A large part of the work medical providers do in the hospital is not just figuring out what a patient needs. It’s also figuring out where and how those needs can be met.
Here is an example of a patient I might evaluate in my work as a high-risk pregnancy doctor: My patient had been breathing OK after the cesarean delivery, but now she’s not. She’s sitting up in bed, pale, and breathing quickly—25 times per minute, much too fast. We are all gathered around her bedside, obstetrics attendings and residents, nurses, anesthesia attendings and residents. We listen to her lungs; we check her belly; we assess her bleeding. We give her an oxygen nasal cannula, then see that that’s not enough and replace it with a mask. Someone draws labs; another doctor is ordering a chest X-ray at the computer while we discuss whether we should really just move toward an urgent CT scan. And in the midst of this, we call the intensive care unit to come see her: “This is my patient. This is her story. Her breathing is not improving. She may need more respiratory support, and we may need an ICU bed. Can you help?”
This scenario doesn’t happen every day on labor and delivery, but it does happen every day, somewhere in the hospital. We all work to figure out: What care should she be getting? Where in this hospital can that care be met? If a patient just had a baby, then she should probably be on a postpartum floor—so far, so simple. But what if her blood pressure is very high, and she needs to have vital signs checked every hour? Many units are not set up for that—the nursing staffing is not sufficient for that level of care. In that scenario, that patient may need to be moved.
It goes both ways, too. Yesterday, the 65-year-old man with chest pain needed to have ’round-the-clock monitoring of his heart rhythm and needed to be on a special cardiac monitoring floor. Today, his tests look negative for a heart attack, and he can go to a regular medical/surgical floor. That precious telemetry bed can be made available for someone else. And tomorrow, hopefully, if he looks even better, he can go home.
Most doctors you know who work in a hospital spend enormous amounts of time on this type of question. Can this patient be managed here? If the answer is “no,” perhaps we can manage them here, just with tweaks. Or do we need to escalate the level of care? It’s a complex decision, and one that changes for every patient, based on needs, and presumed course: Someone who is short of breath, but just needs a bit of fluid to come off and then will be breathing well, might be managed in place. Her counterpart who has a pneumonia and might need days or weeks to start breathing better is a different story. And it changes for each hospital: For example, a large academic hospital might be able to manage dialysis on a regular medical floor, but in a small rural hospital, that might be something that needs to happen in an ICU (or vice versa). System issues are like that in medicine—they end up being a tremendous amount of the work that we do and the care that you receive, something I spent a lot of time exploring in my book on high-risk pregnancy. How the care is delivered is often more important than what type of care was delivered.
Already, before the coronavirus, ICU beds were our most resource-intensive place to provide care. I mean, that’s right in the name. The use of them is husbanded very, very carefully—most intensivists spend a lot of their day figuring out who needs one the most, when they can get it, and when they can get someone else out to a regular floor. And still, ICU beds are often full. Even though data that I found of ICU capacity generally report only about 60 percent, I’ve rarely known an ICU to have beds freely available. Even if the actual bed is empty, there is often not enough staff—usually nursing—to provide care, and so that bed cannot really be used. Recently, I spoke to several intensivist doctors—adult ICU, pediatric ICU, and others—and all said the same thing, regardless of region: We are almost always at capacity; people are always waiting for beds; we manage, but it’s almost always pretty tight.
To some extent, patients who need ICU resources can be managed outside of the ICU. The emergency department, for example, frequently “boards” ICU patients, managing them in the emergency room until an ICU bed can be found. Those nurses and doctors there have to do this frequently and have the training to do so safely. But even though it’s safe, it’s clearly not ideal—studies have shown that outcomes, including mortality, can be worse for those patients, especially if they spend longer and longer waiting for their destination.
This is the state of affairs in most hospitals that I’ve worked in, and in the hospitals where I asked friends and colleagues about, largely in urban areas serving low-income populations, but also in different regions, with different populations, throughout the country. And now, all those hospitals are making plans: What if many more people need the respiratory support that, in general, is reserved for ICUs? How will we do that?
I don’t know the answer yet. I do know, though, that so much of the excellent care my sickest patients receive doesn’t just happen. It happens because I call and say “Can you help?,” and because the answer so far has always been “Yes.”
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