For two weeks, TEMITAYO AYETOTO embedded herself with patients at the accident and emergency centres of two of Nigeria’s biggest tertiary hospitals, LUTH and LASUTH. In the second installation of this two-part series, she reveals how patients’ wait for never-available bed space is at their own risk, and how some beat the queue by calling on ‘somebody who knows somebody who knows somebody’.
‘If you stay, it’s your choice’
The triage doctor who referred us to the spillover ward was still outside, observing new cases. She was looking for the right vein to connect a drip on a young girl of about 17 who was lying in a grey-coloured space car when I approached her.
I particularly asked what her assessment of Ogbonaya’s case was to be sure again that Ebuka’s problem warranted emergency response and we were not exaggerating his pains.
“I have seen the result of his x-ray. It is an emergency situation. But he needs a bed space to be attended to. I can’t attend to him without bed and I don’t know when a bed will be free. It could be in 30 minutes or 2 hours. Some people wait here for two days. If you stay, it’s your choice,” she said, exonerating herself.
It was vivid that we had to wait for the unknown period.
‘Knowing somebody who knows somebody who knows somebody’
Our sojourn at the car park established some truths: that connection with people of strong influence on hospital officials can get a patient into the A&E ward real quick; that getting approved to move into the A&E reception does not necessarily imply getting swift treatment; that not being brought into the hospital by a vehicle or tricycle renders you unqualified for preliminary medical attention; that if there is some cash to spare for the security personnel, a patient could enjoy the luxury of having more than a relative or friend by the side. Notable also was that patients brought in by ambulance from other hospitals stood better chance of attention.
As we waited, a woman of average height, certainly in her 60s, came to the park with a patient — a man who bore no visible ailment. Dressed in a black pair of jeans complemented by a zebra-themed shirt, black pair of glasses, black hair braids and a black bag, she scanned all that were on the wooden bench until she found a spot for herself and her patient.
Not long after a hospital official came around to note her case, she was called in with her patient, within just 30 minutes.
Ebuka, his wife and I were there perplexed. Shortly after that happened, the head nurse on duty came to the car park, flicking through us all for someone in particular. She was a tall dark woman with an intimidating voice. When she couldn’t identify the patient in plain sight, she went back into the gates, looking through her phone. Apparently, after making a call, she dashed out, screaming “Nnamdika! Who is Nnamdika?”
Nnamdika had been there lying limply on her brother’s legs for close to two hours. She couldn’t answer her own name but her brother, Ekene, did and magic happened. A porter in brown uniform surfaced with a wheel-chair to move her in but the car park was occupied by a wine Toyota Camry CE, a red Toyota Camry LE and the silver space bus, all bearing patients writhing in discomfort. Since, the cars blocked access to Nnamdika, Ekene lifted her out and she was in. Ogbonaya was still there, his waiting hours nearing 25 hours.
When we met later in one of the hallways, I asked Ekene if he knew someone who could back us up as well, but he said his link wasn’t straight. He got his sister in quicker on the back of someone he knows, who then knows someone who knows a LUTH official. It was how he described it while he kindly inquired about the health of my supposed brother, Ogbonnaya.
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“We had previously taken her to a private hospital where she was operated on, but there were some complications. Some cells were dead during the operation and they had to be revived. The doctor asked us to come here (LUTH), assuring us that he would call someone who will attend to us.” Ekene explained.
Similarly, the woman who went in initially told me she knows someone who works right in the hospital.
There was also a case of an accident victim brought in by one St. Mary Hospital ambulance on one of the nights I spent in LUTH. Three SUVs accompanied the ambulance. The accident involved the head, leg and claimed some of his fingers.
It was obvious the patient was from a well-heeled background. In less than 30 minutes he was in and his family was ready to go in as well. Not more than a relative, they were informed.
But in a twist of rules, about five of them were in: the mother and father, a couple (family friend) and one of their sons, Tunde. Two others, their eldest daughter and youngest son, waited outside. And after they were assured that the patient was in good hands, they returned outside, thanking God. Tunde cornered one of the security personnel and rubbed in a crisp N1,000 note in his hands. It was all smiles.
Ogbonaya’s hour finally arrived at 1:36 pm.
…but no bed, no specialty doctor
Like the two blind men crying out loud to Jesus for mercy, patients and their relatives fought to win the attention of the triage coordinating doctor the moment he stepped out. The relatives of the woman with diabetes were chief among them.
“You know the problem we are having, there is still no space,” he said and began to soliloquise. “The same people you are trying to help are still the ones that will now start shouting at you after they have sat for two hours in the reception. That is usually the case.”
The elder among those who were with the woman with diabetes started begging. “Don’t be annoyed, my father,” she appealed to the doctor in Yoruba language.
He then turned towards Ogbonaya. “Let them call cardiothoracic surgical unit (CTSU). There is no bed but sit down in the reception. The most important thing is to remove that fluid in your chest,” he said.
Finally, we found our way in 21 hours after presenting an emergency challenge. A rain of hope flooded Ogbonaya’s heart. He was reassured, merely by being let into the reception.
“When I get better, you will stay at home for two weeks. I will be feeding and taking care of you,” he said, heartily stroking his wife’s hair as they continued to wait.
At 2:40 pm, a young doctor, Ogunseye, approached us. “We have informed the surgical team that will attend to you. None of them is around now. When they will come, we don’t know. I just want to inform you; just exercise patience,” he said. The news was received with a mix of inexpressible gloom and a cheer that at least Ogbonnaya was now in their faces.
By 8:07 pm, a noise broke out in the reception. A man was furiously screaming at no one in particular. He accused the hospital officials of leaving his ill mother by herself without attention; he perceived she had got worse. None of the nurses responded until he approached their table, barking at them about how they had been negligent!
The eldest among the nurses matched him up with equal anger that shocked him. “We have been watching her since and all of a sudden you are shouting after returning from wherever you went to. Can I come to your office and start shouting at you? My parents died right here in this hospital,” she yelled, indirectly warning us all to be informed beforehand that her folk were also victims of the poor healthcare. She didn’t need to go further before the aggrieved man swallowed his yearnings.
Thankfully, a doctor, Amuda, showed up at 8:18 pm and Blessing and I didn’t hesitate to relay Ogbonaya’s situation to him, for the pains now resurged. He promised to help notify one of the CTSU doctors, who is a close friend. To ensure he did, I followed him up to ward E1 where he fetched his phone. He realized his friend was not on duty but one Dr. Okeke. His friend promised to call Okeke’s attention.
By 9:10 pm, Dr. Okeke approached us in the company of a younger doctor, Obinna. In total, it took almost 29 hours of wait and staunch faith for Ogbonaya to get treatment attention. Had we not pressed Dr. Amuda, then Dr. Okeke might have shown up too late or even the following day.
And to our dismay, after assessing his x-ray picture, Dr. Okeke himself was in a bigger hurry to carry out minor surgery on Ogbonaya in what he described as a very important procedure to restore his respiration to normal.
But nothing could be done as recommended, because the patient was never informed he would need N54, 489 for the minor operation without histology, and an additional N20,000 charge that was not clear.
In what appeared an expensive sacrifice for a bed space opening, the mother of the man who had earlier picked a fight with nurses over negligence died. And a bed space finally opened. It was past 11 pm that rainy night.
Promotion versus reality
On documents, paper, signboards, and website pages, hospitals string together captivating words to describe the sort of memorable service rendered. But reality checks such as in Ogbonaya’s experience and many others indicate otherwise.
In fact, Ogbonaya appeared to be luckier when compared to the woman with diabetes. She arrived around 7pm on Tuesday night but did not get a bed space until some minutes past 10am on Thursday.
The promises were just often fictitious. On a signboard, stringed to the gate of the A&E ward, the letterings are clear.
“A doctor or nurse will come and attend to you or your patient WITHIN THE SHORTEST POSSIBLE TIME. A quick assessment may be done in this area if the patient moved immediately into the emergency centre. The decision to admit a patient is NOT DETERMINED BY FIRST COME FIRST SERVE basis but is based on HOW CRTICAL OR SERIOUS the case is DETERMINED TO BE BY THE DOCTOR OR NURSE. PLEASE REMAIN CALM; WE PROMISE TO ATTEND TO YOU/YOUR PATIENT AS QUICKLY AS WE CAN. In case of any unnecessary delay, please call: 08070591234 or 08163874391.”
To begin with, the numbers listed were both not functional during the day and at night. The response from calling 08070591234 is: “The number you are calling is not available. To send a voice SMS at regular call charges, please stay on the line. Otherwise, hang up now.”
That from the second line 08163874391 simply says: “The MTN number you are trying to call is currently switched off. Please try again later. Thank you.”
As in all standard cases and like the LUTH management stated, emergency responses are launched in order of priority. Emergency medicine in itself specialises in the acute care of patients who present without prior appointment, either by their own means or by that of an ambulance.
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Considering the unplanned nature of patients’ attendance, the department must provide initial treatment for a broad spectrum of illnesses or injuries, some of which may be life-threatening and require immediate attention.
Patients who exhibit signs of being seriously ill but are not in immediate danger of life will be triaged to acute care where they will be seen by a physician and receive a more thorough assessment and treatment.
Chest pain, difficulty breathing, abdominal pain and neurological complaints include some examples of acute problems. Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood or urine, ultrasonography, CT or MRI scanning.
These are medical steps experts say Ogbonaya should have been exposed to if he had a government that cared enough to empower the public hospitals to respond with such standard of healthcare. Instead, he waited about an hour before he got a triage doctor to notice his presence, despite being glaringly sick. When his case made it into the register, it took another 28 hours for him to see a physician for a thorough assessment. When doctor Dr. Okeke was going to perform a minor operation to drain his chest of fluids, Ogbonaya’s blood had not been tested, neither had his urine.
“What has the A & E been doing?” the doctor asked in wonder. “We don’t even know whether to protect ourselves.” But they did the operation, anyway, without an idea of his infection status for instance.
Nigeria spent an average of 3.4 percent of its total budget on healthcare in the last 10 years to 2016, according to the World Bank database. Out of Nigeria’s budget of $4trillion between 2014 and 2016, $107.1billion was spent on healthcare. The largest African economy lags behind emerging market peers, managing to outperform only Indonesia which had spent 2.9 percent of its total budget in the period.
LUTH and LASUTH, birds of a feather
The twin problem of bed space and overstretched capacity at LUTH were visible at the Lagos State University Teaching Hospital (LASUTH), Ikeja, where I spent two days and nights. The hospital is itself one of the chief referral sources to LUTH. But the triage system was quicker. Patients both at surgical and medical emergency were not subjected to unnecessary wait before understanding their status. Preliminary care was equally administered to sick people in vehicles, since bed spaces weren’t available too.
Initial triage and treatment constitute one of the weakest links in the emergency medical care system in developing countries, according to a report by the World Health Organisation Bulletin in 2002. WHO’s qualitative study of 21 hospitals in seven countries found that poor triage of incoming patients and inadequate provision of emergency care jeopardized the lives of arriving patients.
“Emergency is emergency, except of course for Nigeria where anything goes. Emergency is a place where you are attended to immediately. If your case is severe, you should be attended to even ahead of people who came before you. That is what is called triage in emergency medicine. So, it is an abnormal case, if not completely aberrant that somebody is spending 4 hours or even 29 hours at the gate before he can be assessed. These are not normal situations,” Dr. Olowofela explained.
“In fact, in a good country, that kind of person can stay in his house and call 411 and an ambulance will be sent to pick you up. You will be attended to immediately. It’s that serious. Every hour lost brings a person closer to the grave.”
Besides triage, our experience with the case of Nnamdika and the ‘big madam’ clearly betrayed some of the standards that the hospital associates with. Truly, the admission was neither determined by ‘first come, first serve’ nor by how critical a case is as promised. It was instead determined by knowing somebody who knows somebody who knows a hospital official, many times.
Most pathetic is the unlimited length of waiting period at the emergency gates. Patients who have no hope elsewhere wait endlessly with a strong faith in a miracle. The woman with diabetes waited for roughly 40 hours, from Tuesday November 12 to Thursday November 14.
When patients face these sorts of unnecessary delays, they seek succour in dangerous directions, including the quarters of quacks and herbalists.
The awful impact of Emergency department’s waiting times increases patient mortality and morbidity, in some cases leading to readmission in less than 30 days.
According to a 2015 systematic review of emergency care in 59 low-and-middle-income countries, about 15 per cent of 1.6 million deaths recorded annually in Nigeria are estimated to occur in emergency departments.
“We made a rough calculation for Nigeria, where we identified relevant studies in 21 facilities and mean annual patient volume of 3000 and 5 to 7 per cent mortality. If we assume that the approximately 1000 teaching and general hospitals in the country have the same mean annual patient volume and mortality, then out of the 1.6 million deaths recorded annually in Nigeria an estimated 10 to 15 per cent occur in emergency departments,” the review stated. “It is likely that relatively simple interventions to facilitate triage and improve patient flow, communication and the supervision of junior providers could lead to reductions in mortality associated with emergency”
Waiting time elsewhere
In May 2014, the median wait time to be treated in the emergency department in the US was about 30 minutes, and slightly more than 90 minutes for treatment wait time, reported the US Centres for Disease Control and Prevention. This adds up to roughly two hours in the emergency ward. The shortest median wait time was 12 minutes for patients who had an immediate need to be seen.
In March 2018, patients in Accident and Emergency in the United Kingdom spent an average of 64 minutes awaiting treatment, according to the National Health Service A&E data.
At its worst level on record, 74.5 per cent of people who sought care at the accident and emergency unit in England as of October 2019 were treated and discharged, admitted or transferred within four hours, falling short of 95 per cent of patients targeted to be sorted within the period. Between January and March 2019, 85.1 percent of patients were dealt with in four hours.
The median waiting time for patients who required admission to hospital was four hours as of February 2019. For non-admitted patients, it was significantly lower at 146 minutes.
Moving down to African peers, patients spent approximately 51 minutes from arrival to triage and 2 hours 14 minutes from triage to first healthcare provider between 2013 and 2014 in South African hospitals, a report by the South African Medical Journal shows, implying the total time spent before being seen by a physician was 3 hours 5 minutes.
Wait time is defined as the difference between the time of arrival in the emergency department and the time the patient had initial contact with a physician, physician assistant, or nurse practitioner, according to a National Hospital Ambulatory Medical Care Survey, United States 2010-2011.
The treatment time is considered the difference between the time the patient had initial contact with a physician, physician assistant, or nurse practitioner and the time the patient was discharged from the ED to another hospital unit or to the patient’s residence.
Tackling ED delay
Long waiting time is indisputably a widespread problem in public health management around the world. But hospitals in improved medical climes are increasingly adopting custom means to tackle overcrowding, by modifying normal processes, for instance.
When Abu Dhabi realized that 90 per cent of patients visit emergency care units of Abu Dhabi hospitals for non-emergency cases, it instituted 48 urgent care centres across the emirate to tackle unnecessary overcrowding.
The Department of Health Abu Dhabi categorised emergency departments into two: Emergency Units and Urgent Care Centres. Through this system, they ensure only patients suffering from acute, life-threatening conditions are in the emergency care department, while patients with minor illnesses and injuries have to visit Urgent Care Centres, which will provide initial assessment, diagnostic treatment and referral as appropriate.
In an article published in Harvard Business Review, Nicos Savva and Tolga Tezcan, associate professors of management science and operations at London Business School who have worked with hospitals and emergency departments, suggest waits could be reduced if the emergency departments invest in additional beds, employs a surplus of physicians, and use faster diagnostic technology.
They also proffer financial reward system for hospitals based on average waiting time of patient.
“Our research shows that such financial and outcomes-based incentives create indirect competition on waiting times and have the same effect on outcomes as direct competition has on other service points, without patients needing to exercise choice,” they stated.
For Nigeria: better coordination, health insurance needed, not new centres
For Osinaike, Nigeria does not need to build emergency centres to resolve the problem of efficiency. Rather, the system requires improved coordination of referral network from hospital to hospital. The country needs to be able insure the population against health challenges, as out-of-pocket expenditure is the biggest problem of emergency delay in Nigeria. Finally, hospital officials and consultants must to better with early reviewing of patients.
“One of the first challenges you have with emergency care in the country is lack of coordination. It is irresponsible of a doctor to refer a patient to a hospital you have not made contact with. You can’t refer to LUTH when you have not verified if there is space. LUTH Emergency room is about 35 beds, and [you can’t] expect everybody from federal medical centres and private hospitals to find a space,” he explained.
“Expanding emergency rooms is not the solution for me. Getting the ones we have running efficiently is key. Apart from coordination, health insurance has to work. Some of them have chronic conditions that they could have sought care for without having to come into LUTH. These are things that general hospitals should do. And the hospital has its own fault, too. They can do better with how quickly some of the consultants review patients in the emergency room. If a consultant doesn’t do it quickly enough and it is the junior staff that does it and keeps asking them to do test that they don’t need, patient’s finish their money before the main consultants come to ask for the requisite tests.”
