Israeli Doctors Criticize Plan to Fix Overcrowded Emergency Rooms

New Health Ministry regulations are meant to solve problem of patients waiting for hospitalization, but doctors at internal medicine wards say proposals won’t work.

Ido Efrati
Ido Efrati
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Ido Efrati
Ido Efrati

There are currently 45 patients at the Internal Medicine B department of Ichilov Hospital, Tel Aviv, although the ward has only 39 beds for hospitalized patients. The medical staff maneuvers through the corridors between patients’ beds and their families – a classic picture, especially during the winter months. The story’s the same at the hospital’s eight other internal medicine wards. The hospital’s emergency room, not far away, is also very crowded: some 400 cases are treated every day.

Last month, the Health Ministry’s director general, Prof. Ronni Gamzu, sent a letter (which Haaretz has obtained) to hospital directors. In it, he places full responsibility for the care of patients waiting for over 23 hours in the emergency rooms – known as urgent care centers – on the staff of the hospitals’ internal medicine departments.

“In some of the urgent care centers, there is a phenomenon of patients who are kept waiting after it was decided to hospitalize them,” wrote Gamzu. “The delay lasts from a number of hours to a few days. This is a difficult phenomenon from the point of the quality of the treatment.”

Gamzu also said that hospital directors can decide to set a period of time of less than 23 hours for the transfer of responsibility to the internal medicine wards. The heads of the internal medicine departments were shocked by the new regulations.

“These days, when the internal medicine departments are collapsing, the order is impossible to carry out,” said Dr. Dror Dicker, president of the Israel Society of Internal Medicine and head of the Internal Medicine D department at the Rabin Medical Center, Petah Tikva. “Our staff are also collapsing under the burden.”

There are almost 100 internal medicine departments in Israeli hospitals run by the state or Clalit Health Services (Israel’s largest health maintenance organization). The standard number of inpatient beds in these departments averages about 38 to 40, and this number is limited both by the physical space available and the number of staff attending. The departments are usually overcrowded; this increases in the winter and can reach 50 to 60 patients in a ward with some 40 beds available.

Some of the internal medicine departments also provide medical services that are not part of its official duty. For example, Dicker says, his ward provides intensive care facilities for patients on respirators when there is no room for them in intensive care. Some 200 patients a year are on respirators outside of intensive care every year, and this is in addition to the regular overcrowding, he added. “I can understand the thinking behind the decision to make things easier for the emergency room, but for that to happen we need more personnel,” Dicker noted.

It is hard to take responsibility for patients who are not within the area of the ward, said Prof. Hanan Guzner-Gur, head of the Internal Medicine Wing and director of the Internal Medicine B department at Ichilov. “In the 12 years I have been a department director, and even before that, the number of positions for doctors has not changed, even after all the agreements with the doctors, residents and nurses. In the meantime, the number of patients is rising, and there are no radical solutions here. So the most available solution is to give it administratively to the internal medicine departments.

“On the other hand, it is not a simple matter,” Guzner-Gur added. “There is great overcrowding of the emergency room. It is like entering a war room. It is a miracle that there are no medical mistakes – and here, too, no revolution took place.”

Emergency rooms are, without doubt, the pressure cookers of hospitals. In an ideal situation, the emergency rooms are meant to accept the patients in various levels of severity, diagnose them and provide initial treatment – and from there send them to be hospitalized in the inpatient wards or release them. Last week, the Health Ministry released a report on waiting times in emergency rooms for 2012, and found that 52 percent of patients wait for over four hours in the emergency rooms before either being released or having a decision made over whether to be hospitalized.

The wait for transfer to wards is a result of the overcrowding, but hospital policy can also play a part. In some hospitals, instructions are not to move patients into the inpatient departments without an open space. Instead, they are put in the corridors or forced to wait a long time in the emergency rooms.

Illustration: Emergency room at Rambam Medical Center, Haifa.Credit: Hagai Frid

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