Judith Graham
Every day, the scene performs out in hospitals throughout America: Older women and men lie on gurneys in emergency room corridors moaning or struggling silently as harried medical workers attend to crises.
Even when physicians decide these sufferers have to be admitted to the hospital, they usually look ahead to hours — typically greater than a day — within the ER in ache and discomfort, not getting sufficient meals or water, not shifting round, not being helped to the toilet, and never getting the sort of care medical doctors deem needed.
“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,” mentioned Hashem Zikry, an emergency medication doctor at UCLA Health.
Physicians who workers emergency rooms say this downside, referred to as ER boarding, is as dangerous because it’s ever been — even worse than throughout the first years of the covid-19 pandemic, when hospitals full of desperately unwell sufferers.
While boarding can occur to all ER sufferers, adults 65 and older, who account for practically 20% of ER visits, are particularly weak throughout lengthy waits for care. Also, seniors might encounter boarding extra usually than different sufferers. The greatest estimates I may discover, revealed in 2019, earlier than the covid-19 pandemic, recommend that 10% of sufferers have been boarded in ERs earlier than receiving hospital care. About 30% to 50% of those sufferers have been older adults.
“It’s a public health crisis,” mentioned Aisha Terry, an affiliate professor of emergency medication 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.
What’s happening? I spoke to nearly a dozen medical doctors and researchers who described the chaotic scenario in ERs. They instructed me workers shortages in hospitals, which have an effect on the variety of beds obtainable, are contributing to the disaster. Also, they defined, hospital directors are setting apart extra beds for sufferers present process profitable surgical procedures and different procedures, contributing to bottlenecks in ERs and leaving extra sufferers in limbo.
Then, there’s excessive demand for hospital companies, fueled partially by the growing older of the U.S. inhabitants, and backlogs in discharging sufferers due to rising issues securing residence well being care and nursing residence care, in accordance with Arjun Venkatesh, chair of emergency medication on the Yale School of Medicine.
The affect of lengthy ER waits on seniors who’re frail, with a number of medical points, is particularly critical. Confined to stretchers, gurneys, and even arduous chairs, usually with out reliable help from nurses, they’re liable to dropping energy, forgoing important drugs, and experiencing issues comparable to delirium, in accordance with Saket Saxena, a co-director of the geriatric emergency division on the Cleveland Clinic.
When these sufferers lastly safe a hospital mattress, their stays are longer and medical issues extra frequent. And new research finds that the chance of dying within the hospital is considerably increased for older adults once they keep in ERs in a single day, as is the chance of antagonistic occasions comparable to falls, infections, bleeding, coronary heart assaults, strokes, and bedsores.
Ellen Danto-Nocton, a geriatrician in Milwaukee, was deeply involved when an 88-year-old relative with “strokelike symptoms” spent two days within the ER a couple of years in the past. Delirious, motionless, and unable to sleep as alarms exterior his mattress rang nonstop, the older man spiraled downward earlier than he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton mentioned.
Several weeks in the past, Zikry of UCLA Health helped look after a 70-year-old lady who’d fallen and damaged her hip whereas attending a basketball sport. “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 mentioned. ERs are designed to deal with crises and stabilize sufferers, to not “take care of patients who we’ve already decided need to be admitted to the hospital,” he mentioned.
How frequent is ER boarding and the place is it most acute? No one is aware of, as a result of hospitals aren’t required to report knowledge about boarding publicly. The Centers for Medicare & Medicaid Services retired a measure of boarding in 2021. New nationwide measures of emergency care capability have been proposed however not but accredited.
“It’s not just the extent of ED boarding that we need to understand. It’s the extent of acute hospital capacity in our communities,” mentioned Venkatesh of Yale, who helped draft the brand new measures.
In the meantime, some hospital programs are publicizing their plight by highlighting capability constraints and the necessity for extra hospital beds. Among them is Massachusetts General Hospital in Boston, which introduced in January that ER boarding had risen 32% from October 2022 to September 2023. At the tip of that interval, sufferers admitted to the hospital spent a median of 14 hours within the ER and 26% spent greater than 24 hours.
Maura Kennedy, Mass General’s chief of geriatric emergency medication, described an 80-something lady with a respiratory an infection who languished within the ER for greater than 24 hours after physicians determined she wanted inpatient hospital care.
“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 instructed me. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”
When I requested ER medical doctors what older adults may do about these issues, they mentioned boarding is a well being system situation that wants well being system and coverage adjustments. Still, they’d a number of options.
“Have another person there with you to advocate on your behalf,” mentioned Jesse Pines, chief of scientific innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medication apply. And have that individual communicate up in the event that they really feel you’re getting worse or if staffers are lacking issues.
Alexander Janke, a scientific teacher of emergency medication on the University of Michigan, advises folks, “Be prepared to wait when you come to an ER” and “bring a medication list and your medications, if you can.”
To keep oriented and cut back the potential for delirium, “make sure you have your hearing aids and eyeglasses with you,” mentioned Michael Malone, medical director of senior companies for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Whenever possible, try to get up and move around.”
Friends or household caregivers who accompany older adults to the ER ought to ask to be at their bedside, when doable, and “try to make sure they eat, drink, get to the bathroom, and take routine medications for underlying medical conditions,” Malone mentioned.
Older adults or caregivers who’re serving to them ought to attempt to carry “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 mentioned.
“Experienced patients often show up with eye masks and ear plugs” to assist them relaxation in ERs with nonstop stimulation, mentioned Zikry of UCLA. “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.”
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