Every day, this scene plays out in hospitals across America: older men and women lie on gurneys in emergency room hallways, groaning or suffering in silence as hurried medical staff occupies crises.
Even when doctors determine that these patients need to be admitted to the hospital, they often wait for hours – sometimes more than a day – in the emergency room, suffering pain and discomfort, not receiving enough food or water. , not moving, not receiving help to get to the hospital. bathroom and not receiving the care that doctors deem necessary.
“You walk through the corridors of the emergency room and they are lined from one end to the other with patients on stretchers in various states of distress crying for help, including a number of older patients,” Hashem said Zikry, an emergency room physician at UCLA Health.
Doctors who work in emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been — even worse than during the early years of the COVID pandemic -19, when hospitals were filling with desperately ill patients.
Although boarding can happen to all emergency department patients, adults 65 and older, who account for nearly 20% of emergency room visits, are particularly vulnerable during long waits for care. Additionally, older adults may experience boarding more often than other patients. The best estimates I could find, published in 2019, before the COVID-19 pandemic, suggest that 10% of patients were housed in emergency rooms before receiving hospital care. About 30 to 50% of these patients were elderly.
“This is a public health crisis,” said Aisha Terry, associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences and chair of the board of directors of the American College of Emergency Physicians, which sponsored a boarding summit in September. .
What is going on? I spoke to nearly a dozen doctors and researchers who described the chaotic situation in emergency rooms. They told me that understaffing in hospitals, which affects the number of beds available, is contributing to the crisis. Additionally, they said, hospital administrators are reserving more beds for patients undergoing lucrative surgeries and other procedures, contributing to emergency room bottlenecks and leaving more patients in limbo.
Then there is high demand for hospital services, fueled in part by the aging U.S. population, and delays in patient discharge due to growing problems securing home health care and nursing home care. retirement, according to Arjun Venkatesh, chairman of emergency medicine at Yale University. Medicine School.
The impact of long waits in emergency departments on frail older adults with multiple medical problems is particularly serious. Confined to stretchers, gurneys or even hard chairs, often without reliable help from nurses, they risk losing strength, forgoing essential medications and experiencing complications such as delirium, according to Saket Saxena, co-director of the geriatric center. emergency department at the Cleveland Clinic.
“This is a public health crisis.” —Aisha Terry, chair of the American College of Emergency Physician Board of Trusteess
When these patients finally get a hospital bed, their stay is longer and medical complications are more common. And new research finds that the risk of dying in hospital is significantly higher for older adults when they spend the night in the emergency room, as is the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes and pressure sores.
Ellen Danto-Nocton, a geriatrician in Milwaukee, was deeply concerned when an 88-year-old relative with “stroke-like symptoms” spent two days in the emergency room a few years ago. Delirious, immobile and unable to sleep as alarms outside his bed rang non-stop, the older man collapsed before being moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.
Several weeks ago, Zikry of UCLA Health helped treat a 70-year-old woman who had fallen and broken her hip while watching a basketball game. “She was in a corner of our emergency room for about 16 hours with immense pain that was very difficult to treat adequately,” he said. Emergency rooms are designed to manage crises and stabilize patients, not to “take care of patients who we have already decided need to be admitted to the hospital,” he said.
How common is emergency boarding and where is it most acute? No one knows, because hospitals are not required to publicly disclose boarding data. The Centers for Medicare & Medicaid Services withdrew a boarding measure in 2021. New national urgent care capacity measures have been proposed but not yet approved.
“It’s not just the extent of emergency boarding that we need to understand. That’s the extent of acute care hospital capacity in our communities,” said Yale’s Venkatesh, who helped write the new measures.
Meanwhile, some hospital systems are making their plight known by highlighting capacity constraints and the need for more hospital beds. Among them is Massachusetts General Hospital in Boston, which announced in January that emergency department boarding increased 32% between October 2022 and September 2023. At the end of that period, patients admitted to the hospital increased on average 14 hours in the emergency room and 26 hours. % have spent more than 24 hours.
Maura Kennedy, chief of geriatric emergency medicine at Mass General, described a woman in her mid-80s with a respiratory infection who languished in the emergency room for more than 24 hours after doctors decided she had need hospital care.
“She was not mobilized, she had nothing to cognitively engage her, she hadn’t eaten and she was becoming more and more agitated, trying to get off the stretcher and arguing with the staff,” me Kennedy said. “After a prolonged hospital stay, she left the hospital more disabled than she was when she arrived.”
When I asked emergency physicians what older adults could do to address these issues, they responded that boarding was a health system problem that required changes in the health system and policies. However, they had several suggestions.
“Have another person with you to advocate for you,” said Jesse Pines, chief clinical innovation officer at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And ask that person to speak up if they think your condition is getting worse or if staff members are overlooking problems.
Alexander Janke, clinical instructor of emergency medicine at the University of Michigan, advises people: “Be prepared to wait when you go to the emergency room” and “bring a medication list and your medications, if you can.”
To stay oriented and reduce the risk of delirium, “make sure you have your hearing aids and glasses with you,” said Michael Malone, medical director of senior services at Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “If possible, try to get up and move around.”
Friends or family caregivers who accompany older adults to the emergency room should ask to be at their bedside, when possible, and “try to ensure that they eat, drink, go to the bathroom, and take routine medications to underlying medical issues,” Malone said. .
Older adults or caregivers who help them should try to bring “things that would engage you cognitively: magazines, books… music, anything you could focus on in a hallway where there is no There’s no television to entertain you,” Kennedy said.
“Experienced patients often present with eye masks and earplugs” to help them rest in emergency rooms with continued stimulation, said Zikry of UCLA. “Also bring something to eat and drink in case you can’t make it to the cafeteria or it will take a while for the staff to bring them to you. »
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