No Beds! When Hospitals Differentiate “Complex Medical Procedures” from “Operations”?

Dear Readers, A patient presented recently to a medical center for an elective EP procedure that required post-procedure monitoring overnight in the hospital. She had waited a few weeks for the procedure, which was performed in the morning in an outpatient building attached to the main hospital. The case was uncomplicated and was done using moderate intravenous sedation administered under the direction of the electrophysiologist. Orders were written to admit the patient to the hospital. The patient was moved from the EP laboratory to the recovery bay just outside of the laboratory, where she was placed on a monitor and watched closely by the nursing staff. She then waited for a bed. She waited — and waited. The EP lab nursing staff continued to provide nursing care in the outpatient recovery area, but the outpatient building eventually closes at night. Eight hours after the procedure, the EP team was informed that an inpatient bed was still not available. After dozens of phone calls by the nurse manager, the patient was transferred to the Emergency Department. How is it possible that a patient who comes to a medical center for an elective procedure, scheduled weeks in advance, does not have a hospital bed available after completion of the procedure? Certainly the patient and family found it unbelievable. One can identify at least two system-related reasons for this problem of a lack of post-procedure beds: “running the hospital too full” and treating patients who have had “medical procedures” differently than patients who have had “surgery.” Because many patients with heart rhythm disorders who undergo an EP procedure require admission to the hospital, or at least overnight observation on a telemetry unit, both of these issues have a significant impact on the patients we care for. Most hospitals avoid the problem of beds sitting empty and staff having an insufficient workload by running at a very high census. Besides intentionally running the hospital at a very high census, other reasons for a lack of available beds in particular units include reductions in nursing staff for financial reasons, reallocation of beds within the medical center to different services that are considered more lucrative by the administration, and local politics. Running a hospital at too high of a census, though, leads to major problems and inefficiencies. Those who ultimately suffer are the patients. If a patient who just underwent a procedure is waiting for a bed that is occupied by a patient who is expected to be discharged soon but who suddenly requires further care, there is nowhere for that patient to go. Imagine if an airplane were permitted to take off without clearance from the destination airport. Hospitals should not be allowed to let procedures that require post-procedure hospitalization begin until an empty hospital bed is assigned and held open specifically for that patient for recovery. Hospital regulations should be introduced that require such a policy. The experience of a patient is very different when he or she undergoes elective surgery in an operating room where an anesthesiologist is involved rather than in an EP laboratory where intravenous sedation is used. A post-anesthesia recovery unit bed is routinely held for patients coming out of the OR. At many hospitals, there is no such equivalent for patients undergoing a medical procedure. This artificial, historical distinction hurts the EP team and our patients. Procedures performed by electrophysiologists are increasingly invasive. More patients are undergoing prolonged, highly invasive procedures including catheter ablation via pericardial access, percutaneous extractions of multiple transvenous leads, and ablation for VT storm. Surgeons, on the other hand, are moving toward less invasive approaches using small incisions and robotics. In many ways the fields are heading toward one another — but from very different cultures. Hospitals need to recognize that the post-procedural management of a patient with advanced heart failure who comes in from home to undergo implantation of a cardiac resynchronization pacing defibrillator should not be treated differently after the “procedure” because he or she is a “medical” patient rather than a “surgical” patient. Ways to better handle this operational problem include establishment of centralized recovery units and hospital beds for patients undergoing medical procedures, collocation of operating rooms and procedure units, creation of hybrid interventional labs, and equal consideration by the anesthesia community to medical procedures and surgeries. Until medical centers begin to manage beds more appropriately for patients waiting for hospital beds after medical procedures, and stop differentiating patients who undergo complex invasive medical procedures from those undergoing surgery, patients waiting for a hospital bed to recover after an elective EP procedure will continue to be sent to places like the emergency department. Sincerely, Bradley P. Knight, MD, FACC, FHRS Editor-in-Chief, EP Lab Digest