PREVIOUS ESTIMATES ABOUT excess deaths caused by delays in Irish Emergency Departments (EDs) may be “significantly underestimated”, emergency doctors here have said.
It comes after new UK research, published in the Emergency Medicine Journal, outlined a statistically significant increase in mortality following ED waits over more than five hours.
It is based on an analysis of over 26 million attendances in EDs in England between April 2016 and March 2018. Of those attendances, there were over 7.4 million admissions relating to 5.3 million individual patients.
A total of 433,962 deaths occurred within 30 days of admission, providing an overall 30-day mortality rate was 8.71%.
Significantly, the research found there was “a statistically significant linear increase in mortality” from five hours after time of arrival at the ED. This increase is most significantly observed in patients who waited in an ED for between six to eight hours.
The authors of the report conclude that “for every 82 admitted patients whose time to inpatient bed transfer is delayed beyond six to eight hours from time of arrival at the ED, there is one extra death”.
On foot of the research, the Irish Association for Emergency Medicine (IAEM) has said that previous estimates of excess deaths caused by delays may not reflect the reality.
The IAEM previously used Australian research and extrapolated for the Irish context to approximate 350-360 excess deaths per year as a result of ED delays and overcrowding.
In response to queries from The Journal, the IAEM has said that “the recent UK study suggests the real figure is higher”.
IAEM President Fergal Hickey says that the group will make a new estimation in time based on the new study but that it is clear the previous figure was an underestimation:
We will be saying, whenever we get a chance to provide such an estimate, that this is really, really concerning because it suggests that the figure that has been quoted up to now is a significant underestimate of the number of deaths.
Hickey adds that delays of over five hours in Irish EDs are now “so normal” that mortality rate could be significantly affected.
Wait times
The UK research highlights the importance of a long-standing target in place in Ireland that the vast majority of patients should be no longer than six hours waiting in an ED.
The Emergency Medicine Programme for Ireland has a target that 95% of patients should be either admitted or discharged within six-hours of arriving at an ED.
Prior to Covid-19 this target was not routinely met. Figures from HIQA’s National Inpatient Experience Survey in 2019 found that just 30% of people reported being admitted to a ward within the target waiting time of six hours.
Some reported waiting significantly longer, with 4% of almost 8,000 respondents saying they were waiting 48 hours or more before they were admitted to a ward.
The report itself acknowledges that long waiting times “have been linked with negative health outcomes and therefore pose a risk to patient safety”.
Surge
Cork-based consultant in emergency medicine Dr Chris Luke says it is important to highlight this issue due to the “ominous sense” that hospital EDs are about to experience a surge in people attending compared to before the pandemic.
Luke says that EDs, or Accident & Emergencies as they were previously known, should only be used for emergencies.
Instead, EDs are often seen as what he describes as “temples of health”, where people accept a long wait as the trade-off for being seen by a doctor. This, he says, has become more commonplace by the reduced availability of medical care including retiring GPs.
Luke says a properly functioning ED should operate like a healthy heart, with people regularly flowing in and out. Instead, EDs are becoming clogged, causing the delays observed and the associated negative health outcomes.
‘Golden hour’
For some of the most acute conditions for which people present to ED, such as major trauma, acute coronary cases and big stroke cases, prompt treatment is considered critical and prioritised.
Luke explains, however, that prompt treatment is important across a much wider range of conditions, all of which helps to explain the connection between delays and increased mortality.
“In truth, you can apply that across an ever widening penumbra of sick cases. So people with pneumonia, people with meningitis, people with diabetes crises, people with severe epilepsy, uncontrollable epilepsy, people with severe dehydration, people with an acute appendiceal abscess, there should be a time critical aspect of their management,” he says.
In a nutshell, if people are stuck in an emergency department for hours, there’s no aspect of their care which isn’t detrimentally affected. From their level of distress, to their dignity, to the actual direction of the course of their recovery.
“Blood bleeding from the blood vessel, the abscess formation, the evolving stroke, bleeding from the broken bones, all of that proceeds while people are waiting for care.”
Beds
Asked how the situation with wait times could be improved upon in Irish hospitals, Hickey responds that more beds is clearly the answer
“The reason that people get delayed in emergency departments is that they can get in, eventually, but they can’t get out,” he says, adding that trolley figures are set to get worse when scheduled elective activity increases.
“We can’t afford not to do it because we know that people die as a result, we know there’s higher long-term complication rates, we know that there’s litigation, either way it cost the State far more money.
“So actually deciding to have a properly resourced, from a capital point of view, healthcare system would actually be in a significant investment in the future.”
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