Emergency Department Boarding Is Associated With Postoperative Complications in Patients With Hip Fractures

Emergency department (ED) boarding is common and associated with worse clinical outcomes. Few studies have examined the effect of ED dwell time and boarding on outcomes in patients requiring urgent surgery. Patients with hip fractures frequently experience prolonged ED stays, and orthopedic literature shows that time to hip fracture repair beyond 24 hours from injury results in worse outcomes. We hypothesize that ED length of stay (LOS) is independently associated with postoperative complications for patients with hip fractures and that admitting service is independently associated with adverse outcomes after accounting for complexity.

We conducted a multicenter retrospective cohort study of adults presenting with hip or proximal femur fractures who underwent operative repair across 5 clinical sites. The primary outcome was a composite of postoperative acute kidney injury, unexpected postoperative ICU upgrade, and in-hospital death. ED LOS and boarding were analyzed as continuous variables and quartiles to assess nonlinearity. Multivariable logistic regression assessed associations between ED LOS and the composite outcome.

Among 6,901 encounters, longer ED LOS was associated with higher postoperative complication rates independent of time to operative management. In adjusted analyses, each additional hour of total ED time increased the odds of the composite outcome (aOR 1.03, 95% CI 1.01–1.04, p<0.001). Quartile analysis showed a marked dose–response relationship; compared with the shortest quartile (<5.4 hrs), patients in the longest LOS quartile (>10.7 hrs) had nearly double the odds of complications (OR 1.85, 95% CI 1.54–2.21, p<0.001). Patients admitted to internal medicine had longer ED LOS and longer times to surgery. After propensity matching for comorbidities, ED LOS, and time to surgery, admitting service was not associated with differences in postoperative outcomes.

Prolonged ED LOS and ED boarding are associated with increased postoperative complications in hip fracture patients, with evidence of a sharp escalation in risk among patients with the longest stays. Admitting service is not independently associated with outcomes after accounting for patient complexity. These results suggest that ED LOS may not be merely a proxy for delayed surgery but is an independent risk exposure, leading to post-operative complications.