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Association between delays to patient admission from the emergency department and all-cause 30-day mortality
  1. Simon Jones1,2,
  2. Chris Moulton3,4,
  3. Simon Swift2,5,
  4. Paul Molyneux2,
  5. Steve Black6,
  6. Neil Mason2,
  7. Richard Oakley2,
  8. Clifford Mann3,7
  1. 1 Department of Population Health, New York University School of Medicine, New York, New York, USA
  2. 2 Methods Analytics, London, UK
  3. 3 The "Getting It Right First Time" programme, NHS Improvement, London, UK
  4. 4 Emergency Department, Royal Bolton Hospital, Bolton, UK
  5. 5 Index Unit, University of Exeter Business School, Exeter, UK
  6. 6 Black Box Data Science Ltd, Biggleswade, UK
  7. 7 Emergency Department, Musgrove Park Hospital, Taunton, UK
  1. Correspondence to Dr Chris Moulton, Emergency Department, Royal Bolton Hospital, Bolton, UK; Chris.Moulton{at}boltonft.nhs.uk

Abstract

Background Delays to timely admission from emergency departments (EDs) are known to harm patients.

Objective To 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.

Methods A 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.

Results Between 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.

Conclusions Delays 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.

  • emergency department
  • crowding
  • death/mortality

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The study involved secondary analysis of an existing data set of anonymised data. HES data were made available by NHS Digital (©2018, reused with the permission of NHS Digital. All rights reserved). Publicly-available ONS data were also used.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The study involved secondary analysis of an existing data set of anonymised data. HES data were made available by NHS Digital (©2018, reused with the permission of NHS Digital. All rights reserved). Publicly-available ONS data were also used.

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Footnotes

  • Handling editor Simon Carley

  • Twitter @jones_prof, @DrChrisMoulton, @sib313

  • Deceased Clifford Mann deceased

  • Contributors This study was conceived by SB, SS and PM, following conversations with CMo and CMa. RO and NM undertook data preparation and SJ led the statistical analysis with support from RO and PM. CMo and CMa informed study design, supported interpretation and assessed the likely clinical impact. CMo and SJ drafted the paper. All authors contributed their time free of charge; no funding was provided. SJ is the guarantor of this study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests All authors have completed the Unified Competing Interest form (available on request from the corresponding author). The authors who work for Methods Analytics declare the paragraph given below: Methods Analytics has undertaken work previously on behalf of NHS England, NHS Improvement, CCGs, trusts and local authorities investigating apparent issues with mortality rates as well as analysis pertaining to service redesign within emergency and urgent care settings. Methods Analytics have also undertaken analytical work for NHS England’s “Getting It Right First Time” programme (GIRFT) to develop the emergency medicine provider level data pack, which includes metrics concerning hospital mortality.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Press release Yes.

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