Prioritizing Care of Older Adults in Times of Emergency Department Overcrowding

Abstract

INTRODUCTION The scene is a crowded Emergency Department (ED) triage corridor lined up with patients walking in or delivered by a queue of ambulances. Overcrowding in Emergency Departments has reached historic levels. Overcrowding has often been attributed to system-level barriers to ED input, throughput, and output. 1 Within this framework, ED boarding is a critical contributor to overcrowding. 2 ED boarding is defined as the time an individual remains physically located in the ED following the admission decision and bed request. 2 Even though ED boarding has been associated with increased mortality, medical errors, care delays, discharge against medical advice, cost of care, and decreased patient satisfaction, ED options to mitigate boarding are limited. 1,3 In response to the overcrowding crisis and increased ED boarding, the American College of Emergency Physicians (ACEP) released a policy statement in 2017 highlighting that optimal care is provided on the wards once a patient is admitted. As such, boarding "represents a failure of inpatient bed management." 4 ACEP made several recommendations highlighting that the hospital must be responsible for timely transitions out of the ED with adequate nursing staff, contingency plans, and efforts to improve patient placement. Emergency medicine's ongoing attempts to optimize strategies require a response from policymakers, healthcare payors, health system management, and community organizations, and reorganizing how patients are prioritized for inpatient care. In the years since this statement, the COVID-19 pandemic exacerbated the increased boarding times compared to pre-pandemic levels. 3 Increased inpatient occupancy leading to ED gridlock, financial challenges leading to preferential admission of surgical patients, and nursing shortages are highlighted as some of the causes. 3 To underscore the dire situation EDs in the United States are currently facing, on November 7 th , 2022, ACEP sent a letter to The White House outlining ED overcrowding as a public health emergency. 5 The letter included evidence of the harm from ED boarding, ranging from hours to days and weeks. Several testimonials from ED physicians describe preventable harm, even within pediatric populations, lack of adequate outpatient psychiatric care, provider and staff burnout, and nursing shortages. ACEP called on The White House to convene a stakeholder summit to address this urgent crisis. This letter was signed by multiple specialty societies from across the United States. Although this recent call to action is supported, it fails to highlight how this crisis has disproportionately impacted the vulnerable and growing older adult population in the United States.