Older patients sometimes suffer in ER purgatory
(Pictured: At emergency rooms, patients who are 65 or older account for nearly 20 percent of the visits.)
By Judith Graham
KFF
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 for hours — sometimes more than a day — in the ER in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom, and not getting the kind of care doctors deem necessary.
“You walk through ER hallways, and they’re 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 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, when hospitals filled with desperately ill patients.
While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20 percent of ER visits, are especially vulnerable during long waits for care. Seniors may encounter boarding more often than other patients. The best estimates, published in 2019, before the pandemic, suggest that 10 percent of patients were boarded in ERs before receiving hospital care. As much as half 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 School of Medicine and Health Sciences and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.
Almost a dozen doctors and researchers told me staff shortages in hospitals, which affect the number of beds available, are contributing to the crisis. They explained hospital administrators are setting aside more beds for patients undergoing lucrative surgeries and other procedures, contributing to bottlenecks in ERs and leaving more patients in limbo.
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 healthcare 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 such as delirium, according to Saket Saxena, a 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 more common. And 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, bleeding, heart attacks, strokes, and bedsores.
Ellen Danto-Nocton, a geriatrician in Milwaukee, Wis., was deeply concerned when an 88-year-old relative with “strokelike symptoms” spent two days in the ER a few years ago. Delirious, immobile, and unable to sleep as alarms outside his bed rang non-stop, the older man spiraled downward before he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.
Zikry, of UCLA Health, helped care for a 70-year-old woman fell and broke her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain that was very difficult to treat adequately,” he said. ERs are designed to handle crises and stabilize patients, not “take care of patients who we’ve already decided need to be admitted to the hospital,” he said.
How common is ER boarding and where is it most acute? No one knows, because hospitals aren’t required to report data about boarding publicly. The Centers for Medicare and Medicaid Services, a federal agency that administers Medicare, retired a measure of boarding in 2021. New national measures of emergency-care capacity have been proposed but not approved.
When I asked ER doctors what older adults could do about these problems, they had several suggestions.
“Have another person there 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 have that person speak up if they feel you’re getting worse or if staffers are missing problems.
Alexander Janke, a clinical instructor of emergency medicine at the University of Michigan, advises being “prepared to wait when you come to an ER” and “bring a medication list and your medications, if you can.”
To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses with you,” said Michael Malone, medical director of senior services for Advocate Aurora Health, a 20-hospital system 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, and “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 who are helping them should bring “things that would engage you cognitively: Magazines, books … music, anything that you might focus on in a hallway where there isn’t a TV to entertain you,” Kennedy said.
“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry. “Also, 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.”
Source: KFF Health News, an independent producer of health-related journalism.
