Waiting more than 5 hours in ED may increase mortality risk, British study finds
Waiting more than 5 hours in an ED before hospital admission was linked to an increased risk for death from any cause in the 30 days that followed, according to findings published in the Emergency Medicine Journal.
Compared with patients who were admitted within 6 hours, the study showed that patients who waited between 6 to 8 hours had an 8% higher likelihood of mortality and patients who waited 8 to 12 hours had a 10% higher likelihood of mortality.
“The results from this study show that there is a ‘dose-dependent’ association between time in excess of 5 hours in the ED for admitted patients and their all-cause 30-day mortality,” Chris Moulton, MBChB, DRCOG, DFSRH, MRCGP, FRCA, FCEM, a consultant in emergency medicine in the ED at the Royal Bolton Hospital in England and the vice president of the Royal College of Emergency Medicine, and colleagues wrote.
Moulton told Healio that “it seems likely that the principle that delays in EDs are associated with patient harm is common to all countries that have an ED system.”
Moulton and colleagues conducted a cross-sectional, retrospective observational study of patients who were admitted at major EDs in England between April 2016 and March 2018. Using Hospital Episode Statistics and data from the Office of National Statistics, the researchers quantified the associated risk for death from delays in inpatient admission from EDs. In total, 7,472,480 patient admissions representing 5,249,891 individual patients sought care at an ED during the study period. Their mean age was 50.27 years and 52% were women. Risk association was based on a patient’s first hospital admission. Potentially influential risk factors were adjusted in the risk assessment.
Risk associations by wait time
Overall, 433,962 deaths occurred within 30 days of the patients’ ED visits, which amounted to an overall crude mortality rate of 8.71% (95% CI, 8.69-8.74), according to Moulton and colleagues. They reported a statistically significant increase in mortality among those who waited 5 to 12 hours at an ED before admission. The standard mortality rate for patients based on hours waited in the ED was 0.94 for 4 hours or less, 1.06 for 4 to 6 hours, 1.14 for 6 to 8 hours and 1.16 for 8 to 12 hours. Moulton and colleagues interpreted this into a “number needed to harm metric” of one extra death for every 191 patients who waited 4 to 6 hours in an ED. This metric increased to one extra death for every 82 patients who waited 6 to 8 hours and one extra death for every 72 patients who waited 8 to 12 hours.
Prevalence of long wait times
The average wait time was “just under 5 hours,” according to the researchers. However, 38% of patients waited more than 4 hours for admission and 3% of patients waited for more than 12 hours.
“We must realize that long waits in the ED are inevitably responsible for unrecognized additional patient morbidity and certainly contribute to very poor patient experiences,” Moulton said. “We must therefore strive to minimize those delays to ensure that patients who do have to wait do so in the very best circumstances that we can provide.”
However, the findings should “not deter [primary care physicians] from sending their patients to a hospital whenever they believe that secondary care may benefit the patient,” he said.
References:
5 hour + emergency care wait before admission linked to heightened death risk. https://www.eurekalert.org/news-releases/940252. Published Jan. 18, 2022. Accessed Jan. 24, 2022.
Jones S, et al. Emerg Med J. 2022;doi:10.1136/emermed-2021-211572.
Perspective
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Long ED wait times have many explanations, including elderly and complex patients, full hospitals, staffing shortages and, believe it or not, improper or unnecessary ED use. Wait times have numerous adverse effects such as staff stress, provider and patient dissatisfaction, increases in unnecessary testing, decreased compliance with treatment guidelines, delays in pain management and violence toward staff.
However, research looking at the relationship between ED crowding, long wait times and mortality has drawn mixed conclusions. Most studies evaluating the impact of long ED waits on mortality among hospitalized patients have focused on inpatient mortality. Negative effects of inadequate care during long ED stays (eg, missed home medications) are most likely to cause problems identifiable in hours to days after an ED stay while most patients are still in the hospital. Despite this, prior work has not shown a consistent relationship between delays in the ED and short-term inpatient mortality.
The study by Jones and colleagues uses 30-day mortality as an outcome instead of inpatient mortality. In many situations, 30-day mortality is a better outcome measure; capturing post-discharge deaths is critical in assuring that mortality differences among hospitalized patients across institutions or over time are not the result of discharging patients “quicker and sicker” who then die at home or in post-acute care facilities. Inpatient mortality statistics would not include such deaths.
Much of research evaluates the relationship between an exposure and an event. Identifiable exposures that patients experience may be an acute disease, receiving a medical intervention, or, as in this case, delayed care. Events long after an exposure are less likely to be caused by that exposure. It is difficult to imagine that any deaths after hospital discharge are the result of spending a couple of extra hours in the ED prior to hospital admission.
It is far more plausible that the observed association is the result of a third unmeasured factor that correlates with both time spent in the ED and 30-day mortality. There are patient, staff and hospital characteristics that are unobservable and therefore unmeasured or poorly measured. If these correlate with both spending more time in the ED and 30-day mortality, such “third factors” may lead to the association between ED delays and mortality that the authors show. For example, homeless patients spend more time in the ED than patients with stable housing. Such patients are also less likely to have PCPs and less reliable follow-up care, the absence of which may increase mortality. Similarly, poor health literacy, non-English native language and suboptimal or nonexistent health insurance are factors that may simultaneously increase both time spent in the ED and mortality. Other than 4-hour breach rate, broader facility-level characteristics (such as hospital quality or availability of diagnostic services) were also not considered — those may be at play here. Despite the authors laudable efforts to adjust for the influence of many such factors, the results of this study must therefore be interpreted with caution.
Taken as a whole, considering the conflicting literature on this topic and the caveats of the current study, it is difficult to conclude that ED wait times directly cause excess mortality. The hope of decreasing preventable deaths should not serve as a chief justification to target wait times, which could have unintended adverse consequences. Nonetheless, minimizing ED wait times is a critical objective to lessen their detrimental effects. There is literature to support the potential that telehealth has to reduce ED wait times by decreasing ED patient volume. Promise for reducing ED delays may lie in greater use of telehealth, which has increased dramatically in response to the COVID-19 pandemic. PCPs who assertively develop and implement their telehealth capacity may simultaneously benefit their own patients and the health care system through careful triage and judicious referral of patients to the ED. Finally, patients may play a game-changing role in minimizing ED overcrowding. The ED should only be a place to seek care for urgent conditions. Viewing the ED as a critical and scarce resource to be used parsimoniously will improve the experience for all.
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