Invited Commentary
November 6, 2023
The Risks of Being in Limbo in the Emergency Department
Timothy S. Anderson, Shoshana J. Herzig
JAMA Intern Med. Published online November 6, 2023. doi:10.1001/jamainternmed.2023.5953
Overcrowding of emergency departments (EDs) and hospitals is a growing public health concern in response to a confluence of increased demand for ED care, staffing shortages, and hospital consolidation—all overlaying a withering primary care infrastructure. In the US, 90% of EDs were regularly reporting overcrowding before the COVID-19 pandemic,1 with an average ED wait time of 145 minutes in 2022 and minimal capacity to absorb spikes in demand (as may occur during an infectious disease outbreak).2 Periods of ED crowding have been associated with higher inpatient mortality in some observational studies3; however, mechanisms for this association are not clearly defined.
In this issue of JAMA Internal Medicine, Roussel et al4 investigate the association of boarding overnight in the ED with in-hospital mortality and adverse events among adults aged 75 years and older. The authors conducted a prospective cohort study across 97 EDs in France amid a surge in hospitalizations for a “triple pandemic” of COVID-19, influenza, and respiratory syncytial virus in December 2022. Comparing 707 older adults who stayed overnight in the ED (mean ED length of stay, 23 hours) with 891 older adults who were admitted to a medical ward before midnight (mean ED length of stay, 7.5 hours), the authors found that a substantially higher inpatient mortality rate (16% vs 11%) and risk of falls (6% vs 3%) among the first group after adjusting for facility and patient characteristics. Although a component of unmeasured confounding remains likely, the data on vital signs and chief concerns, plus the large sample of EDs during a unique surge, provide compelling evidence for action by health systems to address the potential harms of overnight ED boarding of older adults who are acutely ill.
Given the findings of Roussel et al,4 how might EDs and hospitals move forward toward improving care? Changes to the ED care environment, responsible personnel, and hospital outflow each deserve consideration.
First, the ED care environment is inevitably less private and more hectic than hospital ward rooms; however, steps to alleviate environmental stresses are possible. Designating a physical section of an ED for patients who have been stabilized and are awaiting a bed may allow for reduction of external stressors (eg, lowering lights, noises, alarms), and moving of patients from stretchers to portable hospital beds with the goal of facilitating rest may reduce risk factors for falls and delirium. In 2014, US emergency medicine and geriatrics professional societies developed geriatric ED guidelines5 that include templates for best practices for staffing, equipment, education, and policies. Unfortunately, these guidelines remain largely aspirational, and low uptake has precluded effectiveness studies.
Second, regarding personnel, Roussel et al4 noted that in France, ED teams are charged with the care of patients awaiting a hospital bed. The authors raise the possibility of insufficient monitoring in this setting given that in a busy ED, when a patient appears stabilized, the ED clinician will need to turn their attention to incoming patients with acute needs. Potentially, this approach may create a vulnerable window of time for patients who cannot be moved to a ward expeditiously. In recognition of this vulnerability, some hospitals have developed systems through which inpatient clinicians assume responsibility for patient care once a decision to admit a patient to the hospital is made, even if a bed is not available for an extended period. Less frequently are nursing responsibilities shifted from ED nurses to ward nurses when patients remain in the ED; however, this too is feasible and would reorient care to be patient centered rather than dictated by hospital geography. Unfortunately, neither of these approaches have been rigorously evaluated; they should be in future research.
Third, hospital outflow is an issue. The underlying sources of ED boarding are surges in patient demand, which are often unavoidable, and an insufficient supply of ward beds, often dictated by staffing rather than available furniture. Reducing bottlenecks of hospital outflow may relieve ED overcrowding; however, widespread staffing challenges can create bottlenecks for patients going from hospital to nursing facilities or to home and in need of home health care. Hospital command centers have been proposed and widely used during COVID-19 to proactively manage patient flow.6 In contrast to newly arrived and acutely ill patients awaiting a bed in the ED, a substantial portion of hospitalized patients are quite stable and simply awaiting final steps before discharge, eg, nursing home bed placements, final test results, or last infusion treatments. Lower-intensity care units could be developed for patients nearing the end of their hospital stay. Some hospitals have begun using discharge lounges,7 allowing discharged patients to leave their rooms while awaiting transportation or final paperwork, thus freeing up valuable hours of bed supply. However, the safety and best practices of these models have not been investigated yet.
Although we have identified 3 general areas ripe for innovation, there are likely many system modifications, both within and beyond these areas, that could improve the experience and outcomes of older adults being transferred from EDs to wards. The striking outcomes documented by Roussel et al4 provide a renewed urgency for developing and rigorously testing new approaches to reduce the risk of patient harm across this vulnerable window of care. Although the most effective and efficient approaches still need to be identified, we can likely all agree that the status quo is not optimal for any patient, especially for an older adult with an acute illness.
