Every day, this scene plays out in hospitals across America: elderly men and women lying on blankets in emergency room corridors writhing or suffering silently, while bewildered medical staff attend to the crisis.
Even when physicians determine that these patients need to be hospitalized, they often wait for hours – sometimes more than a day – in the ER because of pain and discomfort, without adequate food. Or because of not getting water, not being able to move around, not getting help. Bathrooms, and not getting the kind of care that doctors consider necessary.
“You walk through the ER hallway, and they’re lined up with patients on stretchers in various states of distress, including many elderly patients,” said Hashem Zikri, an emergency medicine physician at UCLA Health.
Physicians staffing emergency rooms say the problem, known as ER boarding, is as bad as it has ever been — even worse than during the first years of the COVID-19 pandemic, when Hospitals were filled with extremely sick patients.
While boarding can occur for all ER patients, adults age 65 and older, who account for approximately 20% of ER visits, are particularly vulnerable during long waits for care. Additionally, seniors may face boarding more frequently than other patients. The best estimate I could find, published in 2019, before the COVID-19 pandemic, suggests that 10% of patients were admitted to the ER before receiving hospital care. About 30% to 50% of these patients were older adults.
“This is a public health crisis,” said Ayesha Terry, associate professor of emergency medicine at the George Washington University School of Medicine and Health Sciences and chair of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September. . ,
What’s going on? I spoke to about a dozen doctors and researchers who described the chaotic situation in ERs. He told me that hospital staffing shortages, which affects the number of beds available, are contributing to the crisis. Additionally, he explained, hospital administrators are setting aside more beds for patients undergoing exotic surgeries and other procedures, creating bottlenecks in the ER and leaving more patients in limbo.
Then, according to Arjun Venkatesh, chair of emergency medicine at Yale, there is high demand for hospital services, increased in part by the aging of the American population, and by the growing problems of home health care and nursing home care as patients are discharged. There is a delay in giving. School of Medicine.
The impact of long ER waits is especially severe on vulnerable seniors with multiple medical problems. Often confined to stretchers, gurneys or even rigid chairs, without the dependable assistance of nurses, they are at risk of losing strength, forgoing essential medications and experiencing symptoms such as delirium, according to Saket Saxena, co-director of geriatric medicine. There is a risk of experiencing complications. Emergency Department at Cleveland Clinic.
When these patients eventually get a hospital bed, their hospital stays are longer and medical complications become more common. And new research found that the risk of dying in the hospital is significantly higher for older adults when they stay in the ER overnight, as well as the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes and bedsores.
Ellen Danto-Nocton, a geriatrician in Milwaukee, was very concerned when an 88-year-old relative with “strokelike symptoms” spent two days in the ER a few years ago. Unconscious, motionless and unable to sleep due to the constant ringing of the alarm outside his bed, the old man walked downstairs before being taken to a hospital room. “He really needed to be in a less chaotic environment,” Dento-Nocton said.
Several weeks ago, Zikri, of UCLA Health, helped care for a 70-year-old woman who fell and broke her hip while attending a basketball game. “She remained in a corner of our ER for about 16 hours in extreme pain that was very difficult to adequately treat,” he said. The ER is designed to handle crises and stabilize patients, not “to take care of patients who we’ve already decided need to be hospitalized,” he said.
How common is ER boarding and where is it most intense? No one knows, because hospitals are not required to publicly report data about boardings. The Centers for Medicare and Medicaid Services discontinued boarding as a measure in 2021. New national measures of emergency care capacity have been proposed but not yet approved.
“It is not just the limits of ED boarding that we need to understand. This is the limit of acute hospital capacity in our communities,” said Yale’s Venkatesh, who helped draft the new measures.
Meanwhile, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more hospital beds. is among them Massachusetts General Hospital In Boston, which announced in January a 32% increase in ER boardings from October 2022 to September 2023. At the end of that period, hospitalized patients spent an average of 14 hours in the ER and 26% spent more than 24 hours. ,
Maura Kennedy, chief of geriatric emergency medicine at Mass General, described an 80-year-old woman suffering from a respiratory infection who lay in the ER for more than 24 hours after physicians decided she needed inpatient hospital care. Needed.
“She was not active, she had nothing to cognitively engage in, she hadn’t eaten and she became increasingly agitated, trying to get off the stretcher and trying to get off the staff,” Kennedy told me. Was arguing with.” “After a long stay in the hospital, she left the hospital more disabled than when she arrived.”
When I asked ER doctors what older adults could do about these problems, they said boarding was a health system issue that required health system and policy changes. Still, he had several suggestions.
“Have another person with you to advocate on your behalf,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And if the person feels your situation is getting worse or if staff are ignoring problems, ask them to speak up.
Alexander Janke, MD, clinical instructor of emergency medicine at the University of Michigan, advises people to “be prepared to wait when you come to the ER” and “bring a medication list and your medications if you can. “
To stay oriented and reduce the chance of delirium, “make sure you have hearing aids and glasses,” said Michael Malone, medical director of senior services for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Try to get up and move around whenever possible.”
Malone said friends or family caregivers who accompany older adults to the ER should ask them to stay by their bedside whenever possible and “try to make sure they’re able to eat, drink, go to the bathroom and take care of the underlying health issues.” Take regular medications for medical conditions.” ,
Older adults or caregivers who are helping them should “try to bring things that engage you cognitively: magazines, books… music, anything you can focus on in the hallway.” Where there’s no TV to entertain you,” Kennedy said.
“Experienced patients often come with eye masks and ear plugs,” UCLA’s Zikri said, “which helps them feel comfortable in the ER without the constant stimulation.” “Also, bring something to eat or drink if you can’t get to the cafeteria or it’s taking a while for staff to bring these to you.”
We look forward to hearing from readers about the questions you want answered, issues you encounter in your care, and the advice you need to navigate the health care system. visit kffhealthnews.org/columnists To submit your requests or suggestions.
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