So I got into trouble one day. We had come to the end of the road, literally with a young boy who had suffered a brain injury and was then bedridden among other complications. Naturally, he had been on admission for weeks. And in a tertiary facility like a teaching hospital that means zillions of tests and top-of-the-line medications and medical procedures. Unfortunately, almost all are borne out of pocket by family. The bosses wanted yet another scan. It had already been a week but the family was unable to raise the funds for it. Mum was growing weary. She had lost her customers. She was a market woman dealing in onions. The father, a driver, had gone for an emergency loan with his taxi as collateral for the previous expenditures – and another loan was not possible at this time. Meanwhile, Kofi, not his real name was neither improving nor deteiorating. His condition was the same. Mum provide bedside care and administered his oral medicines. He was no longer on IVs
I had an elaborate discussion with the family about where we were with Kofi. They opted to take him home and come for the scan (which in my opinion was not going to change his immediate or long term outcome) when they had secured funds. Each day spent in hospital was another bill to pay. I discharged them and of course my boss wouldn’t have it. We were not done with the patient.
On the next bed was Yaw (not his real name). He had been referred to us from a regional hospital. We had determine his diagnosis and started appropriate treatment. Five days into admission he was already looking bright and sparkly. Mum wanted to be close to their home so she could return to work while Yaw finished his treatment in their regional hospital. You know what, that was a brilliant suggestion. A down referral back to his home facility to complete his IV injections. I spoke with the doctor in charge of the facility and they were too eager and willing to accept him to continue care. I gave the order for the discharge and down referral. Then my phone started ringing from bosses – patient has to finish all the treatment here in our “plush” tertiary hospital because no one has done what I was attempting before.
In Ama’s (not her real name case) she had received a blood transfusion the night before. She was referred to us because of a severe anaemia. In the morning the clinical team had decided to run a test to check where her blood level was. Actually this test takes less than a minute to run in the laboratory, once the blood sample gets to the unit in the laboratory where test is run. What may delay this test are the time it takes to draw the blood and send to the laboratory, and the volume of samples to be run. Generally one should get results in minutes to hours depending on the circumstances. To my horror, I find Ama on admission the following day, two days after blood transfusion, eating her favorite TZ. Why? We were “awaiting” this test results, while she occupied a rare and expensive tertiary hospital bed
I could go on and on. My point is that “No-bed syndrome” is perhaps a complication of delays in patient care due to:
Lack of decisive clinical decisions and actions
Clinical team leads taking decisions during once a week traditional grand ward rounds.
Lack of implementation of updated evidence-based guidelines leading to the unnecessary admission of patients and prolongation of stay
Poor or absent linkages in care with little or no regard for down referral
Team leads avoiding the difficult conversation about poor prognosis and end of life with family. In many instances practitioners assume all patients want to die in the hospital
Automatically admitting all patients that seek care at the ED to the ward including patients palliative ones seeking specific interventions like reinsertion of a dislodged feeding tube
And my favorite, choosing to await FBC test results 😉
We can never have enough beds at specialised centres for our population. However, we need to manage them with regards to patient turnover, on an ongoing basis. Those that need to take decisions must get involved very early in patient care to limit the risk of avoidable complications that may unnecessarily prolong bed occupancy.
If we can’t manage our beds now, even the facilities from MD Anderson will never be enough for us at this rate
Shared with permission from Dr Lawrence Osei Tutu