A group of medical officers were gisting and lamenting about their night calls. One of them said that his call was ‘light’ because there was no available bed space and so he spent the night sleeping and intermittently referring patients to other hospitals. Another doctor hailed him and called him lucky. ‘O boy! Your own better. For my center we admit patients on examination couches, plastic chairs and wooden benches. We even have ‘taburma space!’ (A space on the ground to spread a mat) No rest! na so-so admission all night long!’
The first time I saw a patient admitted on the floor of a general hospital in rural Nigeria, I was appalled. The child laying on the ground with a cannular and IV tubing attached to the Intr-venous fluid (what Nigerians call ‘drip’). The IVF was hung up on a windowsill using a makeshift sling made from a filthy piece of cloth. The entire sight was pathetic and when I commented so to my superior, his remark stung: ‘The situation may not be ideal, but does it work? By resuscitating a patient with hypovolaemic shock, whether on a hospital bed or on the floor, have you not saved a life?’
That reasoning has since changed my perspective.
The WHO defines a hospital bed as a bed, that is regularly maintained, staffed, and used to accommodate and provide full-time care for a succession of in-patients. It must also be in a ward or other area of the hospital where in-patients receive ongoing medical attention. The aggregated total constitutes the normally available bed complement of the hospital. In-patient hospital care beds accommodate patients formally admitted (or ‘hospitalized’) to a hospital for treatment and care and who stay for a minimum of one night.
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Accordingly, the WHO recommends five (5) beds for everyone thousand (1,000) population. In India, the bed: population ratio is 0.9 beds per 1,000 population, while in Nigeria, it is 5 beds per 10,000 population, which is far below the global average of 2.9 beds per 1,000 population. With an estimated 5 beds per 10,000 population, Nigeria will need an additional 117,000 beds costing approximately $12 billion, to reach the Sub-Saharan African average of 12 beds per 10,000 and an additional 350,000 beds costing approximately $37 billion to reach the global average of 26 beds per 10,000. This shortage of hospital beds in Nigeria could lead to an increased rate of mortality since patients are liable to be discharged prematurely.
The solutions to this lack of bed space predicament are multifaceted and numerous. I will humbly try and do justice to as many as I can.
One of the methods commonly used in Nigeria is the reverse triage approach. This method is a response of the Emergency Department that gives priority to Emergency department patients by the early discharge of inpatients of the hospital. What this means is that, in-patients in other wards in the hospital are discharged earlier (once they are determined to be stable) in order to make room for patients presenting to A&E. This creates more bed capacity where each patient can be sufficiently managed. So, for example, if a patient is involved in a road traffic accident and comes in bleeding, a patient with bone cancer in the ward can be discharged earlier to in order to attend to the man that is bleeding. Meanwhile, the patient with the bone cancer can continue his treatment as an out-patient.
However, while there is still a significant knowledge gap regarding the reverse triage approach, a few studies have reported a significant increase in the incidence of adverse effects and re-admission of these patients. Bed space palaver temporarily solved while further overburdening the health system. A solution to this is to create state-specific guidelines governing the reverse triage approach in cases of disaster and surges in patients’ influx.
Secondly, overcrowding in emergency rooms is a sign of numerous health care system failures. There should be actions to reduce emergency department crowding in system-wide performance improvement targets instead of responding to overcrowding in the emergency department after it has already happened. The emergency tertiary system should create a strategic planning program that is meant to assist hospitals anticipate and prepare for it. Failure to provide appropriate inpatient capacity for an emergency department population with illnesses of increasing severity is the primary contributor to congestion in emergency rooms. The overpopulation situation will need to be addressed systemically and in a multidisciplinary manner. We see it in medical movies all around the world. Why cant we replicate it here?
Thirdly, we should have better home care and nursing home arrangement for the elderly so that they did noy take up hospital bed space in secondary and tertiary facilities. It is recommended that the tertiary emergency centers in Nigeria liaison with nursing homes and long-term care facilities to simplify hospital releases and attention to the patients in need of immediate medical services.
Another solution is to have more organized and meticulous discharge planning, quicker evaluations in the emergency room, for instance, faster turnaround times for labs, radiology, and consultations are all examples of ways to increase the accessibility of acute care beds. Full blood counts or electrolyte panels should not ordinarily take more that 30mins, but in a typical hospital setting in Nigeria, it could take up to three days! Pray tell, what am I supposed to do for the patient while waiting???
Furthermore, measures that could lessen emergency department overcrowding include quicker transfers to different admitting wards if admitted (I once waited for over four hours for a hospital attendant to transfer my patient from the A&E to the ward. In fact, at a point, we pushed the stretcher together), better care of the emergency room bed capacity, better management of chronic diseases in the community to prevent emergency department attendance, and prevention of diseases that cause emergency department attendance.
Finally, is creation of more bed space. I left this for the last because I believe it to be the least of our problems. With the population of this country, I doubt we can ever have the adequate resources to meet the required bed space capacity. What we should emphasize on is managing and maintain the bed spaces we have while focusing on optimizing our primary healthcare facilities. When patients are managed well in PHCs, there is a decreased demand for admission into the A&E. For example, a diabetic patient whose blood glucose level is well controlled as an out-patient will only be coming in for regular follow up visits and will hardly be admitted into the emergency department with diabetic coma. Another good example is malaria; if all malaria cases are managed well at primary care level, why would we have patients with cerebral malaria requiring admission?
Until you have a patient or relative who is being tossed back and forth because of lack of bed space, you will not fully understand the dilemma we are in. Therefore, one of the top concerns in medical emergency treatment in Nigeria should be investing resources to decrease emergency room overcrowding.
