Are long waits in A&E lethal for elderly patients?

On an average shift at St Emlyn’s, we admit a high number of elderly patients, many of whom are frail. These patients are often unable to fully care for themselves due to low mobility, cognitive impairment, and chronic pain.

Hospital wards are usually well-equipped to meet these additional needs, but sourcing a ward bed can be difficult. It is not uncommon at this time of year for our elderly patients to wait hours, if not the better part of a day, for one to become available.

In the meantime, they are cared for in ED – which is not designed or staffed for frailty. We do not have soft beds, pillows, or lights that turn off. We do not store many long-term medications. We do not have enough nurses and support workers to provide regular analgesia, repositioning, and personal care. The list goes on.

With these problems in mind, for February’s journal club, we are looking at a study published in JAMA Internal Medicine last year^​1​ investigating whether long waits in A&E lead to adverse outcomes for older patients. Specifically, the researchers wanted to know whether an overnight stay in the department makes an elderly person more likely to die.

The abstract is below – followed by our summary of the paper – but as ever, we recommend that you read the full text and come to your own conclusions.

The Abstract

Importance: Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown.
Objective: To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality.
Design, settings, and participants: This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group). Main outcomes and measures: The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare endpoints between groups. Results: The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61).
Conclusions and relevance: The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in- hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

What type of study is this? 

This is a prospective cohort study. Retrospective studies^​2​ have been previously been published on admission delays but interpreting their results has been challenging.  

Retrospective data collection is a methodology with key limitations and it is difficult to imagine that it would have allowed the authors to answer their clinical question. Confounding factors must be accounted for to establish with confidence whether elderly patients are especially vulnerable to prolonged ED stays.  

For example, we know that cardiac problems can simultaneously increase the wait for a suitable (i.e. monitored) ward bed and the likelihood of dying. Retrospective data collection from medical notes is an unreliable way to investigate factors like these. 

Tell me about the patients 

1598 elderly ED patients (>75 years) were recruited consecutively at 97 participating French hospitals over a 48-hour period in December 2022.  

Patients were eligible for inclusion if they required hospital admission. They were excluded if they were admitted to a ward at certain time points (more on this later) or required critical care. 

The authors used the Groupe Iso-Ressources (GIR) and Charlson Comorbidity Index (CCI) to estimate the high baseline levels of frailty and comorbidity. Cardiovascular, renal, and metabolic disease were common, as was dementia. Trauma, respiratory illness, and ‘asthenia’ (fatigue) accounted for the majority of admissions.  

What did they study? 

Patients were split into two groups: those who spent a night in ED (midnight to 08:00) while waiting for a ward bed, and a “control” group who reached the ward before midnight. Any patients who spent some of the night in ED but went to the ward sooner (i.e. between midnight and 08:00) were excluded from the analysis. 

At first glance, this might seem strange. A patient in this study could be waiting for a ward bed for fifteen hours (e.g. 08:00 to 23:00) and still be allocated to the “control” group. However, the authors were interested in the effect of an overnight ED stay – not the total length of time spent in the department. In their introduction, they discuss the specific risks of prolonged immobilisation and sleep deprivation in elderly patients. 

As it stands, the patients who spent the night on an ED trolley waited, on average, fifteen hours longer in the department. 

Tell me about the outcomes 

The primary outcome was in-hospital mortality. Secondary outcomes included adverse events and increased length of hospital stay. 

Results were presented as risk ratios with 95% confidence intervals. Adjusted risk ratios were also provided, correcting for clustered factors including (1) age, GIR score, and CCI score, and (2) presenting complaint, time of presentation, and length of ED stay.  

The researchers also used propensity score matching (PSM) to explore the relationship between baseline characteristics and outcomes. PSM is a statistical technique used to adjust for a particular form of bias seen in observational studies: factors that predispose patients to receive the treatment or exposure of interest and experiencing the outcome of interest. To use a blunt example: the success rates of resuscitative thoracotomy are low because the sort of patients who have a ‘propensity’ to receive thoracotomy have catastrophic, often un-survivable injuries. 

Because it would be unethical to randomise patients to spend a night on an ED trolley, there is a strong possibility that this paper’s analysis was biased by factors that predict the primary outcome and patient ‘propensity’ to be kept in ED. A good example would be baseline physiology: patients who were severely unwell and required stabilisation in ED may have been more likely to die and less likely to be accepted by a ward right away. Baseline physiology was one of the many variables included in the authors’ PSM. 

What did they find? 

Overall, 210 patients died in hospital: 111 (15.7%) of those who spent the night on an ED trolley and 99 (11.1%) of those who made it to the ward before midnight. The absolute risk increase was 4.6%, which means the ‘number needed to kill’ for an overnight stay in ED was 21. 

Translated into adjusted risk ratios: patients who spent the night in ED were 50% more likely [aRR 1.5] to die in hospital – albeit with quite a wide confidence interval of 9% to 106%. Virtually the same figure [aRR 1.48] was reported after PSM had been performed, also with wide confidence intervals. 

Adverse events were 7% less common in patients who were admitted to a ward before midnight. Typical adverse events reported in the study included, nosocomial infections, falls, and pressure ulcers. However, in the adjusted analysis this finding was shown to be non-significant [aRR 1.07; 95% CI 0.84-1.36] as were findings relating to hospital length of stay [aRR 1.05; 95% CI 0.93-1.18]. 

The bottom-line is this: when our elderly patients spend the night on an ED trolley, they are more likely to die, regardless of their baseline co-morbidity, frailty, and illness severity. However, it is not clear that this increased mortality risk can be linked to a longer hospital stay, or a greater likelihood of in-hospital adverse events. 

What should we take away from this? 

This study supports our ongoing efforts to improve flow in emergency care. It provides further evidence that getting our elderly patients off the trolleys is, quite literally, a matter of life and death. We reviewed data from our own electronic patient record system in Virchester and found similar figures. 

With that said, there are some caveats to keep in mind as we interpret this paper. These were discussed at our journal club in November last year and felt to be the most significant points for critical appraisal. 

Firstly, and perhaps most importantly: this was an observational study. It was clearly a well-conducted observational study, but any analysis involving non-randomised patients is vulnerable to bias, and there were multiple potential confounders that the authors could not control for. The most glaring were race and ethnicity, which cannot be included in patient records under French law. This is problematic because we know from prior research that ethnic minority groups are more likely to experience poor outcomes in emergency care. 

Another potential confounder missing from the baseline data was ED overcrowding. This is despite recruitment taking place during the early phases of the COVID-19 pandemic!  

We know that the ratio of nurses to patients determines the quality of care. On a quiet night, or at least a well-staffed night, elderly patients receive a high standard of care in ED – similar to what they would receive on the ward. When the department is overflowing, they do not. Nursing ratios would have been a helpful adjustment to the authors’ risk analysis. 

Finally, it is worth considering the primary outcome of this study. The researchers selected in-hospital mortality, which is simple to measure, and of obvious clinical significance. But for research with older patients, is it the most appropriate outcome? We know that many of the elderly people we see in ED have injuries and illnesses that they are not going to survive. Our goals of care for these patients should be comfort and dignity, not prevention of death. 

I would have personally been interested in seeing a sub-group analysis with an outcome measure centred on the successful delivery of palliative care. I suspect this, too, is negatively affected by spending the night on an ED trolley. 

Should this study change our practice? 

I think so. We will not see a randomised study on a topic like this, and the authors have published high-quality, prospective research. Their findings should galvanise changes in the way we practice emergency medicine. Here are some ideas. 

• ED seniors should regularly comb the list for elderly, frail patients who are likely to require hospitalisation: if they are seen out-of-order, a decision to admit can be made earlier, and an overnight stay avoided. 
• ED doctors and nurses should urge bed managers to prioritise elderly patients when ward beds become available, regardless of the impact this has on hospital performance statistics. 
• ED staff at all levels should be advocating for novel approaches to de-congesting ED – such as immediate transfer of patients to the ward after decision to admit^​3​.