Introduction to ER Boarding
At her mother’s home in Illinois, Tracy Balhan flips through photos of her dad, Bill Speer. In one picture, he’s smiling in front of a bucket of sweating beers and wearing a blue T-shirt that reads, “Pops. The man. The myth. The legend.” Balhan’s father died last year after struggling with dementia. During one episode late in his life, he became so agitated that he tried to exit a moving car. Balhan recalls her dad — larger than life, steady and loving — yelling at the top of his lungs.
The Experience of ER Boarding
His geriatric psychiatrist recommended she take him to the emergency room at Endeavor Health’s Edward Hospital in the Chicago suburb of Naperville because of its connection to an inpatient behavioral care unit. She hoped it would help get him a quick referral. But Speer spent 12 hours in the emergency room — at one point restrained by staff — waiting for a psych evaluation. Balhan didn’t know it then, but her dad’s experience at the hospital is so common it has a name: ER boarding. One in six visits to the emergency department in 2022 that resulted in hospital admission had a wait of four or more hours, according to an Associated Press and Side Effects Public Media data analysis. Fifty percent of the patients who were boarded for any length of time were 65 and older, the analysis showed.
Causes of ER Boarding
ER boarding is a symptom of the U.S. health care system’s struggles, including shrinking points of entry for patients seeking care outside of ERs and hospitals prioritizing beds for procedures insurance companies often pay more for. Experts also warn the boarding issue will worsen as the number of people 65 and older in the U.S. with dementia grows in the coming decades. Hospital bed capacity in the U.S. may not keep up. Between 2003 and 2023, the number of staffed hospital beds was static, even as emergency department visits shot up 30% to 40% over that same period.
Number of Hospital Beds at Issue
For older people with dementia, boarding can be especially dangerous, Chicago-based geriatric psychiatrist Dr. Shafi Siddiqui said. One research letter published in June 2024 in the Journal of the American Medical Association looked at more than 200,000 patients and found long ER stays could be linked to a higher risk of dementia patients developing delirium — a temporary state of mental confusion and sometimes hallucinations. “People need to be enraged about (boarding),” said Dr. Vicki Norton, president-elect of the American Academy of Emergency Medicine.
Where Can People Go?
Though long stays in the emergency department are common, there isn’t good data that tracks the extremes, emergency medicine experts said. The Centers for Medicare and Medicaid Services recently ended a requirement that hospitals track the “median” wait times in their emergency departments. An advisory group that develops quality measures for CMS recommended that the agency try to more accurately capture long emergency department stays. That measure has recently been submitted to CMS, which can choose to adopt it. Patients’ families worry that long emergency room stays may make things worse for their loved ones, forcing some to search for limited alternatives to turn for support and care.
Impact on Patients and Families
Nancy Fregeau lives in Kankakee, Illinois, with her husband Michael Reeman, who has dementia. Last year, he visited the Riverside Medical Center emergency department several times, often staying more than four hours and in one case more than 10, before finally getting access to a behavioral care bed. Riverside declined to comment on Reeman’s case. During long waits, Fregeau doesn’t know what reassurance she can offer her husband. “It’s hard enough for anyone to be in the ER but I cannot imagine someone with dementia being in there,” she said. “He just kept saying ‘When am I going? What’s happening?’”
Systemic Issues
In Illinois, there are fewer adult day centers than there are counties, and other resources for people with dementia are shrinking, too. A report from the American Health Care Association and the National Center for Assisted Living found that 1,000 nursing homes in the U.S. closed between 2015 and 2022. At least 15 behavioral health centers, which are facilities that specialize in treating mental health issues, closed in 2023. With fewer places for patients to go after being discharged, hospital beds are being used for longer, exacerbating the boarding problem. It’s becoming more difficult to get a specialty hospital bed, especially when patients’ dementia causes aggression.
Conclusion
The issue of ER boarding is complex and multifaceted, involving systemic issues within the healthcare system, including prioritization of beds for more lucrative procedures and a lack of adequate resources for patients with dementia. As the population ages and the prevalence of dementia increases, it is crucial that policymakers and healthcare providers work together to find solutions to this growing problem. The dignity and well-being of patients like Bill Speer and Michael Reeman depend on it.
FAQs
- Q: What is ER boarding?
A: ER boarding refers to the practice of keeping patients in the emergency department for extended periods while they wait for a hospital bed or further treatment. - Q: Why is ER boarding a problem?
A: ER boarding can lead to worse patient outcomes, especially for older adults with dementia, and is a symptom of systemic issues within the healthcare system. - Q: What are the main causes of ER boarding?
A: The main causes include a shortage of hospital beds, prioritization of beds for more lucrative procedures, and a lack of adequate resources for patients with dementia. - Q: How can ER boarding be addressed?
A: Addressing ER boarding requires a systemic approach, including increasing hospital bed capacity, improving resource allocation, and developing more effective strategies for managing patients with dementia.
