Adrian Boyle

Background: Pressure on emergency departments (EDs) has increased, particularly since the COVID-19 pandemic. There has been limited research into the impact of prolonged emergency department length of stay on inpatient length of stay. This study aimed to evaluate whether a longer stay in the ED increases inpatient length of stay and to quantify any association. Methods: This was a single-centre, observational, retrospective cohort study of all ED patient episodes that led to inpatient admission from January 2022 to December 2022, at a tertiary hospital in the UK. Separate bivariate analyses were performed for adult and paediatric patients. The effect of multiple confounders for the adult population was evaluated with a logistic regression model. The outcome variable used was an inpatient stay of 7 days, as this is a recognised metric by National Health Service (NHS) England. Results: From January 2022 to December 2022 there 31 131 admissions from the ED. 31 020 patient attendances were included, representing 23 286 individual patients. For an ED length of stay of less than 12 h, the inpatient length of stay median was 3 days (mean 7.87 days). This rose to 6 days for patients with an ED length of stay of 12 h or greater (mean 9.94 days). Even after adjusting for cofounding variables in adults, an ED length of stay of 12 h of more significantly increases the likelihood of a prolonged inpatient stay (OR 1.30, 95% Confidence Interval (CI) 1.23–1.37), and this effect increased for an ED length of stay of24 h or more (OR 1.50, 95% CI 1.38–1.63). In children, no statistically significant association was observed between ED length of stay and inpatient length of stay for a 12-hour threshold (Pearson Chi² test (9) = 9.4, p = 0.405). Conclusions: This study confirms that there is a significant association between a prolonged ED stay and an increased inpatient stay for patients remaining in the ED over 12 and 24 h.

Objective: To examine how socioeconomic deprivation influences referral pathways to emergency departments (EDs) and to assess how these pathways affect subsequent hospital outcomes. Design: Retrospective observational study. Setting: Emergency department of a large teaching hospital in the East of England, providing secondary and tertiary care. Participants: 482 787 ED attendances by patients aged 16 years and over, recorded between January 2019 and December 2023. Patients were assigned Index of Multiple Deprivation (IMD) deciles based on residential postcode. Main outcome measures: Referral source (general practitioner (GP), National Health Service (NHS) 111, ambulance, self-referral, other), total ED time, 4-hour breach, hospital admission and unplanned return within 72 hours. Results: Substantial socioeconomic inequalities were observed in referral pathways. Patients from the most deprived areas were significantly less likely to be referred by a GP (4.7%) than those from the least deprived areas (14.7%) and more likely to arrive via ambulance (32% vs 24%). These differences persisted after adjusting for demographic, clinical and contextual variables. Ambulance referrals showed the longest ED stays, ranging from 347 to 351 min across IMD deciles (overall 95% CI 343 to 363) and the highest probability of 4-hour breaches (51%; 95% CI 50% to 53%). Self-referrals had the greatest rates of unplanned returns within 7 days (up to 7.1%; 95% CI 5.5% to 8.7%). In contrast, NHS 111 and GP referrals were associated with shorter stays, lower breach rates and fewer reattendances. Minimal variation in outcomes was observed across deprivation levels once referral source was accounted for. Conclusions: Inequalities in how patients access emergency care, particularly reduced GP and NHS 111 referrals among more deprived groups, appear to underpin disparities in ED outcomes. Referral source captures important clinical and system-level factors that influence patient experience and resource use. Interventions to improve equitable access to structured referral pathways, particularly in more deprived areas, may enhance both the efficiency and fairness of emergency care delivery. Further research using national data is needed to assess broader policy implications and economic costs associated with differential access.

Background: The emergency department represents a potentially valuable opportunity to support smoking cessation. Evidence is lacking around the use of e-cigarettes in opportunistic settings like the emergency department. Objective: To undertake a randomised controlled trial in people who smoke attending United Kingdom emergency departments, testing a brief intervention which included provision of an e-cigarette versus signposting to smoking cessation services, assessing smoking abstinence. Design: A two-arm pragmatic, multicentre, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed-methods process evaluation. Setting: Six emergency departments across England and Scotland. Participants: Adults who smoked daily, who were attending the emergency department for medical treatment or accompanying someone attending for medical treatment, were invited to participate. People were excluded if they had an expired carbon monoxide of < 8 parts per million, required immediate medical treatment, were in police custody, had a known allergy to nicotine, were daily e-cigarette users, were considered not to have capacity to consent or had already taken part in the trial. Intervention: Brief stop smoking advice, e-cigarette starter kit and referral to stop smoking services. Main outcome measures: The primary outcome was biochemically validated sustained abstinence at 6 months. Those lost to follow-up, or not providing biochemical verification, were considered not to be abstinent. Secondary outcomes were: self-reported 7-day smoking abstinence, number of quit attempts, number of cigarettes per day, nicotine dependence and incidence of self-reported dry cough or mouth or throat irritation. Results: At 6 months, of 972 participants randomised, biochemically verified smoking abstinence was 7.2% in the intervention group and 4.1% in the control group (percentage difference = 3.3%) (95% confidence interval 0.3 to 6.3; p = 0.032) [relative risk 1.76 (95% confidence interval 1.03 to 3.01)]. Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (percentage difference = 10.6%) (95% confidence interval 5.86 to 15.41; p < 0.001) [relative risk 1.80 (95% confidence interval 1.36 to 2.38)]. Daily e-cigarette use was 39.4% in the intervention group and 17.5% in the control group at 6 months. No serious adverse events related to taking part in the trial were reported. The economic evaluation found the intervention was likely to be cost-effective, judged by the National Institute for Health and Care Excellence threshold. The process evaluation found the intervention to be acceptable to both staff delivering it and participants receiving it. The brief nature of the intervention was highly adaptable to context, and interviews demonstrated how the intervention supported different pathways towards cessation. Limitations: The inability to blind participants or researchers, the relatively low level of biochemical verification due to the nature of the population recruited and the fact that those in the control group did not receive usual care. Conclusions: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. Future work: Future work will include testing other behaviour change interventions in the emergency department and adapting the Cessation of Smoking Trial in the emergency department intervention for other settings. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR129438.

Objective: To investigate the association between patient time spent in Type 1 emergency departments (EDs) and all-cause mortality 30 days after leaving the department alive. Design: Cross-sectional, retrospective, observational study using national linked data. Setting: All NHS Type 1 emergency departments in England. Participants: 6,721,179 individuals (mean age 41.3 years, 52.6% female, 81.4% White ethnicity) attended an ED at least once between 21st March 2021 and 31st March 2022; had a record populated with a “non-immediate” acuity level and a chief complaint at arrival; and survived to either discharge from the ED or admission to hospital for inpatient care. Main outcome measures: All-cause mortality within 30 days of the ED attendance. Results: Within the study population, 88,657 patients (1.3%) died within 30 days of ED attendance. A positive non-linear relationship was observed between time spent in the ED and post-discharge mortality, with the probability of death increasing after two hours. The marginal probabilities of death (controlling for socio-economic characteristics, clinical factors such as chief complaint, and comorbidities) at two hours in the ED were 0.02% for patients aged 20 years, rising to 0.1% at 40 years, 0.3% at 60 years, and 0.8% at 80 years. Compared with patients who spent two hours in the ED, the adjusted odds of post-discharge death were: 1.1 times higher (1.07 to 1.14) for three hours; 1.6 times (1.48 to 1.68) for six hours; 1.9 times (1.80 to 2.03) for nine hours; and 2.1 times (2.02 to 2.28) for 12 hours. Conclusions: Longer time spent in the ED for non-immediate care is associated with increased risk of all-cause mortality within 30 days of discharge or admission, in a non-linear manner. Our findings suggest that time in the ED may be a risk factor for death after discharge, not just during the visit. These findings could inform policy makers and health professionals when setting ED time targets. Further research is needed to understand causal drivers of post-discharge mortality and confirm whether our findings generalise to more recent periods. Summary box: Section 1: What is already known on this topic: Small, single-centre studies have suggested that there is an increased mortality rate among patients who experience delays between arrival at the emergency department and admission to an inpatient bed. A larger study of over five million individual admitted patients in England, using data from between 2016 and 2018, found an increase in all-cause 30-day mortality that was associated with delays to hospital admission. The quantifiable increase in mortality started as early as five hours after arrival at the emergency department (ED) and increased in a linear “dose-related” fashion. Section 2: What this study adds: Our study suggests that longer ED stays for non-immediate care are associated with an increased risk of all-cause mortality within 30 days of both discharge or admission. Our study builds on previous research by incorporating more recent data, treating time spent in the ED as a continuous rather than a discrete variable; controlling for a broad range of socio-economic variables recorded in England and Wales National Census; and including all patients who attended emergency departments, for both those that were admitted and those that were discharged (rather than just those who were subsequently admitted to hospital for inpatient care).

Objective To investigate the association between monthly turnover rates of hospital nurses and senior doctors and patient health outcomes (mortality and unplanned hospital readmissions). Design Retrospective longitudinal study. Setting All 148 NHS acute trusts in England (1 April 2010 to 30 March 2019), excluding specialist and community NHS hospital trusts. Participants Yearly records on 236 000 nurses, 41 800 senior doctors (specialist, associate specialist and specialty doctors, and consultants), and 8.1 million patients admitted to hospital. Main outcome measures The panel data regression analysis used nine years of monthly observations from administrative datasets at healthcare worker and patient levels. Associations using linear and unconditional quantile regressions were estimated, including controls for seasonality and NHS hospital trust. Four hospital quality indicators (risk adjusted by patient age, sex, and Charlson index comorbidities) were used and measured at a monthly frequency on a percentage scale: mortality risk within 30 days from all cause, emergency, or elective admission to hospital, and risk of unplanned emergency readmission within 30 days from discharge after elective hospital treatment. Results A 1 standard deviation (SD) increase in turnover rate for nurses was associated with 0.035 (95% confidence interval 0.024 to 0.045) and 0.052 (0.037 to 0.067) percentage point increases in risks of all cause and emergency admission mortality, respectively, at 30 days. The corresponding values for senior doctors were 0.014 (0.005 to 0.024) and 0.019 (0.006 to 0.033) percentage point increases. Higher nurse turnover rate was associated with higher mortality risk at 30 days in surgical (PConclusions Lower turnover rates for nurses and senior doctors at hospital level were associated with better health outcomes for patients with emergency hospital admissions. Study registration Integrated Research Application System project ID 271302.