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Hospital emergency department closures not linked to increase in deaths

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Hospital emergency department closures not linked to increase in deaths

But small number, and proximity, of units means findings should be interpreted cautiously

The closure of hospital emergency care departments in England isn’t linked to an increase in deaths from serious conditions warranting urgent treatment, indicates research published online in Emergency Medicine Journal.

Further closures may therefore be possible in carefully selected areas, say the researchers.

But in a linked editorial, the immediate past president of the Royal College of Emergency Medicine, Dr Clifford Mann, says that the findings should be interpreted cautiously, because of the small number of departments and proximity of the hospitals involved.

Emergency care in England is under severe pressure, due to rising demand and staff shortages, potentially risking patient safety.  Over the past decade, attendances have risen by 22% (3 million), and emergency admissions to hospital by 42% (2 million).

As a result, some hospital emergency departments have closed or been downgraded, in a bid to concentrate resources--a move that has attracted controversy. But there has been little hard evidence to inform the debate, say the researchers.

They therefore used national database information and official stats on ambulance journey times (2007-2014) to gauge the impact of emergency department closures/downgrades between 2009 and 2011 on death rates for 16 serious emergency conditions at five hospitals in the towns of Newark, Rochdale, Bishop Auckland, Hartlepool and Hemel Hempstead.

The closures were prompted by concerns about sustainability and the future quality of care.

The death rates, which are a key measure of patient safety, were then compared with those at five other emergency care departments, in different areas, but serving populations of similar size, ethnic mix, and level of deprivation for the two years before, and the two years after the closures. 

During the study period, 19,000 people died of one of the 16 serious conditions within 7 days of admission to hospital or at times other than during an emergency admission, referred to as an out of hospital death, across all 10 sites.

For people affected by the closures, the journey time to the nearest emergency care department increased by an average of 9 minutes, ranging from zero to a maximum of 25 minutes.

But there was no statistically reliable and consistent evidence of an overall increase in deaths from any of the serious conditions subsequent to the five emergency department closures.

On average, there was a slight 2.5% increase in the case fatality ratio—a measure of the risk of death. But this could have arisen as a result of changes in the number of hospital admissions over two or more days, say the researchers.

But if death rates didn’t worsen, they didn’t improve either. “The decisions to close these [emergency departments] may have been taken in the expectation that clinical outcomes could be improved if patients were redirected to other hospitals,” note the researchers.  

“Our findings provide no evidence that any such benefits in terms of patient mortality in emergency accrued.” 

This is an observational study, and as such, cannot establish cause. Nevertheless, while the authors counsel further research looking at the economic and patient experience impacts of such closures, they conclude that: “It may be possible to close further carefully selected [emergency departments] without negative impact on population mortality.”

But in a linked editorial, immediate past president of the Royal College of Emergency Medicine points out that the people affected by the closures represent less than 2% of the population of England and that the proximity of the five departments meant an increase in transport time of only a few minutes.

“It is therefore unsurprising that no greater effect size could be demonstrated--clinical experience tells us that very few patients’ outcomes are determined by an additional 9 minutes in an ambulance,” he writes.

And the argument that closures will save money is a myth, he adds; such a policy is likely to have an impact on equity of access.

“Most hospitals are sited because of local geopolitical decisions made decades ago: as such, their locations are not necessarily best aligned to current population distributions and profiles or travel infrastructure,” he writes, suggesting that any future reorganisation needs to bear these issues in mind. 

[Ends]

18/10/2019

Notes for editors

Research: The impact of closing emergency departments on mortality in emergencies: an observational study doi 10.1136/emermed-2018-208146
Commentary: Consequences of ED closures  doi 10.1136/emermed-2019-208799
Journal: Emergency Medicine Journal

Funding: National Institute of Health Research

Link to AMS labelling system
https://press.psprings.co.uk/AMSlabels.pdf

Peer reviewed? Yes (research); No (commentary)
Evidence type: Observational; opinion
Subjects: People

Links to articles
https://emj.bmj.com/lookup/doi/10.1136/emermed-2018-208146
https://emj.bmj.com/lookup/doi/10.1136/emermed-2019-208799

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