We don't need more hospital beds – we need better patient management

"I am calling to say that my 86 year old mother has been waiting for nine hours on a trolley. This is unacceptable! How can it happen in a first-world country?"

"Peter, we have been trying all morning to get the hospitals on the phone so we can get some answers. It’s not good enough, is it?"

Yet again, there is a city-wide shortage of public hospital beds in Melbourne. Patients are getting tired, relatives cranky, creating the urgent question that reverberates throughout the corridors as doctors like me turn up to work: "can anyone be discharged?". Of course, this urgency is no greater than other days but in recent days the radio waves have been rattling with complaints, and nothing worries bureaucrats more than a crisis that might creep into the evening news when opinions are formed.

I begin the ward round with my eyes scrutinising the patient list for anyone who can go home.

We see Mr Lee first. At 48, he has suffered his first seizure. Although the initial tests are reassuringly normal, he is in the age bracket where it’s prudent to exclude a brain tumour. He can either have an inpatient MRI at the end of this week, or an outpatient MRI next month. He doesn’t speak English, is the sole bread-winner of his six-member family, and is desperately anxious to rule out a serious diagnosis. He stays because it feels inhuman to do any less.

Next to him is Mrs Blake, 90, with early dementia. She left the stove on until the meat burnt to a char and her fingers just escaped. Her grateful husband eagerly consented to the couple being placed in the same nursing home. "It’s not what I had imagined but at least we will be together and she will be safe." But finding a nursing home with two available beds – one in a dementia-specific wing – is an uphill task even with the cooperation of their diligent son and our knowledgeable officer. So she stays too, her risk of incurring a serious setback like a fall or pneumonia increasing with every additional day on the ward.

Two young patients are discharged quickly and we all breathe a sigh of relief. "Have we fulfilled our duty?" a junior doctor asks, both strain and sarcasm evident in his voice. Before I can answer, we are accosted by an irate relative.

"I am telling you now that I am not taking my mum home until you have fixed her."

Her mum is 80 and suffers from osteoarthritis. We have managed her pain, provided physiotherapy, and seen her walking incremental distances safely. She has been cleared by multiple health professionals but her daughter is adamant that we are missing something.

"We can’t reverse osteoarthritis, just manage the symptoms and she is better", I explain gently.

"I am not taking her home until she has seen an orthopaedic surgeon." Getting a surgeon will take time and won't be helpful, but I also know that the daughter has figured out how to play the game. Management by threat works very well in the short term. Meanwhile, the social worker has discovered that the real issue is that the daughter doesn’t want her mother living with her anymore, but doesn’t want to tell her. Family dysfunction is the reason behind this patient’s failure to be discharged. She could be here for weeks.

People looking in from the outside constantly wonder why there is a perennial lack of hospital beds. The images of elderly patients stuck in trolleys have fast become the sine qua non of a healthcare system said to be in crisis. These discomfiting sights reflexively make us demand more hospital beds. But as any modern clinician will tell you, the lack of hospital beds is merely a symptom of a much bigger problem.

Medical wards such as mine are the dominant factor dictating bed availability in hospitals. These wards admit the bulk of elderly patients who typically present with multiple complex and chronic conditions. Their illness itself can sometimes be the easiest part to manage out of the many obstacles they present.

We are fortunate to have access to the most sophisticated investigations, but their increasing demand creates a waitlist. An inpatient test can happen in days, while the same test can take weeks or months as an outpatient. A specialist review is easier to obtain in hospital, especially if you fear that a weak, vulnerable or poor patient may never make it to their outpatient appointment. Having set up the expectation of an intervention, every patient wants it now.

Increasingly, there are never enough beds for respite, rehabilitation or palliative care – patients can experience long delays to be transferred from an acute hospital bed to these places. Council services are usually operating at capacity and seldom accept patients at very short notice. Even a regular recipient of services must wait to have them reinstated after hospitalisation. Add to this mix a public holiday and the hospital groans under the pressure of reduced discharges. On such occasions, I often wonder if hapless healthcare professionals are the only ones who appreciate that the need for ancillary services does not suddenly diminish on a long weekend.

While working out the logistics of residential care is onerous, it can be notoriously difficult returning a resident to their own nursing home. Even when there is consensus that the patient would be best served in a familiar environment, successfully returning the patient to their nursing home in the evening or the weekend is practically impossible. This is another reason why hospital beds are full.

Given the shrill calls of a system in crisis, you could be forgiven for doubting that Australian healthcare is consistently rated at the top of the world. But doctors still contend with unhappy families who "want everything done". Such are our strides of progress that to be reminded of the limitations of medicine seems perverse, but alas, it is true. Since no doctor wants to be perceived as "giving up" on a patient, we keep them in longer, throw in some extra tests, and buy time – but more is not better and is definitely more risky.

An emphasis on improved doctor-patient communication and advance care planning is essential. It is something that we are painfully slow to recognise as a society but the best-served patients will be those who have an active say in navigating their care, especially at the end of life.

Just as giving paracetamol for a fever does not address the underlying illness, simply opening more beds ignores the systemic malady. Good healthcare means more than finding a hospital bed for elderly patients waiting all night in a trolley. It must ultimately address the bottlenecks that prevent them from making room for the next needy patient.

This article is courtesy from The Guardian.