In-hospital mortality rate higher among older adults who spent night in ED vs. ward
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Key takeaways:
- ED patients also had more adverse events and greater length of hospital stay vs. ward patients.
- Increased in-hospital mortality rates were seen among ED patients who needed daily living assistance.
Older patients who spent the night in the ED had higher in-hospital mortality rates vs. those who were admitted to a ward, a study published in JAMA Internal Medicine found.
According to a previous study from the Yale Institute of Medicine, more than 90% of EDs in the United States reported overcrowding to be a problem, and although there are usually enough empty beds to support patients, understaffing typically resorts patients to overnight stays in the ED.
EDs in France and Europe have endured similar issues, Melanie Roussel, MD, from the Rouen University Hospital in France, and colleagues noted.
In addition to an increased risk for prolonged immobilization on a cot, “subsequent sleep disruption in a crowded ED may further exacerbate the risk of death and adverse events,” the researchers wrote. “However, the mortality and morbidity of older patients who spend the night on a [cot] in the ED while waiting for admission are unknown.”
Roussel and colleagues analyzed data from 1,598 French patients aged 75 years and older who visited the ED and were hospitalized from Dec. 12 to 14, 2022. The researchers compared in-hospital mortality and other health outcomes among the 707 patients who spent the night in the ED from midnight to 8:00 a.m. with the 891 patients who were admitted to the ward before midnight.
Overall, the ED group had an in-hospital mortality rate of 15.7%, compared with 11.1% among the ward group (adjusted RR = 1.39; 95% CI, 1.07-1.81).
The ED group also had a:
- higher number of adverse events (30.4% vs. 23.5%; aRR = 1.24; 95% CI, 1.04-1.49); and
- increased median length of stay (9 days vs. 8 days; RR = 1.2; 95% CI, 1.11-1.31) compared with the ward group.
Roussel and colleagues noted that spending the night in the ED was also linked to an increased in-hospital mortality rate (aRR = 1.81; 95% CI, 1.25-2.61) in a subgroup analysis of patients (n = 252) who needed help with daily living activities.
The researchers explained that the higher in-hospital mortality rate could be partly explained by a higher rate of adverse events like falls, bleeding or myocardial infarctions in the ED group.
“These adverse events may have been favored by a night on a hard cot and potentially, insufficient monitoring and care,” they wrote. “Sleep disturbance in the ED may also have increased the mortality and morbidity risks: several studies have highlighted the risks caused by sleep deprivation in older patients, which includes functional and physical decline.”
References:
- Roussel M, et al. JAMA Intern Med. 2023;doi:10.1001/jamainternmed.2023.5961.
- Yale study finds emergency rooms nationwide overcrowded to crisis levels. https://yaledailynews.com/blog/2022/10/24/yale-study-finds-emergency-rooms-nationwide-overcrowded-to-crisis-levels/. Published Oct. 24, 2022. Accessed Nov. 13, 2023.
Perspective
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The caveat about this study is that it focuses on French patients and French overnight ED vs. hospital floor care, and this may not be generalized to the U.S. population because of differences in health system operations, nursing care and severity of illness allowable for floor patients in France. It is a small study of only 1,598 patients and for a very short period in December when disease burden and volume is likely higher than other times of the year. They also only included patients who were admitted during the day and evening shifts but none who were admitted overnight. The sickest patients were excluded from ICU admissions.
However, this study, while small and somewhat limited in scope, confirms what we in the U.S. already know and have published previously but gives us more information about how this issue affects patients in another industrialized country. The effects seem to be much the same as it is here in the U.S., even in the setting of a more universally available/socialized model of health care. Boarding admitted patients in the ED increases length of stay, morbidity/adverse events and mortality.
This study further adds to the clarion call from the house of medicine to regulators and health system leaders around the world to finally resolve ED overcrowding and the boarding of patients. This is costing lives and is consuming increasing amounts of finite resources as our population ages and volume increases. The expanding complexity of disease places further demands on health care systems around the world.
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