High Boarding Rates of Older Adults in the Emergency Department: An On-going Threat to Quality and Safety

Volume 5 | Issue 2 | Article 4 - Collective Wisdom: Editorial

Stacie Levine, MD, FAAHPM, CMD
Full Text

Abstract

Introduction:

Boarding in the emergency department (ED), defined by the American College of Emergency Physicians as “a patient who remains in the emergency department after the patient has been admitted or placed into observation status at the facility but has not been transferred to an inpatient or observation unit,” was first described as a significant barrier to effective patient care in the 1980s.1 Forty years later, it remains a considerable troubling indicator of inefficiencies and dysfunction within health care systems across the United States. Boarding is especially challenging for older adults who have baseline vulnerabilities due to physiologic changes with aging, hearing loss, multimorbidity, frailty, and polypharmacy.2 Without access to a quiet private room and space for their caregiver, they are often left unsupervised, leading to communication errors, falls, and delay in treatment of their medical conditions.3 Boarding also delays essential services such as physical therapy which are known to reduce the risk of early functional decline.4 The bright lights and sounds of an ED during prolonged hallway waiting creates additional psychological stressors, increases anxiety, and reduces patient satisfaction.5 Delirium may result, which is associated with prolonged hospitalizations and poorer
health outcomes.6 Despite boarding being a significant risk factor for clinical decline and mortality,7 there has been little success in finding lasting solutions to this serious problem. Questions remain as to who is at greatest risk for ED boarding and what factors lead to higher rates for some populations versus others. Understanding factors leading to increased wait time in the ED will help health system stakeholders identify ways to mitigate risk for poor outcomes in this vulnerable population.

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