Readers Respond: ED Boarding Tactics and Excited Delirium

We read with interest Dr. Welch’s article on front-end processes amid excessive ED boarding. While the PIT model may improve certain metrics, our experience suggests it fragments care by creating handoffs and lack of ownership of the patient. This increases staffing needs without additional revenue, can cause increased length of stay, shifts left without being seen to left before treatment was complete, and exacerbates stress on staff which leads to worsening burnout and moral injury.

Although a front-end process is often necessary when ED boarding is high, we have implemented an alternative to PIT: a zoned care approach utilizing a robust vertical low/mid acuity process with a vertical care intake model for higher acuity patients—utilizing existing staffing without adopting the PIT model. In this model, high acuity patients awaiting care are temporarily placed in a dedicated intake area, where clinicians can evaluate them alongside nurses—facilitating more appropriate diagnostics and therapeutics. If patients can remain vertical, they return to the waiting room; if critical, they are prioritized to the back once a bed becomes available. Each clinician owns the patient, which leads to a more tailored approach to patient care and improves patient safety by reducing handoffs. This model has proven successful not only at Sentara Leigh Hospital, but across all of our clinical sites, both academic and community sites. While having sufficient nursing staff and treatment rooms is the ideal state, we have found that—in the reality of unprecedented patient volumes—our model is adaptable, scalable, and deployable in multiple environments.

—Doug Browder, MD, PhD, FACEP; and Bruce Lo, MD, MBA, RDMS, FACEP

(This article) is a good review of the conflicted history of that diagnosis. However, I was surprised at the statement by Dr. Jeff Goodloe that, “The 2021 (ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings) strives to highlight that ‘excited delirium with severe agitation’ is not a diagnosis in the living or the deceased.”

The report devotes a six-page section to excited delirium, aimed at providing a “brief discussion of the conclusions reached and limitations of the evidence surrounding (excited delirium syndrome) (ExDS) as a distinct pathophysiologic process” (emphasis mine). More concerning, the report suggests that better documentation (presumably by emergency physicians) will allow us to “fully explore ExDS as a distinct entity.” The section on excited delirium states that better documentation of clinical encounters “allows these deaths to be identified, tracked, and studied to better identify unique features of (excited delirium) and improve patient care. Without the ‘excited delirium’ component, these deaths are lost as routine acute drug intoxication deaths.”

It is clear that the 2021 report does not refute excited delirium as a diagnosis “in the living or the deceased.” Quite the opposite—it appears to be concerned with further legitimizing this almost universally discredited and harmful concept.

—Brooks Walsh, MD