Patients who spend more than four hours in A&E following a hip fracture are significantly more likely to die, according to a study which tracked outcomes among people treated at an Edinburgh hospital.

The study also estimated that the delays resulted in avoidable costs for the NHS of at least £770,000.

The evaluation, published today in the BMJ's Emergency Medicine Journal, is among the first to analyse the impact of spiralling A&E waiting times on hip fracture patients, who are more likely to be older and frailer.

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Dr Nick Clements, a consultant orthopaedic surgeon and Edinburgh University academic who led the research at the Royal Infirmary of Edinburgh - Scotland's largest centre for hip fracture care which deals with around 1000 cases annually - said they wanted to investigate amid a UK-wide increase in patients spending prolonged periods in A&E.

It comes as the latest statistics for Scotland show that one in three patients spent more than four hours in emergency departments in the final week of September, including more than 5,400 waiting more than 12 hours.

Compliance against the four-hour target for A&E/emergency departments has fallen sharply since 2020Compliance against the four-hour target for A&E/emergency departments has fallen sharply since 2020 (Image: PHS) Under the four-hour standard, at least 95% of patients attending A&E should be seen, treated, and subsequently discharged, admitted onto a ward, or transferred within four hours.

Last week the Royal College of Emergency Medicine (RCEM) warned that "alarm bells" should be sounding after statistics revealed that waiting times in August were the worst since records began in 2011, with more than 34% of patients waiting over four hours.

Between August 2017 and August 2024, the number of patients spending over four hours in Scotland's A&E departments has soared from 6,743 to 39,096.

Dr John-Paul Loughrey, RCEM vice president for Scotland, said pressures are "on a level with what we would have experienced during the busiest winter months just a few years ago".

Previous research has shown a clear association between excess mortality and longer time spent in A&E prior to hospital admission, regardless of the underlying condition.

In the study led by Dr Clements, researchers compared outcomes among 3,266 patients aged 50 and older who were admitted to the RIE between January 2019 and June 2022 after suffering a hip fracture at home or in a care home.

Of these patients, 1261 (38.6%) spent longer than four hours in the emergency department.

The researchers found that survival at the 90-day follow-up point was 96% for those who had waited less than four hours in A&E versus 93% for those who had spent more than four hours in A&E.

This is equivalent to one excess death per 36 patients who waited more than four hours.

The survival rate over time for hip fracture patients who spent more than (grey) and less than (black) four hours in A&EThe survival rate over time for hip fracture patients who spent more than (grey) and less than (black) four hours in A&E (Image: BMJ/Emergency Medicine Journal)

After adjusting for factors such as age, sex, and socioeconomic status, they found that spending over four hours in A&E prior to admission was associated with a 36% increased risk of death within 90 days for hip fracture patients.

Dr Clements said that hip fracture patients "never stopped coming" during the pandemic at a time when other attendances sharply declined, but it is difficult to exactly why mortality rates were higher for those who exceeded a four-hour wait.

The study was unable to adjust for other health factors - such as chest infections - which may mean they were sicker and required longer in A&E before being moved to a ward for surgery.

He said: "We don't quite know why those patients died.

"Is it really the ED, or is it just that they were more unwell and that's why they spent longer in ED than those who went straight to a ward?

"But we weren't seeing that prior to Covid when all our patients were getting out of ED within four hours, so we're not quite sure what's going on."

A&E departments have become increasingly gridlocked as hospitals struggle to free up beds on wardsA&E departments have become increasingly gridlocked as hospitals struggle to free up beds on wards (Image: DerekMcArthur/Newsquest)

Patients who waited more than four hours were significantly more likely to have been admitted during the winter, when hospitals are fullest, and this delay was also found to add an average of one day to their overall hospital stay - costing NHS Lothian an extra £770,000 over the course of the study period.

However, the researchers stress that this is probably higher as it is based on 2014 figures, when the average daily cost of accommodating a patient on an acute trauma ward was £610.

Dr Clements added: "It's good for no one to wait longer for surgery. Most importantly, it has ramifications for the patient, but also for the service generally.

"If they spend longer in hospital, that costs more money."

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Following the findings of the research, Dr Clements has been involved in the development of a Scotland-wide "fast-track" care pathway which aims to get hip fracture patients out of emergency departments and onto a ward within two hours without waiting to be accepted by orthopaedics as long as they are medically fit and have met key criteria including hydration, pain relief, pressure care, and basic observations.

Dr Clements said: "Our next job is to audit that pathway to see whether that's helping our patients.

"The only problems is that there's often no beds in the ward.

"I had a patient of my own re-admitted [on Monday] and I had to go down and see her.

"The ED was so busy that she had to wait over seven hours for a bed.

"So even though this fast-track care pathway might be there, whether there's beds available for them to go into is another question."