Navigating Hospital Crowding and Engaging Contest Questions

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 medical errors, compromises to patient privacy, and increased mortality [6]. Kelen et al said boarding is like a canary in a coal mine for the healthcare system and is more likely to happen when hospital occupancy rates exceed 85% to 90% [7]. That comment about the canary reminds me of a tweet by one of my mentors, Dr. Alan Drummond. He has been warning about this problem of overcrowding for years and emphasizes that it is a system problem not just a problem in the ED. Al Drummond posted some sad news on the site formerly known as Twitter saying that "The F-ing canary was dead." There was a study published in the EMJ last year talking about an increased mortality associated with longer wait times in the Nasional Health Service in the UK [8]. They observed an increase in all-cause mortality in the next month for patients who waited more than 5 hours to be admitted. This was not a unique observation and other researchers have published similar findings including our friends Jesse Pines and Peter Viccellio [9-10]. Clinical Question: What is the association between older adults who are boarded in the ED overnight and in-hospital mortality? Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023 Population: Patients 75 years or older from 97 EDs across France who were admitted to the hospital after the emergency medicine evaluation. Excluded: Patients discharged home from the ED (including transfer to a long-term care facility or nursing home), admitted to Intensive Care Unit (ICU), or admitted to a ward between midnight and 8:00 AM. Intervention: ED group spent night in ED on a trolley awaiting ward bed (between midnight and 8AM). Comparison: Ward group admitted to an inpatient ward before midnight. Outcome: Primary Outcome: In-hospital mortality truncated at 30 days. Secondary Outcomes: In-hospital length-of-stay (LOS) and in-patient adverse events (fall, nosocomial infection, bleeding, myocardial infarction, stroke, venous thromboembolism, pressure ulcer, dysnatremia). Type of Study: Retrospective cohort adherent to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards of the EQUATOR Network. Authors’ Conclusions: “For older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy.  Older adults should be prioritized for admission to a ward.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes/Unsure Have the authors identified all-important confounding factors? The authors adjusted for age, sex, high-level of co-morbidity (Charlson Co-morbidity Index >6), high-level of dependency, blood pressure, oxygenation, and trauma-related ED visit. Other factors that could possibly be associated with increased in-hospital mortality could be related to patient-level or hospital-level issues. Patient-level factors could include frailty, cognitive dysfunction, end-of-life scenarios, and what matters most to the patient.  Hospital-level issues could include individual unit crowding delaying access to time-dependent interventions (endoscopy, operating room, catheterization lab, etc.). Was the follow up of subjects complete enough? Yes How precise are the results? The median ED LOS was 23 hours (IQR 18-28) in the ED group and 7 hours 35 minutes (IQR 5.5-10 hours) in the ward group. A substantial number (11%) stayed in the ED for two nights!  In-hospital mortality was higher in the ED group than the ward group (15.7% vs. 11.1%, aRR 1.39 with 95% CI 1.07-1.81).  The risk of adverse events was also higher in the ED group (15.8% vs. 10.8%, aRR 1.24, 95% CI 1.04-1.49), particularly for nosocomial infection and falls.  The median hospital length-of-stay was 9 days in the ED group and 8 days in the ward group. Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study. No direct funding of this research is reported. The Paris Public Hospital Association sponsored the work but did not fund it. Two authors report work with multiple biomedical device and pharmaceutical companies, but the personal fees associated with that corporate work were “outside the submitted work”. Results: The cohort consisted of 1,598 patients with a median [IQR] age of 86 [80-90] years. Female patients comprised 55% of the total sample size. ; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED. Top five reasons for the ED visit were Respiratory (35%), Asthenia (34%), infection (27%), falls (25%) and cardiovascular (16%). Key Result: Among admitted adults older than age 75, overnight stays in the emergency department are associated with significantly increased in-hospital mortality and adverse events over the subsequent 30-days. Primary Outcome: Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). Secondary Outcomes: Older patients who spent the night also had several worse secondary outcomes: Risk of adverse events was also higher in the ED group (15.8% vs. 10.8%, aRR 1.24, 95% CI 1.04-1.49), particularly for nosocomial infection and falls. The median ED LOS was 23 hours (IQR 18-28) in the ED group and 7 hours 35 minutes (IQR 5.5-10 hours) in the ward group. A substantial number (11%) stayed in the ED for two nights! Increased median hospital LOS (9 vs 8 days; rate ratio, 1.