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Health See other Health Articles Title: Defibrillator Implantation Riskier on Afternoons, Weekends Medscape... Defibrillator-implantation procedures are associated with worse in-hospital outcomes when they're performed on weekends and afternoons than on weekdays and mornings, a new study shows[1]. "I do think that there is a good chance that this applies to other elective procedures," Dr Gregory Marcus (University of California, San Francisco) told heartwire . "We know there is less staffing at that time, and we know the people get tired at the end of the day." Marcus is senior author on the study, published October 25, 2014 in the American Heart Journal. In the study of patients receiving implantable cardioverter-defibrillators (ICD) with or without biventricular pacemakers, Marcus and his colleagues reported, those implanted in the afternoon or evening compared with the morning had a significantly greater risk of experiencing in-hospital complications. They included major complications like lead dislodgment, venous dissection, MI, or need for surgery, as well as minor ones like hematoma or drug reactions. Patients also stayed in the hospital longer. Their in-hospital mortality wasn't higher, however. Aware that most hospitals reduce their level of services evenings and weekends, the group turned to the National Cardiovascular Data Registry for ICDs to look at records for all 302 656 patients whose implant data were submitted to the registry between April 1, 2010 and March 31, 2012. They excluded those implanted with a previous device ICD or pacemaker, patients with an epicardial lead placed during the index procedure, and patients with more than one implant episode listed during the hospitalization; that left 148 004 patients for the final analysis. They separated out procedures done during the morning (6 am to noon), afternoon (noon to 5 pm), evening (5 pm to 6 am), and Fridays, other weekdays, weekends, and holidays. Most patients, 52.6%, received their ICDs during morning hours and the vast majority (97.5%) during the regular workweek. The group found a much higher risk of complications in those patients who had these procedures on afternoons and evenings or on weekends. They propose that that these patients might be sicker or could have been admitted for some other reason and then had the implant as an addition to other treatments. "If someone comes into the hospital for some other reason, and they're an appropriate ICD candidate, there can be pressure to put in the defibrillator while the patient is there," said Marcus. In multivariate analyses, researchers found that those patients treated in the afternoon or evening were 8% more likely to have a complication (OR 1.08, P=0.0168) than those done in the morning and to be 29% more likely to have a hospital stay of longer than 1 day (OR 1.29, P=0.0001). But their in-hospital mortality wasn't significantly increased. The weekend and holiday patients were 40% more likely to stay >1 day in the hospital (OR 1.40, P<0.0001), compared with Tuesday through Thursday. Their in-hospital mortality only trended higher (OR 1.52, P=0.0642), and they did not have significantly more complications. Among those 89 950 patients who had been admitted specifically for an ICD implantation, the risk of a prolonged stay was greater on Friday (OR 1.15, P<0.0001) or the weekend (OR 1.35, P<0.0001) vs Tuesday through Thursday. But their elevated risk of complications was no longer significant. Since the study was retrospective, it could establish no more than an association between the timing of the procedures and the risk of complication—it could not show whether the timing caused the increased risk, Marcus pointed out. Still, the study should stimulate further research into the timing of elective procedures, he said. "It's simply not realistic to imagine that all these cases would be done in the morning. The way to extrapolate this in a reasonable fashion is this: those cases that can wait shouldn't necessarily be done after normal working hours," he said. "It may be the better thing for the patient to just have them come back rather than trying to squeeze them in at the end of the day." The investigators hope to do further research pinpointing the reasons that timing might make a difference, such as fatigue or staffing levels, both during the procedure and during the recovery period. The study was supported by the American College of Cardiology Foundation's National Cardiovascular Data Registry (NCDR). Marcus discloses being a consultant for InCarda and receiving research support from Baylis Medical, Gilead, and SentreHeart. Disclosures for the coauthors are listed in the article. Post Comment Private Reply Ignore Thread
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