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Does Prolonged Disposition Time Increase Mortality?

February 27, 2020

Written by Clay Smith

Spoon Feed
Time to ED disposition ≥4 hours was associated with increased 30-day mortality. This was more likely in complex patients or those being admitted to psychiatric, surgical, or oncology services.

Why does this matter?
Previous studies have shown an association of increased mortality with increased time to disposition and inpatient boarding in the ED. In Australia, the government established an Emergency Treatment Performance (ETP) metric, “to ensure ED patients were seen, treated and either discharged or admitted to an appropriate in-patient bed within 4 h of arrival in ED.” This means they actually leave the department in the 4-hour window. What factors contributed to ETP non-compliance? And was ETP non-compliance associated with mortality?

Flow = Life
This was a retrospective study of multiple tertiary care hospitals in New South Wales (NSW) comparing a total of nearly 700,000 patients who met the ETP metric and those who did not. Several factors were associated with ETP non-compliance (i.e. delayed disposition ≥4 hours). At a patient level, those with multiple or complex medical issues compared with no comorbidities had longer disposition times. Also, admission to a psychiatric, surgical, or oncology service delayed disposition compared to general medicine. On the other hand, admission to ophthalmology, urology, or cardiology was associated with improved ETP compliance. Most importantly, after statistical adjustment, prolonged time to disposition ≥4 hours (i.e. ETP non-compliance) was associated with a 28% higher hazard ratio for 30-day all-cause mortality, HR 1.28 (95%CI 1.26 to 1.30). More and more evidence suggests that delays in time to ED disposition is potentially harmful to patients. With finite resources and patients that just keep on pouring in the door on foot or by EMS, we need to be able to treat and disposition current patients to accommodate new ones. Opportunities to improve include increased mental health patient capacity, streamlined workup and imaging, especially in older, medically complex patients, and learning from what more efficient services are doing right to improve disposition time.

Another Spoonful
Can I just say how happy I was when this article showed up in my inbox from senior author Kendall Bein! He helped me in the days of the KeepingUp! podcast. Thanks, Kendall.

Dinh, M.M., Arce, C.P., Berendsen Russell, S. and Bein, K.J. (2020), Predictors and in‐hospital mortality associated with prolonged emergency department length of stay in New South Wales tertiary hospitals from 2017 to 2018. Emergency Medicine Australasia. doi:10.1111/1742-6723.13477

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What are your thoughts?