Healthcare systems simply don’t have enough inpatient beds to provide care in the hospital (admission or observation status) for all the patient we would traditionally care for in the hospital. The results of this are problematic and dangerous from many angles, perhaps most acutely evident in the horrors, especially for vulnerable patients, of prolonged ED Boarding. How are hospitals, and emergency departments, coping with these profound challenges? What is the impact on patient care and outcomes? What are emergency medicine leaders doing to keep their patients safe and their departments operational? We have with us a panel of emergency department experts and health care system leaders from various around the country to provide a robust understanding of the issues and explore possible solutions.

1. Stephen Meldon, Emergency Physician and Co-Director of the Geriatric ED program at the Cleveland Clinic
2. Maura Kennedy, Chief, Division of Geriatric Emergency Medicine, Massachusetts General Hospital
3. Lynn McCullough, UCLA Medical Center, Saperstein Emergency Dept. Director
4. Tony Rosen, Weill Cornell Medical Center Program Director of Vulnerable Elder Protection Team
5. Erin Grossman, Regulatory and External Affairs Manager, American College of Emergency Physicians

Dr. Stephen Meldon

• Dr. Meldon discussed geriatric ED boarding strategies to address overcrowding and staffing shortages in emergency departments.
• He emphasized that ED boarding is a result of capacity issues on the inpatient side, including post-pandemic demand, staffing shortages, and financial pressures.
• Boarding is now at an all-time high and significantly impacts patient flow, care, satisfaction, and caregiver burnout and morale.
• Older adult patients are disproportionately impacted by boarding.
• He discussed several strategies including tracking boarding times, prioritizing high-risk geriatric patients for bed assignment, and having a long-standing boarding policy to transition responsibility for boarded patients to inpatient teams

Dr. Maura Kennedy

• Older adults are more likely to board and board for longer than younger patients
• Every day between 50 and 80 patients spend the first night of their hospitalization in the ED at Mass General, which is not an appropriate therapeutic environment
• Boarding increases risks of delirium, hospital-acquired disability, and higher mortality especially for vulnerable older adults
• Delirium is associated with longer lengths of stay, higher mortality, and longer recovery
• Prolonged immobility in the ED can lead to disability, longer hospital stays, and increased need for post-acute care
• Excess boarding causes moral injury, burnout, and staff attrition for hospitals

Dr. Lynn McCullough

• Lynn presented a case for cohorting geriatric patients in emergency departments to optimize their care
• At UCLA Medical Center, 25% of patients are over 65 and they admit 50% of all patients seen
• Their ED has 41 licensed beds but regularly exceeds capacity with 40-80 patients boarding daily
• Geriatric patients were boarded throughout the ED with limited specialized nursing care
• Patients would spend upwards of 50 hours in the ED, far exceeding recommended limits
• Her team created a 10-bed geriatric ED unit to cohort patients over 75 to improve conditions and care processes. This has been continuously full since September
• The dedicated unit optimizes conditions for geriatric patients and aims to improve care processes like mobility, nutrition, and prevent deconditioning through specialized nurses and amenities

Dr. Anthony Rosen

• Dr. Rosen emphasized prioritizing older adults for inpatient beds and optimizing their care while boarding in the ED to minimize harm
• Strategies included starting with understanding patients’ priorities, managing medications, moving patients regularly, and maintaining mental/social engagement
• Tracking boarding times is important for geriatric ED accreditation, with thresholds to prioritize reducing boarding for high-risk older adults

Erin Grossman

• Erin discussed governmental and regulatory efforts to address boarding crisis in emergency departments, including legislation focused on psychiatric boarding and increasing access to follow-up care
• CMS has discontinued boarding-related measures and attempted to remove a proxy measure, which has been a cause of frustration for ACEP and other organizations
• A new measure called Age-Friendly Hospital incorporates geriatric standards and includes an attestation on reducing ED boarding times for older adults
• ACEP held a summit identifying main causes of boarding like transparency, regulations, mental health issues, financial incentives, and workforce shortages
• ACEP is advocating for policies like a national bed tracking system and improved customer management to address boarding

The Healthcare Systems Roundtable (HSR) is an intimate, curated conversation that sparks action. Our GEDC Healthcare Systems connect quarterly for a think session with multiple chosen speakers and a variety of perspectives on critical topics in improving the care of older adults across healthcare systems. Its format features concise presentations and panel discussions followed by a collective Q&A and further discussions. Our focus is to foster engaging conversations. The true measure of our success is participants departing with enhanced knowledge, clear purpose, and actionable ideas to drive positive change in healthcare.

The HSR aligns West Health Institute, GEDC and GEDA resources to support Healthcare Systems in adopting and implementing GEDs at a systems-wide level.

There are currently 13 participating systems including Mayo Clinic, Kaiser Permanente, Cleveland Clinic, Advocate Aurora Health, Northwell, Dartmouth-Hitchcock, Yale Newhaven Health Network, The University Health Network, Sarasota Memorial, and Veterans Affairs.

To never miss a discussion and to become a part of the Roundtable, you must be a GEDC member. Learn more about membership