Long A&E waits for hip breaks can increase odds of death – study

People who face long waits in A&E after fracturing a hip are at higher risk of death, a study suggests.

Patients who wait more than four hours are also more likely to have a longer stint in hospital, experts found.

Researchers examined data on hip fracture patients aged 50 and over at a trauma centre in Lothian, Scotland, between January 2019 to the end of June 2022.

They looked at the cases of 3,266 hip fracture patients with an average age of 81 years, of whom 72% were female.

Some 38.6% of these patients were in A&E for more than four hours.

Patients were followed up for more than 500 days and, during this time, 1,314 patients died.

Academics found that the odds of still being alive three months after hospital admission were “significantly lower” for patients who were in A&E for more than four hours compared to those who spent less time in the emergency room.

Those who waited more than four hours had a 36% increased odds of dying within 90 days after their hip break compared to those who spent a shorter period in A&E.

The researchers said that the increased risk is the equivalent of “one additional death at 90 days for every 36 patients who waited longer than 4 hours in the emergency department”.

Delay was also associated with an additional day spent in hospital, on average, among those who waited longer than four hours.

It is estimated that a third of females and 17% of males over 80 will suffer a hip fracture, with rates predicted to increase, the authors wrote in the Emergency Medicine Journal.

In light of the findings, the Royal Infirmary of Edinburgh has introduced a new “fast track” service so the majority of patients with hip fracture wait for no more than two hours in the emergency room.

Lead author Dr Nicholas Clement, from the Royal Infirmary of Edinburgh and the University of Edinburgh, told the PA news agency: “We’ve developed a fast track care pathway, just in the knowledge of what this study is found and as part of a quality improvement project.

“Our patients – those that don’t have to like another problem like a heart attack or a chest infection and can go straight at the ward – they go to the ward within two hours now.

“The best thing is that they spend as little time in the emergency department as possible and go to the ward, because they need to come in the hospital anyway – they’ve got a hip fracture, it’s not like any decision needs to be made, they need to come straight in the hospital to get the hip fracture fixed.”

He said that waiting times in emergency departments have increased since the Covid-19 pandemic.

“We’ve noticed our patients are spending longer and longer in the emergency department, not just in our unit, but also across Scotland and also across the UK,” he said.

“We thought we’d look at our hip fracture patients that are more frail than the standard patients that arrives … and sure enough, their length of stay and mortality is increased if they spent longer than four hours in the emergency department.

“It’s kind of understandable – you spend longer on a trolley, the analgesia might not be quite as good, you might be a bit more dehydrated rather being on the ward. So you can kind of imagine it might have an impact on the patient’s outcome.”

The four-hour A&E wait standard was introduced in the NHS in England in 2004 and was later adopted across the UK nations and some other countries.

Under this standard, most patients arriving at A&E must be admitted or discharged within four hours.

It has previously been hailed as a barometer for how the NHS as a whole is performing.

Data from Public Health Scotland show that during August there were 133,454 “unplanned” attendances at A&Es in NHS Scotland.

Of these 69.4% were seen and either admitted to hospital, transferred, or discharged, within four hours.

Meanwhile, in England some 76.3% of patients in England were seen within four hours in A&Es in August.

An NHS England spokesperson said: “We know there is much more to do to deliver timely care for those who need it and we’re rolling out targeted teams across the country to identify frail patients at the front door of our services to ensure they’re treated in the most appropriate setting, such as acute frailty services.

“The NHS has just come out of the busiest summer on record for A&Es, and there continues to be huge pressure on services, so we are committed to working with the Government on long-term solutions as part of the 10-year health plan, while continuing to do everything possible to improve A&E care.”

The spokesperson also pointed to the service’s best practice tariff, which gives hospitals extra payments for meeting clinical standards for hip fracture patients, such as surgery within 36 hours.

But Caroline Abrahams, charity director at Age UK, said: “We recognise that NHS budgets are under huge pressure but it is absolutely essential that older people who need operations are able to get them within a reasonable timescale and do not feel that the only way they can get the help they need, is to pay for it.”

A Scottish Government spokesperson said: “We’ve always recognised the relationship between long waits in A&E and increased risk of harm which is why we are continuously working on improving A&E performance.

“Pressure on our A&E departments is being driven by high levels of occupancy and delayed discharge associated with high numbers of patients who require support to go home. This impacts on patient flow out of emergency departments to inpatient wards.

“Reducing long A&E waits is a key priority for our government and we’re working with health boards and the Centre for Sustainable Delivery to implement actions that will improve patient flow which will in turn reduce waiting times.”