Journal of Pediatric Surgery 49 (2014) 1087–1091

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

The “weekend effect” in pediatric surgery — increased mortality for

children undergoing urgent surgery during the weekend
Seth D. Goldstein ⁎, Dominic J. Papandria, Jonathan Aboagye, Jose H. Salazar, Kyle Van Arendonk,
Khaled Al-Omar, Gezzer Ortega, Maria Grazia Sacco Casamassima, Fizan Abdullah
Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine

a r t i c l e i n f o a b s t r a c t

Article history: Background: For a number of pediatric and adult conditions, morbidity and mortality are increased when
Received 29 July 2013 patients present to the hospital on a weekend compared to weekdays. The objective of this study was to
Received in revised form 5 January 2014 compare pediatric surgical outcomes following weekend versus weekday procedures.
Accepted 11 January 2014 Methods: Using the Nationwide Inpatient Sample and the Kids’ Inpatient Database, we identified 439,457
pediatric (b 18 years old) admissions from 1988 to 2010 that required a selected index surgical proce-
Key words:
dure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation,
Surgical outcomes
National Inpatient Sample
or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were com-
Kids' Inpatient Database pared using logistic regression models that adjusted for patient and hospital characteristics as well as
Weekend effect procedure performed.
Patient safety Results: Patient characteristics of those admitted on the weekend (n = 112,064) and weekday (n = 327,393)
Pediatric surgery were similar, though patients admitted on the weekend were more likely to be coded as emergent (61%
versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were
more likely to die (OR 1.63, 95% CI 1.21–2.20), receive a blood transfusion despite similar rates of
intraoperative hemorrhage (OR 1.15, 95% CI 1.01–1.26), and suffer from procedural complications (OR 1.40,
95% CI 1.14–1.74).
Conclusion: Pediatric patients undergoing common urgent surgical procedures during a weekend admission
have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact
etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of
systems-based deficiencies that may be detrimental to pediatric surgical care.
© 2014 Elsevier Inc. All rights reserved.

Pediatric surgeons frequently perform urgent and emergent 1. Methods

surgical procedures outside the regularly scheduled operating room
hours due to the time-sensitive nature of the disease processes and
because delays in care may contribute adversely to outcomes. How-
ever, operating room staffing and hospital resource availability are
variable outside of the traditional Monday through Friday work week,
and evidence has emerged that for a number of pediatric and adult
conditions, morbidity and mortality increase when patients present to
the hospital on a weekend compared to a weekday [1–16].
Whether this so-called “weekend effect” occurs with regard to
pediatric surgical procedures is unknown. The objective of this study
was therefore to analyze two large national databases to evaluate the
potential effect of weekend admission on surgical outcomes in the
pediatric population.
1.1. Data sources
A retrospective analysis was performed using a non-overlapping
combination of the Nationwide Inpatient Sample (NIS) (1988–2010)
and the Kids’ Inpatient Database (KID) (1997, 2000, 2003, 2006, and
2009). This study was deemed exempt by the Institutional Review
Board of Johns Hopkins Medicine given the deidentified nature of the
data. Both the NIS and KID are aggregated from all-payer state dis-
charge databases and are made available to researchers through the
Healthcare Cost and Utilization Project (HCUP) of the Agency for
Healthcare Research and Quality (AHRQ).
1.2. Study population

⁎ Corresponding author at: Division of Pediatric Surgery, Charlotte R. Bloomberg
Children’s Center, 1800 Orleans Street, Room 7310, Baltimore, MD 21287–0005.
Tel.: +1 410 955 1983; fax: +1 410 502 5314.
E-mail address: sgoldstein@jhmi.edu (S.D. Goldstein).
Patients less than 18 years of age were selected from the NIS and
KID databases if they underwent a surgical procedure on the same
calendar day as their inpatient hospital admission. Selected index
operations for analysis were chosen via an institutional review of
common weekend cases in the American College of Surgeons Pediatric

http://dx.doi.org/10.1016/j.jpedsurg.2014.01.001
0022-3468/© 2014 Elsevier Inc. All rights reserved.
1088 S.D. Goldstein et al. / Journal of Pediatric Surgery 49 (2014) 1087–1091

National Surgical Quality Improvement Program (NSQIP-Pediatric) Table 2

and then defined by International Classification of Diseases, Clinical Selected outcomes with corresponding diagnosis codes.

Modification (ICD-9 CM) procedure codes present in the discharge Outcome Assessed
data. Index procedures chosen were: abscess drainage (AD), appen- Death Directly reported in database
dectomy (App), inguinal hernia repair (IHR), open reduction with Condition Assessed ICD-9 Diagnosis Codes
Hemorrhagic Complications 998.1, 998.11, 998.12, 998.13
internal fixation of bone fracture (ORIF), and placement or revision of
Accidental Puncture or
ventricular shunt (VS). Records were excluded if the admission or Laceration 998.2
operative day was unknown or if the admission was coded as elective. Wound Dehiscence or Nonhealing 998.3, 998.30, 998.31, 998.32, 998.33, 998.83
A complete list of the selection criteria and corresponding ICD-9 CM Wound infection or abscess 998.5, 998.50, 998.51, 998.52, 998.53, 998.54,
998.55, 998.56, 998.57, 998.58, 998.59
procedure codes is provided in Table 1.
Intervention Assessed ICD-9-CM Procedure Codes
Patients meeting these selection criteria were then sub-grouped Transfusion 99.0, 99.00, 99.01, 99.02, 99.03, 99.04, 99.05,
based on the day of the week that the patient was admitted and 99.06, 99.07, 99.09
operated upon; those admitted on a Saturday or Sunday were de-
ICD-9: International Classification of Diseases, Ninth Revision.
signated as weekend cases while those admitted on any other day ICD-9-CM: International Classification of Diseases, Clinical Modification.
were designated weekday cases. The outcomes of interest were death,
hemorrhagic complications, accidental puncture or laceration,
wound-related complications, infectious complications, transfusion procedures on the weekend were slightly older; were more frequently
of blood products, length of hospital stay, and total hospital charges. male, white, and uninsured; and had less comorbidity at discharge
A complete list of the corresponding procedure and diagnosis codes (Table 3).
for each index occurrence type is provided in Table 2. Finally, the Children undergoing procedures on the weekend were more likely
number of co-morbid conditions was assessed by counting the num- to have been admitted emergently (60.9% vs. 52.6%) and were slightly
ber of unique ICD-9 diagnosis codes associated with each admission. less likely to be at teaching hospitals or at facilities located in the West
region of the country (Table 4). Weekend procedures were less
1.3. Data analysis frequently AD, IHR, and VS and were more frequently App and ORIF
(Table 5).
Gender, race, insurance status (uninsured or insured), number of
co-morbid conditions, geographic region (Northeast, Midwest, South 2.2. Unadjusted outcomes: weekend vs. weekday
or West), type of hospital (urban teaching, urban non-teaching or
rural) and type of surgical procedure performed were compared In unadjusted analysis, 373 (0.11%) patients in the weekday
between weekend vs. weekday admission using Pearson’s chi-square group and 156 (0.14%) in the weekend group died prior to discharge
test for categorical variables and the Kruskal–Wallis test for non- (p = 0.099). Patients undergoing weekend procedures more fre-
normally distributed continuous variables. quently experienced an accidental puncture or laceration (0.21% vs.
Outcomes of surgical procedure performed on the weekend versus 0.18%, p = 0.018) and received transfusion of blood products (0.71%
weekday were compared using multivariable logistic regression and vs. 0.60%, p = 0.002). Patients in the weekend group were less likely
linear regression models adjusting for age, gender, race, insurance to receive the diagnosis of dehisced or non-healing wound (0.11% vs.
status, comorbid diagnoses, geographic region, type of hospital, ad- 0.13%, p = 0.044). The weekend and weekday groups were similar
mission type, and surgical procedure. Adjusted odds ratios (aOR) are with regard to rates of hemorrhage and wound infections (Table 6).
presented using weekday as the reference group. Statistical analyses
were performed using Stata MP, version 11 (College Station, TX). 2.3. Adjusted outcomes: weekend vs. weekday

2. Results After adjusting for the type of procedure performed as well as

patient and facility characteristics, patients undergoing an index
2.1. Study population operation on the weekend were significantly more likely to die before
discharge compared to patients undergoing a procedure on a weekday
A total of 439,457 admissions meeting inclusion criteria were (aOR 1.63, 95% CI: 1.21–2.20, Fig. 1). Patients undergoing weekend
identified, consisting of 327,393 (74.5%) with a weekday procedure procedures were also more likely to suffer an accidental puncture or
and 112,064 (25.5%) with a weekend procedure. Children undergoing laceration (aOR 1.40; 95% CI: 1.14–1.74) and to receive a blood
transfusion (aOR 1.14; 95% CI: 1.01–1.26).
Other complications examined did not demonstrate significant
Table 1
Patient selection criteria. associations with weekend versus weekday procedures. Specifically,
patients undergoing weekend procedures had a similar risk of intra-
Age (years) 0–17 inclusive operative hemorrhage (aOR 0.94, 95% CI: 0.77–1.15), wound dehis-
Procedures ICD-9-CM Procedure Codes
Performed
cence or nonhealing wound (aOR 0.97, 95% CI: 0.73–1.27), and wound
AD: 27.0, 28.0, 47.2, 47.20, 49.01, 50.0, 54.19, 59.09, 60.81, 86.01 infection (aOR 1.02, 95% CI: 0.93–1.12).
App: 47.0, 47.01, 47.09, 47.1, 47.11, 47.19
IHR: 53.00, 53.01, 53.02, 53.10, 53.11, 53.12, 53.13
ORIF: 79.3, 79.30, 79.31, 79.32, 79.33, 79.34, 79.35, 79.36, 79.37,
3. Discussion
79.38, 79.39
VS: 02.3, 02.31, 02.32, 02.33, 02.34, 02.35, 02.39, 02.4, 02.41, This analysis of two large national databases comparing out-
02.42, 02.43, 54.94 comes of select pediatric surgical procedures found a higher risk of
Operative Date Day of Admission (weekend or weekday)
death, blood transfusion, and procedural complication for patients
Hospital Admission
Excluded Types Elective admitted for urgent or emergent surgery over the weekend compared
Years 1988–2009 to on a weekday. The increased rate of transfusions was in the context
ICD-9-CM: International Classification of Diseases, Clinical Modification.
of similar rates of reported hemorrhagic events. Importantly, these
AD: Abscess Drainage, App: Appendectomy, IHR: Inguinal Hernia Repair, ORIF: Open differences were independent of variations in patient and hospital
Reduction/Internal Fixation of Fracture, VS: Revision of Ventricular Shunt. characteristics. Our results are consistent with a growing body of
 S.D. Goldstein et al. / Journal of Pediatric Surgery 49 (2014) 1087–1091 1089

Table 3
Demographics for patients undergoing weekday versus weekend surgical procedures.

Patient Characteristics Day of Procedure Total p

Weekday Weekend

Age (years), mean [SD] 10.8 [4.71] 11.1 [4.46] 10.9 [4.65] b 0.001
Male Gender, n (%) 198,389 (60.6) 69,103 (61.7) 267,492 (60.9) b 0.001
Race, n (%) b 0.001
White 159,022 (48.6) 55,230 (49.3) 214,252 (48.8)
Hispanic 64,583 (19.7) 21,492 (19.2) 86,075 (19.6)
Black 21,820 (6.7) 7,064 (6.3) 28,884 (6.6)
Other/Unknown 81,968 (25.0) 28,278 (25.2) 110,246 (25.1)
Insured, n (%) 292,092 (89.2) 99,651 (88.9) 391,743 (89.1) b 0.001
Number of comorbities, mean[SD] 2.04 [1.70] 2.03 [1.72] 2.04 [1.71] b 0.001
Total (% of all cases) 327,393 (74.5) 112,064 (25.5) 439,457

evidence that mortality is overall increased during weekend hospi-
talizations [1–5]. To date, specific adult conditions that have shown
to be subject to a detrimental weekend effect in the literature in-
clude diverticulitis [6], stroke [7], pneumonia [8], TBI [9], and inten-
sive care unit admission [10–12]. Children’s hospitals have not been
immune to this phenomenon, particularly in pediatric intensive care
units [13–16]. This study now adds evidence of a similar phenome-
non, specifically regarding children undergoing common urgent sur-
gical procedures.
We believe these findings to be predominately a result of systems
issues such as decreased availability of staff and other hospital
resources that contribute to patient care in a manner that is multi-
factorial and difficult to individually ascertain. Clearly, a tertiary
hospital-based surgical practice must include the capability to offer
emergency surgery regardless of time of day or day of the week.
Furthermore, the quality of this surgical care should indisputably be
maintained as uniformly as possible. Much has been written about
the timing of urgent and emergent surgery and the effects of delay,
which tend to be disease specific [17–20]. In this context, weekends
pose a particular problem as a two-day period during which staffing
levels are often lower and response times protracted, though some
studies have questioned the presence of detriment as a result of this
effect [21,22]. A positive aspect of this line of thought is that when
urgent and emergent needs are appropriately anticipated, as in a
mature trauma system, thoughtful design of systems can mitigate the
weekend effect [23].
One prior study of emergency medical admissions in Europe found
an increased weekend mortality that was statistically accounted for
by disease severity at presentation [2]. Accordingly, our multivariable
model incorporated patient and hospital characteristics to adjust for
Table 4
Admission characteristics associated with weekend versus weekday surgical procedures.
Admission Day of Procedure Total
Characteristics
Weekday Weekend
the potential differences in disease severity within each cohort. For
example, we wished to not be confounded by a potential scenario
such as gender differences or higher severity trauma on the week-
end manifesting as increased mortality following ORIF in this data-
set. Thus, in contrast to the European study, the presumption of a
systems-based root cause of the outcomes observed in our study is
reasonable due to the specific adjustment for clinical and demo-
graphic discrepancies between weekend and weekday patient
populations. This indicates to us that patient and disease character-
istics are not likely to confound our findings of increased mortality on
the weekend. In addition, with the possible exception of ORIF, the
specific procedures chosen do not have any obvious disposition to
present on the weekend in a different manner than during the week.
One variable that does appear to differ meaningfully is the proportion
of emergent admissions, which likely reflects the mechanisms by
which these conditions are logistically approached and managed on
Saturday and Sunday when outpatient clinics are closed. However,
even with multivariate adjustment and the inclusion of comorbid
diagnoses, it is not possible to eliminate all potential sources of bias.
Unfortunately, indices such as Charlson and Elixhauser tend to under-
estimate comorbid disease in children, and the ability to risk-adjust
pediatric inpatients is currently limited.
It is important to recognize and acknowledge the absolute as well
as relative magnitude of effects noted in this study. The mortality
associated with pediatric surgical procedures is generally very low,
requiring the large patient numbers included in these cohorts to
detect potential differences. As an illustration, the significant adjusted
odds ratio for mortality of 1.63 represents an increase in actual
unadjusted death rate of only 0.03% (0.14% from 0.11%) It is possible
to interpret this as statistical significance without clinical relevance,
which is a phenomenon that can occur in samples of this size. For
example, we believe that our conclusions are supported by the
presence of only minimal differences in demographics between
patients presenting during the week and on the weekend, but even
p these slight discrepancies reach statistical significance in Table 3.
Nevertheless, we emphasize that a reduction of weekend mortality to

n (%) n (%) n (%)

Region b 0.001
Northeast 65,866 (20.1) 22,853 (20.4) 88,719 (20.2) Table 5
Midwest 36,619 (11.2) 13,362 (11.9) 49,981 (11.4) Types of surgical procedures performed on weekdays versus weekends.
South 91,092 (27.8) 32,539 (29.0) 123,631 (28.1)
West 104,586 (32.0) 33,689 (30.1) 138,275 (31.5) Procedure Type Day of Procedure Total p
Hospital Type b 0.001
Weekday Weekend
Rural 39,609 (12.1) 14,223 (12.7) 53,832 (12.3)
Urban, Non-teaching 130,522 (39.9) 46,105 (41.1) 176,627 (40.2) n (%) n (%) n (%)
Urban, Teaching 154,076 (47.1) 50,558 (45.1) 204,634 (46.6) AD 14,578 (4.5) 4,785 (4.3) 19,363 (4.4) 0.010
Admission Type b 0.001 App 240,252 (73.4) 83,164 (74.2) 323,416 (73.6) b 0.001
Emergent 173,160 (52.9) 68,257 (60.9) 241,417 (54.9) IHR 10,602 (3.2) 1,850 (1.7) 12,452 (2.8) b 0.001
Urgent 75,299 (23.0) 19,675 (17.6) 94,974 (21.6) ORIF 44,510 (13.6) 19,558 (17.5) 64,098 (14.6) b 0.001
Newborn 587 (0.2) 127 (0.1) 714 (0.2) VS 15,460 (4.7) 3,290 (2.9) 18,750 (4.3) b 0.001
Trauma Center 843 (0.3) 523 (0.5) 1,366 (0.3) Total (% of all cases) 327,393 (74.5) 112,064 (25.5) 439,457
Other/Unknown 77,504 (23.7) 23,482 (21.0) 100,986 (23.0)
AD: Abscess Drainage, App: Appendectomy, IHR: Inguinal Hernia Repair, ORIF: Open
Total (% of all cases) 327,393 (74.5) 112,064 (25.5) 439,457
Reduction/Internal Fixation of Fracture, VS: Revision of Ventricular Shunt.
1090 S.D. Goldstein et al. / Journal of Pediatric Surgery 49 (2014) 1087–1091
Table 6
Unadjusted outcomes associated with weekend versus weekday surgical procedures.
Unadjusted Outcome Day of Procedure
Weekday
N (%)
Death 373 (0.11)
Hemorrhage, hematoma, or seroma 814 (0.25)
Accidental Puncture or Laceration 580 (0.18)
Dehiscence or Non-Healing Wound 412 (0.13)
Wound infection or abscess 3,762 (1.2)
Blood product transfusion 1,960 (0.60)
Total (% of all cases) 327,393 (74.5)
the levels seen during the workweek would represent a greater than
20% reduction of inpatient death representing approximately 30
patients over the study period. And, though the change in absolute
mortality rate is indeed modest, it is accompanied by increases in
other perioperative complications in the multivariable adjustment
model—namely blood transfusion and procedural complication. This
suggests that further analysis of the root causes related to differential
morbidity and mortality observed during the weekend and involving
these common procedures could identify broader risks within the
health care delivery system and be hypothesis generating in terms of
systems design.
Other limitations of this study include potential error stemming
from deficiencies in the NIS and KID databases. Coding errors may
exist, though systemic differences in coding accuracy between
weekday and weekend admissions are unlikely, as administrative
coding is usually performed by dedicated staff during business hours.
Furthermore, our reliance on administrative admission date when
applying inclusion criteria will artificially exclude some emergent
cases, as when a patient is admitted at 10:00 PM on Saturday and
subsequently taken for procedure three hours later at 1:00 AM on
Sunday (i.e. excluded because the procedure was not performed on
the same day as admission). Late Friday night cases would be similarly
excluded even if the operation was the same calendar day, as only
Saturday and Sunday were considered as weekend days. Lastly,
though the inclusion of specific cases was predicated on the most
Fig. 1. Adjusted odds ratios with 95% confidence intervals for selected postoperative
complications following surgical procedures performed on weekends (referenced to
weekdays). Adjusted for type of procedure performed, patient age, sex, insurance status
and number of diagnoses, hospital characteristics, and admission year.
Total p
Weekend
N (%) N (%)
156 (0.14) 529 (0.12) 0.099
244 (0.22) 1058 (0.24) 0.459
238 (0.21) 818 (0.19) 0.018
125 (0.11) 537 (0.12) 0.044
1243 (1.1) 5005 (1.1) 0.649
791 (0.71) 2,751 (0.63) 0.002
112,064 (25.5) 439,457
common weekend cases in our institution’s NSQIP-Pediatric database,
results may not generalize to centers with a different case-mix.
The potential implications of this study are two-fold. First, are
there design shortcomings within hospital systems that deliver
pediatric surgical care that can be improved to mitigate the dele-
terious outcomes that we have identified? This possibility motivates
further study to detail the multifactorial effects of weekend staffing
on patient care. For instance, it is unclear whether the increased
weekend mortality can be traced to the timeliness and quality of clinical
interventions delivered in emergency departments, in operating rooms,
or in recovery areas. The increase in procedural complications could be
arguably localized to the operating room, potentially as a function of the
expertise or workload of available staff. Even if not occurring during
the index procedure, an increase in “accidental perforation by catheter
or other instrument during a procedure” (ICD-9 description of 998.2)
suggests a systemic cause of provider error. A recent study reporting
that degree of pediatric specialization of surgeons affects outcomes
could also be relevant in this context if provider training and
background vary substantially after hours [24].
Secondly, given the disparities in personnel that exist between
weekends and weekdays, are there surgical conditions for which the
systems-based benefit of delay would outweigh the traditionally
perceived risk of delaying surgical intervention? Alternatively, is there
sufficient justification for hospitals to commit to extended operating
room hours with full staffing? Further studies with cost analysis
would be required to answer these questions.
In conclusion, this study examined a large population of children
in two national inpatient databases and identified a significant in-
crease in the rates of blood transfusion, periprocedural complications,
and postoperative mortality following urgent pediatric surgical pro-
cedures that were performed upon admission on a weekend. While
the exact etiology of these findings is not clear, these findings moti-
vate a careful search for systems-based deficiencies that may be a
detriment to pediatric surgical care provided on the weekend.
References
[1] Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on
weekends as compared with weekdays. N Engl J Med 2001;345:663–8.
[2] Mikulich O, Callaly E, Bennett K, et al. The increased mortality associated with a
weekend emergency admission is due to increased illness severity and altered
case-mix. Acute Med 2011;10:182–7.
[3] Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional
risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74–84.
[4] Buckley D, Bulger D. Trends and weekly and seasonal cycles in the rate of errors in
the clinical management of hospitalized patients. Chronobiol Int 2012 Aug;29(7):
947–54.
[5] Cram P, Hillis SL, Barnett M, et al. Effects of weekend admission and hospital
teaching status on in-hospital mortality. Am J Med 2004;117:151–7.
[6] Worni M, Schudel IM, Østbye T, et al. Worse outcomes in patients undergoing
urgent surgery for left-sided diverticulitis admitted on weekends vs weekdays: a
population-based study of 31 832 patients. Arch Surg 2012;147:649–55.
[7] Tung Y, Chang G, Chen Y. Associations of physician volume and weekend admis-
sions with ischemic stroke outcome in Taiwan: a nationwide population-based
study. Med Care 2009;47:1018–25.
 S.D. Goldstein et al. / Journal of Pediatric Surgery 49 (2014) 1087–1091
[8] Chang G, Tung Y. Factors associated with pneumonia outcomes: a nationwide
population-based study over the 1997–2008 period. J Gen Intern Med 2012;27:
527–33.
[9] Schneider EB, Hirani SA, Hambridge HL, et al. Beating the weekend trend:
increased mortality in older adult traumatic brain injury (TBI) patients admitted
on weekends. J Surg Res 2012;177:295–300.
[10] Barnett MJ, Kaboli PJ, Sirio CA, et al. Day of the week of intensive care admission
and patient outcomes: a multisite regional evaluation. Med Care 2002;40:530–9.
[11] Bhonagiri D, Pilcher DV, Bailey MJ. Increased mortality associated with after-hours
and weekend admission to the intensive care unit: a retrospective analysis. Med J
Aust 2011;194:287–92.
[12] Laupland KB, Shahpori R, Kirkpatrick AW, et al. Hospital mortality among adults
admitted to and discharged from intensive care on weekends and evenings. J Crit
Care 2008;23:317–24.
[13] Fendler W, Baranowska-Jazwiecka A, Hogendorf A, et al. Weekend matters: Friday
and Saturday admissions are associated with prolonged hospitalization of
children. Clin Pediatr (Phila) 2013 Sep;52(9):875–8.
[14] Salihu HM, Ibrahimou B, August EM, et al. Risk of infant mortality with weekend
versus weekday births: a population-based study. J Obstet Gynaecol Res 2012
Jul;38(7):973–9.
[15] Arias Y, Taylor DS, Marcin JP. Association between evening admissions and higher
mortality rates in the pediatric intensive care unit. Pediatrics 2004;113:e530–4.
1091
[16] Hixson ED, Davis S, Morris S, et al. Do weekends or evenings matter in a pediatric
intensive care unit?Pediatr Crit Care Med 2005;6:523–30 619–621.
[17] Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in
recognition and surgery for acute appendicitis. J Surg Res 2013 Oct;184(2):723–9.
[18] Kluger Y, Ben-Ishay O, Sartelli M, et al. World society of emergency surgery study
group initiative on Timing of Acute Care Surgery classification (TACS). World J
Emerg Surg 2013;8.
[19] Ingraham AM, Cohen ME, Bilimoria KY, et al. Effect of delay to operation on
outcomes in adults with acute appendicitis. Arch Surg 2010;145:886–92.
[20] Gurusamy KS, Samraj K, Davidson BR. Early versus delayed laparoscopic
cholecystectomy for biliary colic. Cochrane Database Syst Rev 2008 Oct 8;(4):
CD007196.
[21] Kim S, Hong K, Hwang S, et al. Weekend admission in patients with acute ischemic
stroke is not associated with poor functional outcome than weekday admission.
J Clin Neurol (Korea) 2012;8:265–70.
[22] Worni M, Ostbye T, Gandhi M, et al. Laparoscopic appendectomy outcomes on the
weekend and during the week are no different: a national study of 151,774
patients. World J Surg 2012 Jul;36(7):1527–33.
[23] Carr BG, Reilly PM, Schwab CW, et al. Weekend and night outcomes in a statewide
trauma system. Arch Surg 2011;146:810–7.
[24] Rhee, et al. Comparison of pediatric surgical outcomes by the surgeon's degree of
specialization in children. J Pediatr Surg 2013;48(8):1657–63.