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Patient Safety Tip
of the Week
February
8, 2022
ED
to Inpatient Delays Increase Mortality
A study from England has revealed a disturbing finding
regarding the relationship between long stays in emergency departments before
admission to the hospital and mortality rates. Jones et al. (Jones
2022) found that 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. In fact,
there was a predictable dose–response effect for delays between 5 and 12 hours
(accurate data were not available beyond 12 hours). 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.
There
was a 10% increase in the SMR (standardized mortality rate) within 30 days for
admitted patients remaining in the ED between 8 and 12 hours in comparison with
those who leave the ED within 6 hours
Below
are the adjusted absolute mortality rates as a function of time spent in the ED:
up to
4 hours 8.2%
4-6 hours
9.2%
6-8
hours 9.9%
8-12
hours 10.1%
We’ve long recognized the impact posed by delays in moving
patients from the ED to inpatient beds. In our January 29, 2013 Patient Safety
Tip of the Week “A Flurry of Activity on
Handoffs” we
noted that back in the 1990’s we realized that patients with community-acquired
pneumonia at some renowned organizations were not getting their first dose of
antibiotics for up to 18 hours. That, of course, was related to bottlenecks in
moving patients from the ED to the floor and problems with handoffs (relating
to both information transfer and transfer of responsibility for managing the
patients). Fortunately, we had performance improvement projects that focused on
ensuring timely administration of the antibiotics regardless of physical
location of the patient.
The
authors of the Jones study pose several potential explanations for their
findings:
- Long lengths of stay in the ED are
associated with exit block and crowding, which has been shown to increase
time to analgesia, time to antibiotics and time to other vital treatments
- Lack of ED space leads to mitigation
processes with patients accommodated in suboptimal areas that make it more
difficult for close observation and for the delivery of good care
- Long periods in the ED usually reduce
temporospatial clues (eg, patient unable to see
the external environment) with consequent increases in disorientation and
precipitation or exacerbation of delirium, especially in elderly patients
- Long waits in the ED, especially for
elderly patients, are correlated with an increase in subsequent hospital
length of stay. This, in turn, increases the risk of hospital-acquired infection,
iatrogenic harm and physiological and psychological deconditioning
- Delayed admission (exit block) from the
ED is usually related to bed occupancy levels, which are highest in the
late afternoon and usually lower around midnight. Thus, a disproportionate
number of delayed patients are moved to a ward during night hours when
staffing levels are at their lowest
We’ll
add several of our own potential explanations. Several things happen when there
are long delays before patients are admitted from the ED to the inpatient
services, each of which may contribute to worse patient outcomes:
- Overcrowding, less attention
When the bottleneck of inpatient beds occurs, the census in the ED increases. As that ED gets busier, the physician and nursing staffs in the ED have less time to spend with each patient and often prioritize new patients over those that have been in the ED for longer periods of time. - Dispersion of responsibility
In cases where the decision is made to admit the patient to a specific service, it must be crystal clear who is assuming responsibility for care of the patient while that patient is awaiting a formal bed on the inpatient service. All too often we see examples where the inpatient team thinks the ED team is providing care and vice versa. - Delay in orders being carried out
This is a biggie! Often admission orders are written/input once the decision to admit is made. But those are often expected to be carried out once the patient arrives on the inpatient floor. In several of our columns on sepsis, it’s been noted that the first dose of antibiotics is timely but the delay in formal movement of the patient to an inpatient bed often results in a delay in the second dose of antibiotics. And we already mentioned the historical observation that patients with community-acquired pneumonia (CAP) often had long delays in receiving antibiotics because of the delays in formal transfer to the inpatient units. So, just as there must be clarification of physician responsibility for the patient, there must be clarification nursing responsibility for the patient once admission orders have been made but the patient has not yet been moved. - Change of shift/Handoffs
If a patient is in the ED for such long periods of time, there is a good chance there may be at least one change of shift for both nurses and physicians. With each change of shift there are handoffs, which present opportunities for vulnerability. Good handoffs require an environment that is quiet, insulated from distractions and interruptions, and provides sufficient time for two-way conversations where the recipient has opportunities to ask questions and get clarifications. The often hectic ED environment may not be optimal for smooth handoffs. - Monitoring issues may occur
Many of the patients awaiting transfer to an inpatient bed still require physiological monitoring. When the ED gets overcrowded, there may not be enough monitoring equipment for all patients. Patients moved from an ED room to a gurney in the hallway sometimes lose their monitoring capabilities. And consider how the increased total number of monitors in the ED increases the likelihood of alarm fatigue.
Focusing
on the bottleneck(s) elsewhere in the hospital is of utmost importance.
Having a nursing “bed coordinator” may be useful. That individual works
with the clinical teams to identify patients ready for discharge today or
“likely to be ready for discharge tomorrow”. During periods of high inpatient
occupancy, a “discharge lounge”, where patients simply waiting for
transportation home, may make sense. Sometimes, even the simplest of problems
can delay freeing up inpatient beds. We’ve seen cases where hospitals are
unaware of where all their wheelchairs are located, leading to delays in moving
patients out (good opportunity for some of the tracking technologies we
discussed in our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies”). And we also often see cases where a
patient has physically left their inpatient room but there is a delay in
notification of the staff to clean the room for the next occupant.
And,
in teaching hospitals, we often see teams deferring discharge orders and
arrangements until completion of rounds rather than addressing those
early, taking a break to do the discharge work, then reconvening for complete
rounds.
One
critical bottleneck we see is in opening up
ICU beds. Many of the patients with long waits in the ED are awaiting ICU beds.
As a hospital medical director, we’d often round with our Director of Nursing
in the ICU’s in the morning. We’d routinely find patients who no longer
required “intensive care”. Physicians often equate “severity” of a condition
with the need for intensive care without consideration of what actual nursing
care is needed. For example, a neurologist or neurosurgeon may consider a
patient with a subarachnoid hemorrhage to be “critical” because of the
potential for deterioration rather than recognizing that the nursing care needs
for a stable patient may not be so great.
Similarly,
the bottleneck may be in telemetry units. In our numerous columns on
alarm fatigue, we often recommend hospitals first focus on use of telemetry.
Hospitals should have policies that spell out the evidence-based indications
for telemetry and make sure that the criteria for stay on a telemetry unit are
complied with (both for admission to such units and continued stay on such
units).
In addition to focusing on removing the bottlenecks, the
most critical element needed is clear-cut transfer of responsibility and
accountability to the clinical teams (both physician and nursing). While
such transfer to the inpatient physician team takes some burden off the ED
physician team, there may also be downsides. It is difficult to care for
multiple patients when they are not all clustered or cohorted on one unit, but we’ve all had to deal from time to time with
some of our patients being “boarded” in other sites. Perhaps more important is
delineation of nursing responsibility and accountability. Obviously, some of
the monitoring of the patient needs to be done by the nurse on location (i.e. the ED nurse). But the ED nurse and the inpatient nurse
need to review any admission orders and ensure that there is clarification of
who will administer medications, etc.
ED
staffing patterns may occasionally contribute to the problem. Most ED’s
already plan their ER staffing according to expected use, increasing staffing
during the times of day when they historically see more patients. But an
unexpected surge of patients in the ED may stress the system and lead to longer
patient stays in the ED. Trauma centers usually have mechanisms in place to
deal with the surge you might see with a multi-casualty event. But a small
rural hospital may only have one ED physician working at any time.
And note that long ED wait times may have an impact not
just on patients admitted to the hospital but also on patients discharged from
the ED. A Canadian study (Guttmann 2011)
found that presenting to an emergency department during shifts with longer
waiting times, reflected in longer mean length of stay, was associated with a
greater risk in the short term of death and admission to hospital in patients
who are well enough to leave the department. Patients who leave without being
seen were not at higher risk of short-term adverse events. Those authors felt
that delays in treatment alone were not likely the cause of the adverse
outcomes. Examples they gave of potential contributing factors included
reluctance to order time consuming tests or consultations and shortened
observation periods (both of which could increase missed diagnoses), incomplete
treatment, or inadequate planning and communication of care after discharge. An
increased risk of adverse events for low acuity patients in their study suggested
that processes might be more likely to break down if patients are thought to be
low risk. They point out that patients initially thought to be low acuity can,
with careful evaluation, be discovered to have serious illnesses and require
hospital admission.
Jones
et al. note that several prior studies with limited numbers of patients or
hospitals had also shown increased mortality in patients admitted to hospitals
after long ED stays. But the Jones study used a database of over 7 million ED
visits with matched hospital inpatient admissions. Note that the period of the
Jones study was between April 2016 and March 2018, thus prior to the COVID-19
pandemic. It is quite likely that the surge demands on hospitals due to
COVID-19 has increased delays in admissions from the ED to an even greater
degree. That makes it even more important that hospitals have good systems in
place to address the issues raised above.
References:
Jones
S, Moulton C, Swift S, et al. Association between delays to patient admission
from the emergency department and all-cause 30-day mortality. Emergency
Medicine Journal 2022; Published Online First: 18 January 2022
https://emj.bmj.com/content/early/2022/01/03/emermed-2021-211572
Guttmann
A, Schull MJ, Vermeulen MJ, et al. Association between waiting times and short term mortality and hospital admission after departure
from emergency department: population based cohort study from Ontario, Canada.
BMJ 2011; 342: d2983
https://www.bmj.com/content/342/bmj.d2983
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