Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Patients frequently board overnight in the emergency department (ED) while awaiting medical admission, sometimes in hallway care spaces. Prior literature suggests that timing of boarding may matter; a single overnight stay in the ED may be associated with increased mortality and adverse events, especially for older adults. Given the deliriogenic ED environment, these effects may be magnified in the hallway. However, little is known about the effects of prolonged hallway stays. We evaluated whether an overnight stay in the ED hallway, compared to an ED room, was associated with increased delirium and adverse outcomes for geriatric patients.

Methods: We conducted a retrospective multisite cohort database study of patients aged 65 years and older admitted to a general medicine service January 1, 2022, to December 31, 2023, who spent an entire night (midnight to 8 am) in the ED prior to admission. We compared those who spent the entire night in the ED hallway with those who were in ED rooms. Our primary outcome was a composite outcome for incident delirium and severe agitation (defined by the International Classification of Diseases, 10th Rev, code for delirium, positive nursing screen, use of parenteral antipsychotics, and/or physical restraints, since delirium was not routinely screened for at these sites). Secondary outcomes included hospital length of stay (LOS), inpatient and 30-day mortality, and 30-day ED revisit and readmission. We implemented mixed-effect regression models and adjusted for confounders.

Results: A total of 8,576 patients met inclusion criteria, including 1,231 patients (14%) in the hallway group. Overall, 847 patients (9.9%) developed incident delirium and severe agitation: 160 (13%) of the hallway group and 687 (9%) of the non-hallway group. An overnight stay in the ED hallway was not associated with delirium and severe agitation (OR, 1.06, 95% CI, 0.58–1.94; P = .84), but increased ED LOS was independently associated with delirium and severe agitation (OR, 1.01; 95% CI, 1.0–1.01 per hour; P = .01). There was no association between an overnight stay in the hallway and secondary outcomes except increased hospital LOS (OR 1.01, 95% CI, 1.00–1.01 per hour; P = .01).

Conclusion: An overnight in the ED hallway care space was not associated with increased delirium and severe agitation for geriatric patients, but prolonged ED LOS was associated with this outcome. Hospital systems should consider prioritizing geriatric patients for expedited transfer from the ED to inpatient units, and prospective research with consistent delirium screening is needed to rigorously evaluate the safety of hallway care for older adults.