no room at the inn

Tuesday, February 8, 2011

Not all Super Bowl stories come from events on the field; even fans can make news. This year it had to do with hundreds who had a ticket to the game but couldn’t get in because at kickoff the seats were still being built and were deemed unsafe. The NFL saw the error of their ways and gave those fans the opportunity to come back next year. It’s not an uncommon practice since airlines overbook seats routinely and hope people don’t show up to claim their seats. While customers tolerate this behavior in from the business community, surprisingly patients are treated the same way in the medical world. Hospitals have only so many beds and when they run out even are in need can be made to wait.

Hospitals have two streams of patients. Those who are elective arrive to have scheduled stuff done. Operating rooms get scheduled for all sorts of procedures, from those that take a few hours like an older patient undergoing screening colonoscopy and an infant getting tubes in their ears, to those whose recovery from surgery may require days. Then there are the urgencies and emergencies. Nobody plans to have a heart attack, get their appendix removed or have their diabetes get out of control, but these patients need a place to go that will take care of them. Sometimes a bed is available immediately and sometimes that bed may not be there. Waiting has become a fact of medical life in the US and boarding patients in a hallway is an all too common occurrence. The location does make a difference for the patient’s care, comfort and safety.

One of the worries about providing health insurance to more people is that there services promised may not be there. It is no different than selling more tickets than you have space on the plane or in the stadium. When full, hospitals have few options. The first is to triage a patient out of a bed that they already occupy, presumably because they need it. The second is to go on diversion and turn away ambulances. If no beds are available in the inn, emergency patients can’t be moved out of the ER and the waiting room starts to fill, perhaps with the patient with indigestion who is really having a heart attack or the child with a fever who has meningitis. Sometimes the problem is not the lack of beds but instead the lack of doctors, nurses, technicians, cleaning staff and all those people who work silently in the background to care for the patient. Without the people providing the care, all the beds in the world won’t make a difference.

The issue has to do with the supply of available medical care and the demand for that care by people who are ill. Tweaking the system and getting rid of the inefficiencies is a given in today’s medical environment but cutting waste can get you only so far. Sometimes the need is for more buildings and more people to work in them. There are few ways to balance the equation. Either people get healthier and need less care or the services that they need are taken away.

The story in the United States may not be that of unaffordable insurance. North of the border, where Canadians have universal health care insurance, not having a bed is routine. Not only do patients get boarded in the ER, elective surgeries are routinely canceled but the operating rooms are full and there are no places to put the patient once the surgery is done. Stephen Duckett, the former head of Alberta Health Service, discussed the crisis in the province’s health care saying that only 25% of patients admitted could get a hospital bed within 8 hours. This was a decline from 60% a decade ago. Waiting for a bed is such a big deal in the US, that states have issued guidelines to look after patients in ER hallways. http://www.vdh.virginia.gov/news/PressReleases/PDFs/2010/09012010BoardingGuidance.pdf

As the population ages and as medical care gets more sophisticated and time consuming, the wait times will likely increase. Most times, people are just inconvenienced because of the delay but eventually, those delays turn catastrophic as the window of opportunity to offer treatment closes. Curative care may turn into palliative or comfort care for the lack of a bed, a nurse or a therapist. There will be another Super Bowl and another plane will take off in a few hours or a day, but will there be a place for your medical needs tomorrow? If sleeping in an airport is an inconvenience, how do you rate dying in a waiting room?

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