Seniors stranded in ER suffer avoidable harm
Elderly are especially vulnerable to ‘boarding’
Every day, the scene plays out in hospitals across America: Older men and women lie on gurneys in emergency room corridors moaning or suffering silently as harried medical staff attend to crises.
Even when physicians determine these patients need to be admitted to the hospital, they often wait in the ER for hours – sometimes more than a day – in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom and not getting the care doctors deem necessary.
ER hallways are “lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Dr. Hashem Zikry, an emergency medicine physician at UCLA Health.
Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been – even worse than during the first years of the COVID-19 pandemic.
While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20% of ER visits, are especially vulnerable during long waits for care. Also, seniors may encounter boarding more often than other patients. Estimates published in 2019 suggest that 10% of patients were boarded in ERs before receiving hospital care. About 30% to 50% of these patients were older adults.
“It’s a public health crisis,” said Aisha Terry, an associate professor of emergency medicine at George Washington University and president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.
Staff shortages, high demand, financial priorities
Almost a dozen doctors and researchers described the situation. They said staff shortages are contributing to the crisis. Also, they said, administrators are setting aside more beds for patients undergoing lucrative procedures, contributing to bottlenecks.
Then there’s high demand for hospital services, fueled, in part, by the aging of the U.S. population, and backlogs in discharging patients because of growing problems securing home health and nursing home care, according to Arjun Venkatesh, chair of emergency medicine at the Yale School of Medicine.
The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys, or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications and experiencing complications, according to Dr. Saket Saxena, co-director of the geriatric emergency department at the Cleveland Clinic.
When these patients finally secure a hospital bed, their stays are longer and medical complications are more common. New research finds that the risk of dying in the hospital is significantly higher for older adults when they stay in ERs overnight, as is the risk of adverse events such as falls, infections, heart attacks, strokes and bedsores.
No one knows exactly how common ER boarding is and where it's most acute because hospitals aren’t required to report that data. The Centers for Medicare & Medicaid Services retired a boarding measure in 2021. New national measures of emergency care capacity have been proposed but not yet approved.
In the meantime, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more beds. Among them is Massachusetts General Hospital, which announced in January that ER boarding had risen 32% from October 2022 to September 2023.
Dr. Maura Kennedy, Mass General’s chief of geriatric emergency medicine, described an octogenarian woman with a respiratory infection who languished in the ER for more than 24 hours.
“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy said. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”
How to stay healthier when waiting
When asked what older adults could do about these problems, ER doctors pointed to the need for larger system and policy changes. Still, they had several suggestions.
“Have another person there with you to advocate,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions.
To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses,” said Dr. Michael Malone, medical director of senior services for Advocate Aurora Health in Wisconsin and Illinois. “Whenever possible, try to get up and move around.”
Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside when possible. “Try to make sure they eat, drink, get to the bathroom and take routine medications for underlying medical conditions,” Malone said.
Older adults or caregivers should try to bring “things that would engage you cognitively: magazines, books … music,” Kennedy said.
“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. Finally, “bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”