Long Waits in ER Dangerous for Patients

Dr. Ackroyd-Stolarz found that older people who stayed longer in the emergency department were more likely to have adverse events. In her retrospective cohort study, she included 982 patients 65 and older. The average age was 77.8 years, and 75 percent of them experienced a prolonged ED stay of six hours or more. Studying the records, she found that 140 had adverse events. Adjusting for total ED stay, she found that long stays in the emergency department were associated with a higher risk of adverse events. Those who suffered an adverse event stayed in the hospital twice as long as those who did not (20.2 days versus 9.8 days). Because the patients stayed in the hospital longer, they occupied acute care beds, an increasingly scarce commodity that exacerbated ED crowding.

Even when there are readily available beds, elderly people tend to stay longer in the emergency department because they come in with more complex illnesses and require a longer workup. But by far, the lack of inpatient beds is the most significant contributor as to why they are waiting, Dr. Ackroyd-Stolarz said. There is evidence that the elderly are more likely to be admitted to the hospital. They don't want to go to the emergency department unless they are really sick because they know they will wait, she said.

The higher risk for these patients often comes from a decreased physiologic reserve. They are often sicker with comorbid conditions, she said. In the future, we need to demonstrate that this association holds true in other hospitals.

Fixing the problem requires a system approach, said Dr. Ackroyd-Stolarz, not just focusing on the emergency department. People outside of emergency medicine will say, 'If we just fix how they do their business,' but it goes beyond the doors of the emergency department, she said, noting that hospitals need to investigate bed management and what occurs in the community, such as whether services are available to help avoid ED visits. If we provide more primary care services to nursing home residents, we may prevent that transfer to an emergency department in the middle of the night because there is no physician in the nursing home, she said.

Emergency Medicine News
July, 2009