Why patients are dying in hospitals awaiting admission

At 10:20am, a pregnant woman is driven into a hospital’s emergency department complaining of sharp abdominal pains.

But this is where a different kind of pain begins.

The emergence/casualty area receives new patients who require immediate and intensive care.

But for this woman, the urgent intervention begins after 12 hours.

Her case was recorded by researchers from the Kemri-Wellcome Trust Research Programme in Nairobi, among other institutions. They found rampant delays sometimes leading to death in public hospitals’ emergency and casualty areas.

 A nurse and clinical officer promptly take the pregnant woman’s vitals, fix an IV line and order a blood test. Then comes a long wait. Relatives must queue to pay for the test and get a receipt, which must be presented  to the lab.

 A medical officer later requests an abdominopelvic ultrasound to determine the cause of the pain. Another long payment process. Then another queue at the radiology department. Two hours later, the radiologists report the abdominal ultrasound cannot be carried out because the patient is required to have had no meal hours before the test. 

The doctor now demands specifically a pelvic ultrasound. Yet another waiting nightmare.

Twelve hours later (10.30pm) the woman is admitted to the gynaecological ward after a diagnosis of a ruptured ectopic pregnancy. It causes bleeding that can result in organ failure and death. She is wheeled into theatre for “urgent” surgery.

 Researchers, who followed the case, were investigating how public hospitals triage patients at the emergency department/ casualty area.

 They found extreme delays and that in some hospitals, triage itself is non-existent.

 “We found that while the hospitals had allocated physical space in the emergency and outpatient departments for triage, time to triage was markedly increased and effective triage practice was mostly postponed or forfeited altogether,” the researchers reported.

 Triage is the early identification of critical illness to determine the urgency of their need for treatment and the nature of treatment required.

 There is evidence that delays in providing the appropriate care to patients results in increased deaths at the ED and heighten the risk of death from any cause within the next 30 days.

 The study was done in four secondary-level public Kenyan hospitals across four counties around Nairobi between March and December 2021. Researchers interviewed healthcare workers and followed seven patients, including the pregnant woman, from arrival to admission to wards or mortuary.

In general, the time to essential care was between four and 12 hours.

 The study is published in the BMJ Open Journal. It is titled: "Third delay in care of critically ill patients: A qualitative investigation of public hospitals in Kenya."

It comes at a time when conflicts between relatives of patients and health workers at emergency departments have been reported. Relatives mostly accuse medics of failing to attend to their dying relatives.

The authors observed one street woman brought in at a city county health facility with difficulties in breathing.

She was put on an oxygen mask, which kept on slipping off but there was no one to help her. After nearly two hours, she fell off the chair and was confirmed dead.

They noted inflexible non-clinical business-related processes such as payments wasted a lot of time that could save patients’ lives.

“With most hospitals having a centralised payment point, processing the laboratory and radiological tests ordered took considerable amounts of time. The delays were occasioned by long, inflexible registration and payment processes and long queues in these departments,” they noted.

Prescribed tests and investigations were not processed until the patients or their relatives paid for these services and in between, care was often withheld while the payments were sorted out.

“Staff in some facilities felt that it would help if there were systems to hold off payments for basic tests until later when the results are out, and the patient has been attended to,” the authors said.

All the hospitals lacked enough health workers to provide proper triage.

“Sometimes the strained staffing capacities led to coping measures such as rationing of care even seriously ill patients, in order to spread out the care to as many patients as possible,” they added.

They also identified ineffective communication systems as a major limitation. Most departments lacked a functional departmental telephone, and communication between departments was largely through the health workers’ personal mobile phones.

The authors call for policies to help hospitals implement proper triage at the ED. They also recommend administrative stumbling blocks, such inflexible payments terms should be reduced to reduce the congestion in the emergency care pathways.

The other authors are from University of Oxford, London School of Hygiene and Tropical Medicine, and Karolinska Institutet, Uppsala University, and Nyköping Hospital all of Sweden. Others are from the Muhimbili University and Ifakara Health Institute of Tanzania.