Rosa McNamara, Ireland
Worldwide crowding in EDs has been highlighted as a threat to the core mission of EM as highlighted by IFEM's Access Block Taskforce. The problem is a familiar one that has become far more acute in the last year in many countries.
Delivering care on corridors is difficult and dangerous – it is impossible to interview patients with any privacy, conduct proper physical examination, obtain timely diagnostics, or to provide personal care with dignity. This is worse for those with cognitive impairment, mobility impairment or communication problems who struggle to communicate their needs and/or to get assistance from overstretched staff for the most basic elements of care such as eating, drinking or toileting. Constipation and new incontinence are not uncommon sequalae of prolonged ED stays.
The ED itself is busy, noisy, and brightly lit 24/7, is delirium inducing as those with cognitive impairment become increasingly disorientated and sleep deprived while boarded awaiting beds or waiting to be seen. This means that patients who may not have needed admission or for whom a brief admission was suitable now end up admitted needing more assessment and a revised safe discharge plan. For those who are discharged with delirium – it is far more likely that they will have a ‘failed discharge’ and require unscheduled admission. It is also more likely that they will suffer functional loss and loss of independence.
There is an immediate need to plan for how older people access unscheduled care in systems where crowding has become common. Health systems with unscheduled care designed for single acute episode care management are simply no longer fit for purpose. Urgent consideration needs to be given to the ED environment, staff skill set and levels of staffing with the needs of older people in mind. Additionally, pathways to urgent care need to be simplified so that people who do not need the services of the ED are not funneled there by systems that have few other alternative access points for unscheduled care.
The effect of crowding on care for all using the ED is overwhelmingly negative but for older people, particularly those living with frailty or dementia it is most profound and the need for solutions more urgent.