Enhancing Emergency Department Patient Care

Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023 Date: December 18, 2023 Guest Skeptic: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic. Case: An 85-year-old patient (Ms. McG) presents to your emergency department (ED) after being found by family on the ground at her independent living facility. Her family was concerned because she has had multiple recent falls, and she wasn’t answering the telephone that morning.  They found her in a pool of blood with a scalp laceration and complaining of left hip pain. Although she had exhibited occasional disorientation and gradually diminishing physical activity over the last 5-years, she was still functionally independent.  While your ED evaluation, computed tomography (CT) imaging of her head and spine demonstrated no traumatic injury and an x-ray of her pelvis showed no fracture or dislocation, she was unable to bear weight due to her hip pain, so you ordered a CT to further evaluate for occult fracture. Advanced imaging was unavailable until morning by the time that test was ordered.  Suspecting an occult fracture, you consult Orthopedic surgery for admission, but they wanted to wait for the CT the next day.  You then consult Internal Medicine/Hospitalist who also want to wait for CT imaging in case the admission is more appropriate on the Orthopedic surgery service.  After all these consultant calls it is now after midnight and you are concerned that the patient will be in the ED all night and what the consequences of a preventable episode of overnight ED boarding might have on the patient and the rest of the department since the waiting room still has 20 patients awaiting evaluation. Background: Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [1]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [2-4]. Older adults who are admitted to the hospital after a fall will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year. Because it is such a serious topic, we have covered it several times on the SGEM: SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the Emergency Department SGEM#351: How to Stop Geriatrics from Free Fallin’ GEMCast: How to Help Prevent the Next Fall in Your Older Patients Geriatric ED Collaborative Falls Resources: Falls and Mobility EDs are becoming more and more crowded. The Canadian Association of Emergency Physicians (CAEP) flagged this issue 10 years ago in 2013. They published a position statement with several suggested solutions. Unfortunately, things have only gotten worse, and it does not seem to be an isolated problem in Canada. The American College of Emergency Physicians (ACEP) held a summit of stakeholders across health care in September of 2023. They got together a wide range of leaders in various organizations to discuss potential solutions to what is called “boarding” of patients. Perhaps we should define the term boarding as we are using it in the context of emergency medicine. It is when patients have been assessed and deemed to need admission to hospital. However, there are no beds available in the hospital and the patient remains in the ED. They can end up waiting for hours, days or even have their entire in-patient hospital care delivered in the ED. The Joint Commission is an organization in the US that sets standards to improve safety in healthcare. They have identified the boarding of patients in the ED as a significant safety risk. In 2012, they said patients should not remain in the ED after the decision to admit to hospital of more than four hours [5]. It has been reported that waiting longer than four hours can result in downstream harms which include but are likely not limited to increased medic...