JAMA Intern Med：老年患者在急诊科过夜与病死率

Key Points

Question  Is spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients?在急诊科(ED)住一晚是否与老年患者的院内死亡率和发病率增加相关?

Findings  This French cohort study of 1598 patients 75 years and older, those who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.法国的这项队列研究纳入了1,598例75岁及以上的患者，与午夜前入住病房的患者相比，在急诊科住一晚的患者显示出较高的院内死亡率和不良事件风险。这一发现在自主性有限的患者中尤其显著。

Meaning  These findings suggest that older patients, particularly those with limited autonomy, who spend the night in the ED awaiting hospital admission may have a higher risk of in-hospital mortality and morbidity; they should be prioritized for admission to a ward.这些发现提示，在急诊科等待入院的老年患者，尤其是自主权有限的患者，院内死亡和发病的风险可能较高。他们应该优先进入病房。

Abstract

Importance  Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown.在急诊科(ED)，躺在轮式婴儿床上等待住院的患者可能会受到伤害。然而，在急诊科过夜的老年患者在内科病房等待床位时的死亡率和发病率尚不清楚。

Objective  To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality.评估在急诊科候诊一晚的老年人院内死亡风险是否增加。

Design, Settings, and Participants  This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group).这是一项对法国97家急诊就诊并于2022年12月12 ~ 14日入院的老年患者(≥75岁)开展的前瞻性队列研究。根据入院时间分为两组:急诊科午夜至8:00住院患者(急诊科组)和午夜前入住病区患者(病区组)。

Main Outcomes and Measures  The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups.主要终点是30日时截短的院内死亡率。次要结局包括院内不良事件(即跌倒、感染、出血、心肌梗死、卒中、血栓形成、褥疮和钠血症)和住院时长。采用广义线性回归混合模型比较组间终点。

Results  The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61).总样本包括1,598例患者(中位年龄[IQR]， 86[80 ~ 90]岁;880名[55%]女性和718名[45%]男性)，其中急诊组707名(44%)，病房组891名(56%)。在急诊科过夜的患者院内死亡率较高，分别为15.7%和11.1%(校正风险比[aRR]， 1.39;95% ci, 1.07 ~ 1.81)。他们发生不良事件的风险也高于病房组(aRR, 1.24;95% CI, 1.04 ~ 1.49)和中位住院时长增加(9 vs 8天;率比为1.20;95% ci, 1.11 ~ 1.31)。在对日常生活活动需要协助的患者进行的预设亚组分析中，在急诊科过夜与较高的院内死亡率相关(aRR, 1.81;95% ci, 1.25 ~ 2.61)。

Conclusions and Relevance  The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.这项前瞻性队列研究的结果表明，对于老年患者，在急诊科过夜等待入住病房与院内死亡率和发病率增加相关，尤其是在自主权有限的患者中。老年人应优先入住病房。