Emergency department managers warned of 'catastrophic' crowding due to elderly

Study says total number of visits could double in 10-year period

The number of patients between the ages of 65 and 74 who visit the nation's EDs annually is likely to double from 6.4 million in 2003 to 11.7 million by 2013, according to a new study published in the Annals of Emergency Medicine.1 This growth, the authors warn, could lead to catastrophic overcrowding.

While the actual numbers may come as a surprise to ED managers and other emergency medicine experts, the trend does not. "There is definitely an increase in ED visits, and the fastest segment is the elderly population," says David Seaberg, MD, FACEP, dean and professor of emergency medicine at the University of Tennessee College of Medicine and an ED physician at Erlanger Hospital, both in Chattanooga. "As the population lives longer, people develop more problems and need more care, and the fact is that Medicare patients have a difficult time getting in to see primary doctors, who do not want to take new Medicare patients into their practices."

For several years, the complexity of Medicare-aged patients coming into EDs, and the varieties of complaints, has been increasing, says Susan M. Nedza, MD, MBA, FACEP, chief medical officer of Region V for the Centers for Medicare & Medicaid Services in Chicago. "The ACEP [American College of Emergency Medicine] geriatric section has recognized this for years and projected this wave would be coming."

This increase should be an alarm bell, says Mary Pat McKay, MD, MPH, one of the article's authors and director of the Center for Injury Prevention and Control at The George Washington University Medical Center in Washington, DC. "It's an opportunity in 2008 to do something prospectively — or else wait until the pandemic flu in 2013 when all these old folks come to the EDs and we have no surge capacity," McKay says. Such an event, she warns, "could be worse than the pandemic flu in 1918."

Addressing capacity issue

While recognizing that overcrowding is a complex issue, McKay says a large part of the solution lies in disposition: getting patients — especially admitted ones — out of the ED.

"The average stay of this population is longer, and the percentage of the elderly we admit is about to grow exponentially," she observes.

What is the answer? "Just moving people to floors upstairs is not it," says McKay. "We need to understand how many ED beds we need in the hospital community, because we are not going to prevent them from coming to the ED." Short of that, she says, managers need to start planning now for different ways to move them out of the ED. "The 'newest' way may be the oldest: build more beds and staff them," McKay says.

That approach may not be best, however, counters Kenneth Iserson, MD, MBA, an ED physician at the University of Arizona Medical Center and professor of emergency medicine at the University of Arizona School of Medicine, both in Tucson. Instead, Iserson suggests, ED managers should look for more alternative sites for such patients, or they should look for easier access to other facilities once they have been evaluated in the ED. "Part of the answer is to get more social workers and case managers to help out," he says. Then, change the laws — "for example, those that say elderly patients have to be admitted a certain length of time before you can put them in a nursing home," Iserson says. "This ties up beds unnecessarily."

Develop some outpatient links to home health agencies, visiting nurse organizations, care centers, nursing homes, and assisted living facilities, says Robert Fitzgerald, MD, FACEP, an attending physician in the ED at Boswell Hospital in Sun City, AZ. Boswell also lectures at Harvard University in Cambridge, MA, on designing the ED for the elderly patient. "We will also have to get better at asking whether the patient truly needs an inpatient bed, or if there is a better or safer location for them," Fitzgerald says.

Improving, speeding treatment

At the same time ED managers are looking for additional facilities outside of their hospital, they must work on limiting the amount of time elderly patients stay in their department, say McKay and other observers.

"The key is decreasing the time from when I decide the patient needs to be admitted to when they go upstairs," she says. "When they stay 12, 24, or 36 hours, that's a huge problem."

In one hospital where McKay worked, the amount of time such patients could stay in the ED was negotiated, and there was a limit of four hours put on how long the patient could stay in the ED before being moved upstairs. Once you were past that deadline, the facility fee for the DRG was attributed back into the ED, she explains. "That may be a way to emphasize the importance of this issue."

When you speak to hospital administrators, McKay adds, money talks. "When you say the ED group is losing money because you are not moving patients upstairs and that you [the administrators] need to be paying for that, it provides an incentive to get the patient out of the ED," she asserts.

Making sure your staff understand what to look for in elderly patients also can decrease the time they spend in your department, adds Fitzgerald. "Make sure everyone has the clinical knowledge to appreciate what is going on," he advises. Elderly patients in general will show up with atypical presentations of common complaints, Fitzgerald says. "For example, with acute coronary syndrome, instead of the proverbial elephant standing on their chest, they could be experiencing nausea or delirium," he suggests. "Or, they may have same common disease and not come in with the typical story you hear."

Speeding the diagnosis and eliminating certain possibilities immediately is especially important with elderly patients, Fitzgerald continues. "Geriatric patients demand what most EDs can't give you, which is time," he says. "It may take five minutes just to undress them or perhaps they have dementia or they can't hear you."

An ED nurse or physician simply doesn't have hours to spend taking a history, Fitzgerald says. "In sexual assault cases, for example, we have special nurses — a crisis team — to do that," notes Fitzgerald, suggesting a possible solution with elderly patients. "We will have to modify our personnel in the EDs, and that may well require more than what the typical ED provides," he says. "If you can't figure that out and you have to keep them in the department longer, it will literally break the bank."

Finances, more than anything else "will push us to change dramatically the way we take care of this patient group," Fitzgerald says.

Nedza agrees. ED managers need to look at their capacity for providing the kind of services these patients require, she says. "They may have higher levels of acuity, longer stays in the ED, more testing, and need more resources for evaluation," Nedza says. These demands have staffing ramifications as well as risk ramifications, she says. "Leaving a 70-year-old in the waiting room is different than leaving a 40-year-old there," Nedza says.

Reference

  1. Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med 2007; Dec 5 [Epub ahead of print]. Web: www.biomedcentral.com/1471-227X/7/1.

Sources

For more information on treating elderly patients in the ED, contact:

  • Robert Fitzgerald, MD, FACEP, Attending Physician, Emergency Department, Boswell Hospital, Sun City, AZ. E-mail: rtfitz@cox.net.
  • Kenneth Iserson, MD, MBA, University of Arizona Medical Center, Tucson, AZ. E-mail: KVI@u.arizona.edu.
  • Mary Pat McKay, MD, MPH, Director, Center for Injury Prevention and Control, The George Washington University Medical Center, Washington, DC. Phone: (202) 741-2947.
  • Susan M. Nedza, MD, MBA, FACEP, Chief Medical Officer, Region V, Centers for Medicare & Medicaid Services, Chicago. Phone: (312) 886-5341. E-mail: SNedza@cms.hhs.gov.
  • David Seaberg, MD, FACEP, Dean, Professor of Emergency Medicine, University of Tennessee College of Medicine, Chattanooga. Phone: (423) 778-6956.