Suomessa aiemmin merkittävässä määrin tutkittu. Korva-, nenä ja kurkkutautien erikoisalalla toimenpiteet ovat pääosin päiväkirurgisia. Yhdessä ortopedian ja käsikirurgian kanssa erikoisalat edustavat yli puolta päiväkirurgisista toimenpiteistä. Toimenpide sopii päiväkirurgiseksi, jos alle 3 % potilaista joutuu jäämään osastolle. Mikäli potilas ei kotiudu suunnitellusti toimenpiteen jälkeen, vaan joutuu jäämään osastolle (englanniksi overstay), potilaan valinta päiväkirurgiseen toimintaan katsotaan epäonnistuneeksi. Toisinaan potilas voi joutua tulemaan sairaalaan kotiutumiseen jälkeen, joko päivystykseen tai jopa osastohoitoon (englanniksi readmission). Näitä ns. readmissioita seurataan hoidon onnistumisen ja potilasturvallisuuden mittareina. Tutkimalla näitä readmissioita voidaan selvittää, onko päiväkirurgia laadukasta ja pyrkiä löytämään ne potilasryhmät, joiden hoidon turvallisuutta voisi vielä parantaa. Tämän väitöskirjan tarkoituksena oli selvittää potilasturvallisuutta Suomen suurimmassa sairaanhoitopiirissä. Tutkimuksessa käytettiin kahta potilasturvallisuuden arvioinnissa hyvin tunnettua ja tutkittua indikaattoria, sairaalakuolleisuutta sekä readmissiota. Näiden indikaattorien seuraaminen antaa tietoa potilasturvallisuuden tasosta ja sitä kautta voidaan pyrkiä alentamaan kuolleisuutta sekä potilaiden haittatapahtumia sekä lisätä hoidon vaikuttavuutta. Metodit: Kahdessa ensimmäisessä osatyössä tutkittiin sairaalakuolleisuuden ja ensimmäisen 30 kotiuttamisvuorokauden kuolleisuuden vaihtelua viikonpäivän mukaan Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) alueella erikoisaloittain sekä elektiivisessä että päivystystoiminnassa vuosina 2000-2013. Nämä retrospektiiviset rekisteritutkimukset kattoivat kaiken kaikkiaan 1 998 906 osastohoidossa ollutta potilasta. Kolmannessa ja neljännessä osatyössä tarkasteltiin päivystyskäyntejä ja osastohoitojaksoja 30 vuorokauden aikana päiväkirurgisen leikkauksen jälkeen sekä korva-, nenä- ja kurkkutautien että ortopedian ja käsikirurgian erikoisaloilla. Kaikista tammi-maaliskuun 2015 aikana Helsingin yliopistollisen sairaalan Korvaklinikan ja Herttoniemen sairaalan päiväkirurgisissa yksiköissä leikatuista potilaista kerättiin sähköisestä potilasjärjestelmästä seuraavat tiedot: ikä, sukupuoli, ASA-luokka, anestesiamuoto ja toimenpideryhmä. Kummankin yksikön 15 yleisintä toimenpidettä sisällytettiin tutkimukseen. Ortopedian ja käsikirurgian potilaista myös kerättiin perussairaudet, omat lääkitykset, painoindeksi, tupakointistatus ja leikkaukseen liittyvä lääkitys ja tiedot. Tulokset: Sairaalakuolleisuuden viikonloppuilmiö havaittiin sisätautien, kirurgian ja naistentautien erikoisaloilla sekä yliopistollisessa että reunasairaaloissa. Lisäksi yliopistollisessa sairaalassa neurologian erikoisalalla oli nähtävissä viikonloppuilmiö. Viikonloppuilmiö havaittiin monella erikoisalalla elektiivisessä toiminnassa. Korva-, nenä- ja kurkkutautien päiväkirurgisten toimenpiteiden jälkeen ”overstayn” tai readmission riskiä nostivat naissukupuoli, 16-64 -vuoden ikä ja nielu- tai kitarisatoimenpide. Näiden tapahtumien yleisimmät syyt olivat leikkausalueen verenvuoto sekä pahoinvointi tai oksentelu. Ortopedian ja käsikirurgian päiväkirurgisten potilaiden toimenpiteiden jälkeen ”overstayn” riskitekijöiksi nousivat yleisanestesia ja vahvojen kipulääkkeiden suuri tarve. Suunnittelemattomien päivystyskäyntien ja readmissioiden riskiä nostivat naissukupuoli, vahvojen kipulääkkeiden määrä ja pahoinvointilääkkeen tarve. Näiden tapahtumien yleisimmät syyt olivat leikkausalueen tulehdus sekä pahoinvointi tai oksentelu. Johtopäätökset: Yliopistosairaalassa viikonloppuilmiö esiintyi monella erikoisalalla, sekä päivystyspotilailla että elektiivisillä potilailla. Reunasairaaloissa ilmiö havaittiin usealla erikoisalalla elektiivisillä potilailla. On tarpeellista rajoittaa elektiivisiä toimenpiteitä viikonloppuisin ja potilasvalintakriteereitä olisi hyödyllistä tarkentaa. Ennen henkilöresurssien lisäämistä tautikohtainen tutkimus on tarpeen sen selvittämiseksi, mitkä potilaat hyötyisivät eniten resurssimuutoksista. ASA-luokka ja anestesiamuoto eivät lisänneet haittatapahtumien riskiä korva-, nenä-ja kurkkutautien päiväkirurgiassa, mutta sukupuoli, toimeenpiteen tyyppi ja ikä lisäsivät. Naispotilailla, joille tehtiin ortopedian tai käsikirurgian päiväkirurgiaa yleisanestesiassa ja jotka tarvitsivat suuria määriä opioideja leikkauksen yhteydessä, on selvästi enemmän haittatapahtumia. Paikallispuudutusta ja regionaalista anestesiaa pitäisi käyttää mahdollisuuksien mukaan, koska anestesiamuoto ei lisännyt haittatapahtumien riskiä. ”Overstay”:den, readmissioiden ja kontaktien määrät olivat samalla, tai alemmalla, tasolla kuin kansainvälisissä tutkimuksissa

Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period

Background: The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach. Materials and methods: We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty. Results: A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect. Conclusions: The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible. (C) 2020 Elsevier B.V. All rights reserved.Peer reviewe

Weekend effect on mortality by medical specialty in six secondary hospitals in the Helsinki metropolitan area over a 14-year period

Background The weekend effect is the phenomenon of a patient's day of admission affecting their risk for mortality. Our study reviews the situation at six secondary hospitals in the greater Helsinki area over a 14-year period by specialty, in order to examine the effect of centralization of services on the weekend effect. Methods Of the 28,591,840 patient visits from the years 2000-2013 in our hospital district, we extracted in-patients treated only in secondary hospitals who died during their hospital stay or within 30 days of discharge. We categorized patients based on the type of each admission, namely elective versus emergency, and according to the specialty of their clinical service provider and main diagnosis. Results A total of 456,676 in-patients (292,399 emergency in-patients) were included in the study, with 17,231 deaths in-hospital or within 30 days of discharge. A statistically significant weekend effect was observed for in-hospital and 30-day post-discharge mortality among emergency patients for 1 of 7 specialties. For elective patients, a statistically significant weekend effect was visible in in-hospital mortality for 4 of 8 specialties and in 30-day post-discharge mortality for 3 of 8 specialties. Surgery, internal medicine, and gynecology and obstetrics were most susceptible to this phenomenon. Conclusions A weekend effect was present for the majority of specialties for elective patients, indicating a need for guidelines for these admissions. More disease-specific research is necessary to find the diagnoses, which suffer most from the weekend effect and adjust staffing accordingly.Peer reviewe

Risk factors for evaluating early mortality after microvascular reconstruction of head and neck cancers

Background: Free tissue transfer reconstruction carries significant complication rates in surgical head and neck oncology. A registry-based approach offers a possibility to investigate the factors affecting increased morbidity and early mortality, that is, death within 6 months of treatment. Methods: A retrospective registry review was conducted on a series of 317 consecutive microvascular free tissue transfers in head and neck cancer patients performed during 2013-2017 at the Helsinki University Hospital (Helsinki, Finland). All surviving patients had a minimum follow-up of 2 years (range 24-84 months). Results: Overall, 36 (11.4%) early deaths occurred in this series. In multivariable logistic regression analysis, patients aged 75 years and older (p = 0.019), Adult Comorbidity Evaluation-27 (ACE-27) score of 3 (p = 0.048), tumor class T3 (p = 0.005), lymph node class N2 (p = 0.014), or thrombocyte count of 360 (x 10(9) L) or more (p = 0.001) were more likely to die within 6 months of surgery. Of these 36 patients, 27 (75%) had a complication warranting hospital care and most (n = 22, 61%) had several complications. Conclusions: Early postoperative mortality most frequently affects patients aged 75 years and above, with a high ACE-27 score, advanced tumor stage, or high thrombocyte count. Therefore, preoperative assessment and patient selection should have a crucial role in this patient population.Peer reviewe

Overstay and Readmission in Ear, Nose, and Throat Day Surgery—Factors Affecting Postanesthesia Course

Aims:Many procedures in ear, nose, and throat (ENT) day surgery are carried out under local anesthesia in Finland, whereas many other countries use general anesthesia. We investigated overstay and readmission rates in local and general anesthesia at Helsinki University Hospital.Material and Methods:We conducted a retrospective study on ENT (n = 1011) day surgery patients within a 3-month period using the hospital?s surgery database to collect data pertaining to anesthesia, overstays, readmissions, and contacts within 30 days of surgery.Objectives:We examined the effect of American Society of Anesthesiologists (ASA) class, age, sex, type of procedure, and anesthesia type on overstay, contact, and readmission rates.Results:A multivariable logistic regression model included ASA class, age, sex, type of procedure, and anesthesia (local vs general). Sex, age, and type of procedure had an effect on the outcomes of overstay, readmission, or contact. With general anesthesia, 3.2% (n = 23) had an overstay or readmission compared to 1.4% (n = 4) after local anesthesia. This was mainly explained by the number of study outcomes in tonsillar surgery that was performed only in general anesthesia.Conclusions:Day surgery could be done safely using local anesthesia, as the number of study outcomes was no greater than in general anesthesia. Sex, type of procedure, and age affected the rate of study outcomes, but ASA class and anesthesia form did not. Our overstay, contact, and readmission rates are on the same level, or lower, than in international studies.Peer reviewe

Hammasperäinen poskiontelotulehdus

Vertaisarvioitu.Hammasperäinen poskiontelotulehdus määritellään paikalliseksi poskiontelon limakalvon paksuuntumiseksi, joka liittyy tulehtuneeseen tai laajasti hoidettuun hampaaseen tai suukirurgiseen toimenpiteeseen. Hammasperäinen syy saattaa olla taustalla 15 %:ssa poskiontelotulehduksista, erityisryhmien osalta jopa 40 %:ssa. Hampaan tukikudos- ja juurikanavatulehdukset aiheuttavat yli puolet hammasperäisistä poskiontelotulehduksista. Hammasperäiset tulehdukset ovat yleensä anaerobivoittoisia ja polymikrobisia. Tyypillisimmät oireet ovat toispuolinen märkäinen erite sekä tukkoisuus, paha maku tai haju, toispuolinen poskikipu tai -arkuus, liman valuminen nenänielusta, epämukava tunne kasvoissa tai ikenissä ja hammassärky. Kuvantamisessa käytetään panoraamakuvausta, intraoraalikuvia ja kartiokeilatietokonetomografiaa, joihin liittyy kuitenkin virhelähteitä. Hoito onnistuu, jos suun tulehdus hoidetaan. Hammashoidon lisäksi tarvitaan yleensä mikrobilääkehoito, usein poskiontelopunktio ja joskus sivuontelokirurgiaa.Peer reviewe

Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery : a retrospective observational cohort study

Background While previous studies have evaluated the effect of some patient characteristics (e.g. gender, American Society of Anesthesiologists (ASA) class and comorbidity) on outcome in orthopedic and hand day surgery, more detailed information on anesthesia related factors has previously been lacking. Our goal was to investigate the perioperative factors that affect overstay, readmission and contact after day surgery in order to find certain patient profiles more prone to problemed outcomes after day surgery. Methods We examined orthopedic and hand day surgery at an orthopedic day surgery unit of Helsinki University Hospital. Patient data of all adult orthopedic and hand day surgery patients (n = 542) over a 3-month period (January 1 - March 31, 2015) operated on at the unit were collected retrospectively using the hospital's surgery database. These data comprised anesthesia and patient records with a follow-up period of 30 days post-operation. Patients under the age of 16 and patients not eligible for day surgery were excluded. Patient records were searched for an outcome of overstay, readmission or contact with the emergency room or policlinic. Pearson chi-square test, Fischer's exact test and multivariable logistic regression were used to analyze the effect of various perioperative factors on postoperative outcome. Results Various patient and anesthesia related factors were examined for their significance in the outcomes of overstay, readmission or contact. Female gender (p = 0.043), total amount of fentanyl (p = 0.00), use of remifentanil (p = 0.036), other pain medication during procedure (p = 0.005) and administration of antiemetic medication (p = 0.048) emerged as statistically significant on outcome after day surgery. Conclusions Overstay and readmission in orthopedic and hand day surgery were clearly connected with female patients undergoing general anesthesia and needing larger amounts of intraoperative opioids. By favoring local and regional anesthesia, side effects of general anesthesia, as well as recovery time, will decrease.Peer reviewe

Hammasperäinen poskiontelotulehdus

Vertaisarvioitu.Hammasperäinen poskiontelotulehdus määritellään paikalliseksi poskiontelon limakalvon paksuuntumiseksi, joka liittyy tulehtuneeseen tai laajasti hoidettuun hampaaseen tai suukirurgiseen toimenpiteeseen. Hammasperäinen syy saattaa olla taustalla 15 %:ssa poskiontelotulehduksista, erityisryhmien osalta jopa 40 %:ssa. Hampaan tukikudos- ja juurikanavatulehdukset aiheuttavat yli puolet hammasperäisistä poskiontelotulehduksista. Hammasperäiset tulehdukset ovat yleensä anaerobivoittoisia ja polymikrobisia. Tyypillisimmät oireet ovat toispuolinen märkäinen erite sekä tukkoisuus, paha maku tai haju, toispuolinen poskikipu tai -arkuus, liman valuminen nenänielusta, epämukava tunne kasvoissa tai ikenissä ja hammassärky. Kuvantamisessa käytetään panoraamakuvausta, intraoraalikuvia ja kartiokeilatietokonetomografiaa, joihin liittyy kuitenkin virhelähteitä. Hoito onnistuu, jos suun tulehdus hoidetaan. Hammashoidon lisäksi tarvitaan yleensä mikrobilääkehoito, usein poskiontelopunktio ja joskus sivuontelokirurgiaa.Peer reviewe

Cost analysis of face-to-face visits, virtual visits, and a digital care pathway in the treatment of tonsillitis patients

Purpose The aim of this study was to compare the costs of two different telemedicine-assisted tonsillitis care pathways with traditional face-to-face visits at the Department of Otorhinolaryngology – Head and Neck Surgery (ORL-HNS) at Helsinki University Hospital. Methods We characterized and analyzed the patient flows and their individual episodes of all tonsillitis patients at the Department of ORL-HNS between September 2020 and August 2022. Records were collected by doctors at the clinic. We investigated costs and allocated resources in four categories: invoice from the Department of ORL-HNS to the public payer, expenses to the Department, patient fees, and doctor's resource. Results At least a third of the tonsillitis patients were eligible for telemedicine. The digital care pathway was 12.6 % less expensive for the public payer compared to the previous virtual visit model. For the Department, the expense of the digital care pathway was 58.8 % less per patient than the virtual visit model. Patient fees decreased 79.5 %. The digital care pathway reduced the doctor's resource from 30.28 min to 19.78 min, which accounts for a 34.7 % reduction. Patients finished the digital care pathway in a median of 62 min (SD = 60) compared to the 2–4 h which they would spend on an outpatient clinic visit. Conclusion Our study demonstrates that tonsillitis patients are eligible for preoperative telemedicine. With at least a third of the tonsillitis patients being eligible for telemedicine, major cost savings can be achieved with efficient e-health-assisted solutions.Peer reviewe

Etälääketiede - hyvä oivallus vai harha-askel?

Hyvin suunniteltu etähoito auttaa sekä potilasta että terveydenhuoltojärjestelmää