title: The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study.
abstract: BACKGROUND
  Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours.
  
  
  METHODS
  This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002-2005, 2006-2009, and 2010-2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models.
  
  
  RESULTS
  Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1-2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours.
  
  
  CONCLUSIONS
  At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. windmill@fmu.ac.jp.|Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, 960-1295, Koriyama, Fukushima, Japan. windmill@fmu.ac.jp.
authors.forename: Yuko
authors.initials: Y
authors.lastname: Ono
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. toki007-lightning@poem.ocn.ne.jp.
authors.forename: Tokiya
authors.initials: T
authors.lastname: Ishida
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. yudai.i0213@gmail.com.
authors.forename: Yudai
authors.initials: Y
authors.lastname: Iwasaki
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. kawakami-ykh@umin.ac.jp.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Kawakami
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. inokuchir-icu@h.u-tokyo.ac.jp.|Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, 113-8655, Tokyo, Japan. inokuchir-icu@h.u-tokyo.ac.jp.
authors.forename: Ryota
authors.initials: R
authors.lastname: Inokuchi
authors.affiliation: Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, 960-1295, Koriyama, Fukushima, Japan. c-tase@fmu.ac.jp.
authors.forename: Choichiro
authors.initials: C
authors.lastname: Tase
authors.affiliation: Emergency and Critical Care Medical Center, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, 963-8558, Koriyama, Fukushima, Japan. k-shinohara@ohta-hp.or.jp.
authors.forename: Kazuaki
authors.initials: K
authors.lastname: Shinohara
mesh_terms: D039602:After-Hours Care / Q000706:statistics & numerical data*; D015897:Comorbidity; D005260:Female; D006297:Health Services Accessibility; D006764:Hospitals, Community / Q000458:organization & administration*; D006801:Humans; D007564:Japan; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010561:Personnel Staffing and Scheduling; D012189:Retrospective Studies; D016019:Survival Analysis; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*