The study shows one extra death within 30 days for every 82 patients delayed after 6-8 hours.

A British study found that patients who present to hospital emergency departments are more likely to die if it takes more than five hours to admit them.

Waiting longer than 5 hours in emergency care before being admitted to hospital is associated with an increased risk of death from any cause during the next 30 days, according to the research of more than 5 million patients in England published online in the Emergency Medicine Journal.

The researchers believe that this can be assessed and portrayed as a ‘number needed to harm metric,’ with one extra death for every 82 patients delayed by 6-8 hours.

In an effort to combat emergency department overcrowding, the 4-hour waiting time objective before hospital discharge, admission, or transfer was implemented in England in 2004 and shortly thereafter in the other devolved nations.

Several other countries, such as Canada and Australia, also took steps in the same direction. However, as patient demand has increased, performance against this goal has significantly fallen in recent years.

The researchers intended to evaluate the increased risk of death associated with delays in prompt admission from emergency departments, which have been connected to patient harm.

They used Hospital Episode Statistics and Office of National Statistics data for England, which included every patient admitted to a hospital from a major (type 1) emergency department between April 2016 and March 2018.

They compared deaths from any cause within 30 days after admission to those expected, taking into account a wide range of potentially important factors.

Sex, age, deprivation level, concurrent conditions, time of day and month, past attendances/emergency admissions, and crowding in the emergency room at the time were among the factors considered.

In England, 26,738,514 people visited an emergency room between April 2016 and March 2018, with 5,249,891 of them being admitted to hospital.

During the study period, 433,962 individuals died within 30 days. The overall 30-day death rate was just under 9% unadjusted.

The average age of the patients admitted was 55, and the number of concomitant conditions increased as they became older. Patients from areas of highest deprivation accounted for nearly twice as many as those from areas of least deprivation.

The most common time for patients to arrive was between 12:00 and 17:59 hours, with the first three months of the year accounting for the most patients. The average wait time in the emergency department was slightly under 5 hours, with a breach rate of roughly 38% of the 4-hour target.

For waits in the emergency department of more than 5 hours, there was a statistically significant linear rise in the death rate.

After controlling for potentially important risk factors, the death rate was 8% higher than predicted among patients who waited 6-8 hours before being admitted to the hospital, and 10% higher than expected among those who waited 8-12 hours, compared to patients who left within 6 hours.

According to the researchers, this may be assessed and depicted as a ‘number needed to harm metric,’ with 1 additional mortality for every 82 patients delayed for 6-8 hours.

“The results from this study show that there is a ‘dose-dependent’ association between time in excess of 5 hours in the [emergency department] for admitted patients and their all-cause 30-day mortality,” they wrote in their paper. 

“Moreover, 30-day mortality is a relatively crude metric that does not account for either increases in patient morbidity or for the inevitably worse patient experiences.”

As this is an observational study, no causal relationship can be established.

“Despite limited supporting evidence,” the researchers highlighted, “there are a number of clinically plausible reasons to accept that there is a temporal association between delayed admission to a hospital inpatient bed and poorer patient outcomes.” 

Long stays in the emergency room are linked to exit blockage and crowding, which can cause delays in receiving life-saving treatments. According to the researchers, they are linked to an increase in subsequent hospital length of stay, particularly in elderly patients.

According to the researchers, this raises the risk of hospital-acquired infection as well as physiological and psychological deconditioning.

Exit block is frequently correlated with bed occupancy levels, which are typically highest in the late afternoon and lowest around midnight.

They explain that a disproportionate number of delayed patients are likely to be transferred to a ward at night when staffing levels are lowest.

“This study confirms that healthcare policy makers should continue to mandate timely admission from the [emergency department] in order to protect patients from hospital-associated harm,” they concluded.

Source: 10.1136/emermed-2021-211572

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