15 General introduction and outline of the thesis CHAPTER 1 Impact of ageing on emergency departments and quality of care The growing population of older adults with a rising life expectancy challenges health services (17). Care must be reorganized to meet the specific needs of older adults (18). This applies especially to EDs, where the utilization of medical resources has increased most among older adults compared to other demographic groups (19). Older adults currently constitute an average of 24% of ED visitors in the Netherlands (20). Additional challenges that have accompanied the increase in the population of older adults presenting at the ED is the prolonged length of stay at the ED and crowding at the ED (21). Published data show that prolonged length of stay is not only a result but also a cause of ED crowding, yielding a vicious cycle: a greater number of patients present at the ED at the same time leads to longer stays at the ED, while longer stays at the ED also lead to increasing crowdedness at the ED (22). There is a growing understanding of the relationship between crowding, ED length of stay, and poor patient outcomes (23, 24, 25). Studies investigating the relationship between crowding and ED length of stay have shown that length of stay increases with increased crowding. One of these studies reported a 10% increase in ED length of stay for patients who presented at times when the ED was crowded (24). An increase in ED length of stay during crowded periods was observed for both medical and surgical complaints (25). The consequences of ED crowding on patient outcomes have been extensively studied. Studies have shown that crowding results in poorer outcomes (26-29), including increased mortality (30-33). One study showed that ED crowding was associated with increased inpatient mortality among critically ill patients (31). The effect of ED crowding was highest in patients suffering from trauma, followed by patients with infection. Another study raised important concerns about the quality of care during periods of ED crowding by illustrating that increased bed occupancy was associated with an increase in the rates of 30-day adverse outcomes (32). This remained true even after adjustment for patient and ED characteristics. In the previous study, a 10% increase in ED bed occupancy was associated with a 3% increase in mortality. Comparable results were found by a third study: compared to patients who were admitted on days without high ED crowding, patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (33). These studies indicate that it is necessary to alleviate ED crowding and to avoid prolonged ED length of stay to improve the quality of care for older adults at the ED.
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