Association between delays to patient admission from the emergency department and all-cause 30-day mortality

Abstract

BackgroundDelays to timely admission from emergency departments (EDs) are known to harm patients.ObjectiveTo assess and quantify the increased risk of death resulting from delays to inpatient admission from EDs, using Hospital Episode Statistics and Office of National Statistics data in England.MethodsA cross-sectional, retrospective observational study was carried out of patients admitted from every type 1 (major) ED in England between April 2016 and March 2018. The primary outcome was death from all causes within 30 days of admission. Observed mortality was compared with expected mortality, as calculated using a logistic regression model to adjust for sex, age, deprivation, comorbidities, hour of day, month, previous ED attendances/emergency admissions and crowding in the department at the time of the attendance.ResultsBetween April 2016 and March 2018, 26 738 514 people attended an ED, with 7 472 480 patients admitted relating to 5 249 891 individual patients, who constituted the study’s dataset. A total of 433 962 deaths occurred within 30 days. The overall crude 30-day mortality rate was 8.71% (95% CI 8.69% to 8.74%). A statistically significant linear increase in mortality was found from 5 hours after time of arrival at the ED up to 12 hours (when accurate data collection ceased) (p<0.001). The greatest change in the 30-day standardised mortality ratio was an 8% increase, occurring in the patient cohort that waited in the ED for more than 6 to 8 hours from the time of arrival.ConclusionsDelays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. Between 5 and 12 hours, delays cause a predictable dose–response effect. For every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death.

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“…A patient admitted to an inappropriate hospital unit will have a longer length of stay (LOS) and higher care costs [ 6 ]. Other issues identified in the literature include a longer hospital stay [ 6 ], a higher morbidity rate [ 7 ], a higher mortality rate [ 8 , 9 , 10 , 11 ], and a greater proportion of patients who leave the ED without being seen [ 12 ]. Many of the research groups are working on ways of tackling these problems and limiting the effects of overcrowding: pre-hospital dispatch before attending at the ED (to encourage alternative healthcare provision); better bed coordination; triage by emergency medical staff; front-loading investigations; triage systems; fast tracks; optimized transfer to the destination ward (even if the bed is not ready); and a greater number of available beds [ 13 , 14 , 15 ].…”

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“…This causes significant risks and increased mortality as they are not designed to provide this care. 26 Delays can be caused by inadequate use of direct admission or SDEC pathways, lack of beds, blocks to discharge, or a mismatch between staffing levels and peaks of activity. If these issues arise then ideally care should be provided by the appropriate speciality team, also facilitating early transfer to the right care environment; however, this requires a redistribution of an often-constrained workforce.…”

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“…The overcrowding of emergency departments is a major global issue, which has been further exacerbated by the lack of in-person services during the COVID-19 pandemic [1], having a detrimental effect on health outcomes by prolonging access to relevant care [2].…”