The “No Bed Night” study: A night spent on a stretcher in the emergency room increases the risk of hospital mortality for elderly patients by almost 40%, from 11.1% to 15.7%

In December 2022, emergency services in France and Europe experienced a considerable increase in the number of patients requiring emergency hospitalization, including a large proportion of fragile and elderly patients.

The hospital system could not effectively cope with such pressure due in part to a triple concomitant epidemic: COVID-19, influenza, and respiratory syncytial virus (RSV). This situation was aggravated by a reduction in the number of beds available downstream in the hospitals’ emergency departments, caused by a shortage of personnel. Thus, an unusually high number of elderly patients had to spend at least one night on a stretcher in the emergency room while waiting for a hospital bed.

Several preliminary retrospective studies had suggested that this situation could worsen patient mortality, without this risk being clearly established or quantified in the absence of a prospective study to formally establish a causal link. In particular, the quantification of the risk in the most fragile patients was lacking.

On an initiative of the Hospital-University Federation IMProving Emergency Care (FHU IMPEC) and with the support of the French Society of Emergency Medicine and Samu - Urgences de France, the “No Bed Night” study was set up quickly to assess the impact of this overload of emergency services, and its consequences on elderly patients.

The study took place from December 12 to 14, 2022, in 97 emergency departments in France, including 1,598 patients over the age of 75 hospitalized after going to the emergency room.

After taking into account comorbidities and the initial severity of patients, this study shows that spending a night in the emergency room is associated with a significantly higher risk of in-hospital death: a night spent on a stretcher in the emergency room increases by almost 40% the risk of hospital mortality, which increases from 11.1% to 15.7%.

To illustrate these figures: if all the patients in this study could have been admitted to a hospital room before nightfall, 3% of deaths could have been avoided. This deleterious effect is confirmed on the risk of complications appearing during hospitalization (nosocomial infections, falls, bleeding, etc.).

Among patients with a limited level of autonomy and requiring daily assistance, spending the night on a stretcher in the emergency room increases the risk of mortality by almost two times.

In conclusion, this large prospective study of national scope, published in the journal JAMA Internal Medicine, shows that a night spent in the emergency room while waiting for a hospital bed significantly increases the mortality of patients over 75 years of age, and in particular for that of the most fragile. Measures must be taken to avoid this excess mortality as much as possible, and the objective of “zero stretcher beds” in emergency departments, particularly for patients over 75 years of age, must be considered a public health objective

Mélanie Roussel, Dorian Teissandier, Youri Yordanov, Frédéric Balen, Marc Noizet, Karim Tazarourte, Ben Bloom, Pierre Catoire, Laurence Bérard, Marine Cachanado, Tabassome Simon, Said Laribi, Yonathan Freund. JAMA Internal Medicine.

The Risks of Being in Limbo in the Emergency Department Timothy S. Anderson, MD, MAS; Shoshana J. Herzig, MD, MPH JAMA Internal Medicine

Interview with Yonathan Freund, MD, PhD, author of Overnight Stay in the Emergency Department and Mortality in Older Patients, and Timothy S. Anderson, MD, MAS, author of The Risks of Being in Limbo in the Emergency Department. Hosted by Louise Aronson, MD, MFA.