23 and living with HIV - One Woman's story
When is the Worst Time to Go to the Hospital? By Pauline W. Chen M.D.
It wasn’t even noon yet, and the emergency room already had gurneys crammed into every available space. Supply carts, usually full of gauze, syringes, basins and bedpans, looked as if they had been hastily looted, and the din typical of the department was louder than usual, punctuated by shrieks from inebriated patients or cries for help from elderly ones. While some patients were lucky enough to have secured a modicum of privacy behind the curtains of makeshift rooms, most waited in the hallways for their beds to come open up upstairs.
Scanning the scene, I couldn’t help but believe that when a hospital was bursting at the seams and about to receive multiple, severely injured trauma patients, it had to be the worst possible time to be a patient there. But I also had to ask myself why we couldn’t have done anything to prevent this predicament.
“The inn is full,” the nurse said, shrugging her shoulders. “And it’s not like we can just turn patients away.”
I remember agreeing with her that morning; people could not plan their illnesses or accidents. But in the years since, every time I’ve asked myself about the best time to be a patient in the hospital, I’ve also wondered if some cut-off point existed for hospitals. Was there a known threshold of occupancy, staffing or whatever, above which patient safety was compromised?
There is. Or rather, there are.
Analyzing the records of almost 40 hospitals and nearly 175,000 patients, researchers at the University of Michigan in Ann Arbor found that four factors — high hospital occupancy, weekend admissions, nurse staffing levels and the seasonal flu — can affect a patient’s risk of dying in the hospital. But while these factors universally influence in-hospital mortality, they can also interact with one another in such a way that each hospital ends up with its own particular threshold of risk.
The key is identifying not some universal cutoff point, but an individual hospital’s limits.
“These patterns are as individualized as fingerprints,” said Dr. Matthew Davis, an associate professor of pediatrics, internal medicine and public policy at the University of Michigan and senior author of the study, published in the journal Medical Care. “There is an optimal balance that is different for each hospital.” Ideal nurse-to-patient ratios, for example, can vary depending on the patient populations served. Similarly, a hazardous level of occupancy might be 70 percent for one hospital and 90 percent for another.
But unlike our fingerprints, a hospital’s limits can change. During flu season, for example, hospital staff can decrease their patients’ mortality risk by getting vaccinated. Hospitals can also shift the schedule of elective admissions to free up beds and hospital staff for admissions from the emergency room. “Understanding these vulnerabilities in a hospital system can pay very big dividends,” said Dr. Peter L. Schilling, lead author of the study and a resident in orthopedic surgery at the University of Michigan.
Because of these findings, the University of Michigan health care system has taken steps to address its own threshold, increasing weekend staffing of nurses, physicians and other health care services and creating a new 20-bed observation area in the emergency department. In addition, hospital administrators have shifted part of their elective surgery schedule to accommodate for predictable influxes of emergency admissions.
“We were doing a lot of surgery cases early in the week but were also typically getting a lot of emergency department admissions on Monday,” said Dr. Darrell A. Campbell Jr., chief of clinical affairs at the Michigan health system and a study author. By scheduling more elective operations later in the week, the hospital has been able to ease overcrowding. “We have to be creative about the ways we think about the specific problems we have,” he said.
Hospitals have also traditionally been in competition with one another and under contract with different insurers. But once a hospital has identified its particular threshold, it could conceivably work with other hospitals to mitigate factors once believed to be solely under the control of fate. “When we reach very high occupancy levels, we don’t always know what the occupancy levels of other hospitals in our area are,” Dr. Campbell said. “Diverting from one hospital to another might be a better solution than holding a patient overnight in the emergency room or in the operating suites’ recovery room.”
In the end, the trauma we anticipated that morning when the hospital was full and the emergency room overflowing was not nearly as catastrophic as it could have been. The school bus turned out to be a van, and instead of the dozens of injured children, we treated only three teenagers and a driver for minor cuts and bruises.
But I knew back then that our day and their outcomes could have been much worse. And I know now that their experiences, and those of every patient in the hospital that day, could have been much better.
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