People with hip fractures who wait more than four hours for treatment in emergency care face a heightened risk of death and a longer hospital stay. That is the finding of researchers who conducted a single centre study, the findings of which are published online today (9 October) in Emergency Medicine Journal.

More than one patient in three waited longer in an emergency department (ED) than the four-hour national standard, which now requires that 76 per cent of patients must either be discharged or admitted to hospital within that time frame. 

By the time they reach the age of 80 one woman in three and 17 per cent of men will have fractured a hip – figures which are predicted to double by 2033, explain the researchers. The article’s first author is Nicholas Clement, who is based at the Royal Infirmary of Edinburgh and the Department of Orthopaedics at the University of Edinburgh.

Early surgery is associated with lower risks of death and perioperative complication rates, but with ED waiting times currently lengthening across the UK and elsewhere, it’s highly likely that hip fracture surgery may end up being delayed, Dr Clement and colleagues note.

To assess the potential impact on hip fracture patients of four-plus hour waits in the emergency department, the researchers retrospectively evaluated local hip fracture database entries for all patients aged at least 50. The patients had been admitted to a single trauma centre between 1 January 2019 and 30 June 2022, and subsequently monitored for at least eight months until February 2023. 

Data culled from more than 3,000 patients

The trauma centre in question serves a population of 916,310 people in Lothian, Scotland and manages more than 1,000 hip fractures annually. Details on demographics, treatment, progress through the service, and death were collected from the patients’ case notes and the trauma centre’s documentation.

Some 3,611 patients were admitted to the centre with a hip fracture during the study period. After various exclusions, including those with incomplete admission and discharge time data, 3,266 patients were included in the analysis.

Their average age was 81, but ranged from 50 to 104, and 2,359 (72 per cent) o them were women. They spent an average of 3.9 hours in the emergency care department. The average length of time before surgery was 27 hours, with the average time between admission and surgery 22.5 hours.

The average length of their hospital stay was nine days, with subsequent follow-up lasting 529 days, during which time 1,314 (just over 40 per cent) of these patients died. In all, more than a third (1,261; 39 per cent) patients waited longer than four hours in the emergency department.

They were significantly more likely to be admitted during the winter, to pose more of a surgical risk, to have sustained a fracture that is more difficult to repair, and to have waited longer for their surgery than those who spent four hours or less in the emergency department. 

Almost 96 per cent of those who waited less than four hours were alive at 90 days compared with almost 93 per cent for those waiting longer – equivalent to one additional death at 90 days for every 36 patients who waited more than four hours, say Dr Clement and his fellow researchers.

We found … an association between ED waiting time and poorer hip fracture outcomes. Adoption of ED-accelerated care pathways in our institution may help improve their outcome [Nicholas Clement et al]

Associated financial costs of lengthy waits

The 90-day risk of death rose in tandem with the length of delay before surgery, reaching around 14 per cent after 24 hours. Male sex, older age, admission during the winter months, higher operative risk, care home residence, and longer time between admission and surgery were also all independently associated with death at 90 days.

After taking account of potentially influential factors, a four-plus hour wait was associated with 29 per cent, 36 per cent, and 15 per cent heightened risks of death at 60 days, 90 days, and at final check-up, respectively. 

Patients who waited four-plus hours in the emergency department were also much more likely to spend one day longer in hospital, adding up to about £770,000 in total, if costed at £610/day (2014 prices), note the researchers.

Caveats and conclusions

As this the study was observational in nature, Dr Clement and colleagues acknowledge that cause cannot be established. They also acknowledge the relatively small size of their study and the lack of adjustment for the patients’ overall state of health and factors delaying their admission, all of which may have influenced their outcomes.

But while it is not clear exactly why spending more than four hours in the emergency department should be associated with poorer outcomes for hip fracture patients, given that there is a link, direct transfer to theatre from the emergency department might improve the chances of survival for these patients, the researchers suggest.

Dr Clement and the team conclude: ‘In this service evaluation, we found that over a third of patients with a hip fracture spent more than 4 hours in the ED and there was an association between ED waiting time and poorer hip fracture outcomes. Adoption of ED-accelerated care pathways in our institution may help improve their outcomes.’

The article is titled Delayed admission of patients with hip fracture from the emergency department is associated with an increased mortality risk and increased length of hospital stay Doi: 10.1136/emermed-2023-213085