Friday, January 04, 2008

Rosa's death coincides with a long article in yesterday's La Vanguardia titled, "Chronic emergencies." She died in the emergency room at Vall d'Hebron; they had transferred her on Saturday from Traumatology at Vall d'Hebron to the rehabilitation department at Pere Virgili, the former Hospital Militar. When the people at Pere Virgili discovered her urinary infection on Sunday, she was transferred to Emergency at Vall d'Hebron, where she died Monday morning; they did not check her into intensive care.

I got there at about 9PM Saturday night, and the emergency room was overcrowded and understaffed. They have about thirty cubicles, called "boxes" (they use the English word), where the most serious cases are secluded. Everyone else piles up on stretchers in the hallways. Rosa got a cubicle, but not a lot of attention from the staff, since they were so thinly stretched. The logjam of people in the central hallway was all older folks with breathing or heart problems, who were waiting their turn; I didn't see anyone with a trauma injury.

Here's the article, by Marta Ricart; it gets a front-page teaser, and occupies pages 26 and 27 of the January 3 issue. I've boldfaced the first three words of every paragraph so as not to put the whole thing in italics.

Chronic emergencies: Measures by hospitals and Health Department fail to prevent overcrowding every winter

"Three hours of waiting, at least one more than usual, is the very least that anyone who goes to the emergency room can expect to face these days. The overcrowding of medical facilities every winter, especially the emergency rooms, has become a chronic illness. The measures taken by the hospitals and the Health Department cannot prevent, one day at one hospital and another day at another one, emergency rooms from being overcrowded. The hospitals and the department attribute it to several factors, and assure us that the "winter reinforcements plan" is working. The hospitals admit that several aspects could be improved, but at the same time, they say that it is very difficult to solve the problem.

The emergency rooms, the general practitioners' clinics (CAPs), and the house calls service are flooded every winter because the demand for care for the flu and other viruses, which affect the entire population and especially aggravate the condition of those who are chronically ill.

Health counselor Marina Geli said on Tuesday that this increase in the demand for care has multiplied because of population growth in recent years in Catalonia, and the aging of the populace.

In the last week, according to Health, emergency room activity had been 14.7% more than usual (at the beginning of November, for example), with 11.4% more patients and 24% more hospital deaths. Emergency ambulance calls these days have been 52% higher than usual. The number of children's emergencies has declined over the last week, according to the coordinator of the winter plan, Josep M. Argimon. Health said yesterday that the situation in the hospitals is not critical. Things may get worse, since he predicts that this week and next week the number of adult patients will increase. Last winter, patient numbers increased dramatically during the second half of January.

The increase in demand for care has not been accompanied in recent years by an equivalent increase in medical capacity, complain the hospitals. It is compensated for by the winter reinforcements plan from December to April. "It prevents greater overcrowding," said Joan Manuel Salmeron, the emergency room chief at the Hospital Clinic in Barcelona.

The hospital emergency rooms are where the inadequacy of services is most obvious; they are too small; almost all the big hospitals (Vall d'Hebron, Clinic, Mar, Germans Trias) have plans for expansion. The delay in construction, one more year, is one of the most frequent complaints among health professionals.

At the hospitals they stress that 80% of the people who go to an emergency room go on their own, and so it is difficult to predict and regulate the flow of patients, unless that flow is limited. Many of those patients could be attended at the CAPs, but they prefer--despite the waiting--the high degree of specialization at the hospitals since it saves them further visits, according to Salmeron.

Boi Ruiz, the president of the employers' association Unió Catalana d'Hospitals, estimated that up to 80% of those who go to the emergency room on their own do not need hospital care. "We need," he says, "a civic campaign on the use of the health care system, just as we are trying to educate about saving energy. People should know which service they should go to according to each need, what is normal at each one, and they should become aware that the public system has limitations and it should be used correctly."

The hospitals use triage: a doctor or a nurse evaluates the patient in order to determine the seriousness of the case--there are five levels--and keep the more urgent from waiting. The hospitals say that medical care begins there, and that those who have to wait are not in serious condition. Many hospitals organize rapid diagnosis units, and others specifically for cardiac and respiratory patients.

In order to take the pressure off the emergency rooms, Health thought up 'emergency CAPs,' which can take stronger steps, but it has opened relatively few. Another measure is coordination among hospitals and emergency rooms. There are 'coordination groups,' especially in Barcelona, which meet in order to evaluate the demand for care and redistribute patients, says Argimon. Salmeron confirms that "coordination is becoming a reality." He believes that it is a model that will be introduced during the entire year, though the redistribution of patients needs to be further developed. The Hospital Clinic, on Sunday, could not keep up with the number of ambulances bringing in patients. Geli said that in recent days similar problems have occurred at Mar and Sant Pau. Argimon mentioned the increase in emergency ambulance calls.

Spanish hospitals have been reducing the number of beds--they are among the ones with the fewest in the OECD--for better financial results, but they must do more operations in order to keep the waiting lists down. This makes occupation high, and when demand increases, Emergency cannot rapidly order the check-in of patients and they accumulate in open spaces, Salmeron admitted. Manel Chanovas, the president of the Societat Catalana d'Urgències, said that the reduction of beds was done in order to promote new services such as outpatient surgery, which permits more patients to be attended each year.

These days the hospitals are increasing the number of patients released, and increasing 'home hospitalization' so as to have more beds for new patients. Those responsible for the winter reinforcement plan predict that they will be able to handle 18,109 additional patients in the next four months, 1015 more than last winter. For that purpose, extra beds have been set up at the hospitals (24 at the Clinic, 24 at Bellvitge), and Health is renting others at private clinics like Plató, Sagrat Cor, and San Rafael. Of these new patients, 14,357 will be for short stays, and the rest for 15 or more days. Argimon said yesterday that this capacity for patients had not yet been reached this winter. Professionals agree that beds for long-term stays are lacking at public hospitals.

Health's winter reinforcement plan increases, from November to April, the staffs at the hospitals by 187 doctors and 340 nurses. The unions say that this is not enough personnel to handle the increase in demand, since there is normally a staff shortage. Manel Chanovas said that the health care system had already reached its ceiling regarding available professionals. Although emergency facilities could be expanded and the budget could be increased, it would be difficult to make the staffs much larger, he says, "And Emergency is the last service in which professionals want to work because it is hard work, under great pressure, and with the worst schedule." Boi Ruiz adds that hospitals have difficulty finding new staff, especially nurses."

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