47 Interventions to relieve ED crowding by older adults CHAPTER 3 Introduction Background Crowding is a constant and persistent phenomenon for the majority of emergency departments (EDs) around the world [1, 2]. ED crowding can be defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time [3,4]. This phenomenon often occurs when EDs need to handle with a greater number of patients than they are ideally designed for [3]. Consequently, ED crowding is associated with increased adverse clinical outcomes [5-10], care delays [6, 11-13], patient dissatisfaction with emergency care [13], higher left without being seen rate [6, 14] and an increased chance of avoidable and costly hospital admissions [9, 15]. Findings of a systematic reviewof 102 studies byMorley et al. show that older people at the ED have a significant negative impact on ED crowding [16]. Older people are often attending the ED with atypical and psychosocial problems that can complicate the provision of appropriate and timely ED care [17]. Despite the clear need to reduce ED crowding by older adults, a comprehensive evaluation of the effectiveness of interventions targeting this problem is lacking. Several reviews have studied the nature and effectiveness of interventions for older patients in need of emergency care [18,19,20]. However, McCusker and Verdon evaluated a specific type of intervention (i.e., comprehensive geriatric assessment; CGA) on a single effect measure (i.e., ED visits) [18]. Fan et al. reviewed the effectiveness of interventions targeting the older adult population in reducing ED utilization [19]. Effects of interventions on other relevant ED crowding indicators (e.g., waiting time, ED boarding time) therefore remain unknown. The review by Aminzadeh and Dalziel was conducted more than a decade ago, included studies with weak designs and did not specifically evaluate the intervention’s impact on ED crowding [20]. Better insight into interventions that reduce crowding by older adults in the ED is needed to assist managers and healthcare providers in emergency medicine worldwide with deliberately selecting and implementing strategies based on available evidence. Therefore, our aim is to systematically review the effectiveness of interventions targeting the older adults in reducing ED crowding, and identify core characteristics shared by successful intervention models.
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