To the Editor.—
Arias et al1 and Bell and Redelmeier2 recently identified associations between timing of admission and mortality rates in North America. Such studies highlight potential areas for improvement in health care delivery. Hospitals in less-developed countries are typically under-resourced and understaffed all of the time.3 However, similar to North America, there may be differences in health care delivery outside of office hours.
We previously conducted a prospective study of 12 893 consecutive admissions of children ≥90 days old to our own district hospital in Kenya and developed prognostic scores for inpatient deaths occurring <4 hours after admission (very early), 4 to 48 hours after admission (early), and >48 hours after admission (late).4 Prognostic characteristics were length of history, prostration, coma, seizures, subcostal indrawing, deep breathing, wasting, kwashiorkor, axillary temperature, and severe anemia. Using these data, we compared the risk-adjusted mortality among weekend (midnight Friday to midnight Sunday) versus weekday pediatric admissions.
During the weekends, there were 2754 (21%) admissions, although 29% (2 of 7 days) would be expected if they were distributed evenly throughout the week. Of those admitted during the weekend, 171 of 2754 (6.2%) died, compared with 487 of 10139 (4.8%) admitted on weekdays (crude odds ratio [OR]: 1.31; 95% confidence interval [CI]: 1.10–1.57). There was no evidence for differences in mortality between any of the weekdays. The majority of admissions were for a febrile illness (see Table 1). During the weekends, admitted patients were more likely to have unconsciousness or seizures and less likely to have a prolonged illness, malnutrition, or subcostal indrawing. There was no evidence for differences in the distributions of very early, early, and late prognostic scores between weekend and weekday admissions (Kruskall-Wallis tests: very early χ2 = 1.08, P = 0.30; early χ2 = 0.51, P = 0.47; late χ2 = 2.53, P = 0.11). When adjusted for prognostic score, age, bacteremia and Plasmodium falciparum parasitemia, admission during the weekend was associated with ORs for death of 2.05 (95% CI: 1.26–3.31) within 4 hours of admission, 1.54 (95% CI: 1.17–2.03) within 4 to 48 hours, and 1.09 (95% CI: 0.80–1.47) >48 hours after admission.
There was a substantially higher risk of early inpatient death among weekend compared to weekday pediatric admissions. Because we adjusted for the presence or absence of the major clinical correlates of mortality, we cannot simply attribute the excess mortality on weekends to children being more severely ill on arrival on the ward. It could be argued that the prognostic scores were not sensitive enough to detect clinically important differences. Yet, the greatest mortality excess was in the first 4 hours, and the very early prognostic score had previously been shown to very accurately predict these deaths in this population.4
We recently reported that mortality among severely ill children with severe anemia is associated with delayed blood transfusion.5 Delays in identification and treatment of other common, severe complications such as hypoxemia, hypovolemia, metabolic acidosis, or hypoglycemia could be similarly associated with increased risk of early mortality. We think that these findings warrant a careful audit of the quality of care provided during the first few hours after admission. Since these data were collected, we have examined staffing levels and strengthened training in basic and advanced life support.
- ↵Arias Y, Taylor DS, Marcin JP. Association between evening admissions and higher mortality rates in the pediatric intensive care unit. Pediatrics.2004;113(6) . Available at: www.pediatrics.org/cgi/content/full/113/6/e530
- ↵Berkley J, Ross A, Mwangi I, et al. Prognostic indicators of early and late death in children admitted to district hospital in Kenya: cohort study. BMJ.2003;326 :361
- ↵World Health Organization. Management of the Child With a Serious Infection or Severe Malnutrition. Guidelines at the First Referral Level in Developing Countries. Geneva, Switzerland: World Health Organization; 2000
- Copyright © 2004 by the American Academy of Pediatrics