Lisa Manley shifted uncomfortably on her narrow gurney in Bay 28 of the Massachusetts General Hospital emergency room, watching nurses and doctors rush past the open curtain of her cramped cubicle.
It was 11 on an August morning, and she was back where her battle against cancer had begun a year earlier. The previous night, she had spent 2 1/2 pain-filled hours in the waiting room, throwing up into a plastic supermarket bag. Then, at 1 a.m., a nurse had led her into one of the ER's 49 bays, where Manley changed into a johnnie and at last received morphine and nausea medicine.
So far, she'd spent 12 1/2 hours in the emergency room, with no idea when she would get a room upstairs - an uncomfortable limbo faced by ER patients in hospitals across the country. Though a physician had decided to admit her for treatment, there were more patients than available beds.
What Manley couldn't see from her gurney was the sometimes wrenching behind-the-scenes decision-making that occurs at Mass. General about how to distribute one of the most valuable resources in medicine: hospital beds.
While Manley and 21 other emergency room patients waited for beds, a team of triage nurses pored over computer screens and reports that offered a worrisome picture. The hospital's medical and surgical floors were at 96 percent capacity. The few open beds were off-limits because they were in specialized units, or because patients in those rooms were contagious or especially susceptible to infection.
The nurses' phones and pagers buzzed with requests - internists seeking space for longtime Mass. General patients, surgeons wanting patients transferred from other hospitals, and physicians pushing for beds for family members. All day, the triage nurses shouldered dilemmas with no easy answers.
For several days, Mass. General allowed a reporter and photographer access to the hospital's triage operations, an attempt to shed light on one of the vexing problems of US healthcare - why so many patients are trapped in the emergency room for hours, so close to a hospital bed, yet unable to get one - and how the hospital, with some success, is tackling the problem.
Patients at Mass. General spend an average of about eight hours in the ER before getting a hospital bed, but some, like Manley, wait far longer.
She felt the nurses and surgeons provided very good care, but the delays were stressful, she would say later. "I got so anxious," she said. "You see someone right away but then you wait and wait."
The wait begins
Manley was supposed to be enjoying Basel, Switzerland, not staring at the worn, gray linoleum floor in the emergency room.
In June 2006, Novartis, the giant pharmaceutical company, offered her a job heading global recruiting. She accepted and underwent a routine physical for new employees. The couple's Newburyport house was packed and a flight booked for Aug. 30. But four days before they were to leave, a doctor diagnosed advanced colon cancer and the family's plans suddenly were on hold.
Mass. General surgeon Dr. David Rattner removed the tumor, and this August she underwent follow-up surgery.
A week later, she walked 2 1/2 miles along the ocean, feeling almost like her old self. Out of nowhere, labor-like pains shot through her abdomen. She wanted to go to nearby Anna Jacques Hospital, which she knew was small and fast. But Rattner urged her to leave immediately for Mass. General, so his team could care for her.
X-rays taken in the ER showed a possible intestinal blockage, probably a complication from her earlier operations and radiation therapy, and then her wait for a bed began.
When her sister and a friend left at 3:30 a.m., she slept restlessly for two hours on the hard mattress. Nurses hurried in and out of her bay to grab supplies from a tall metal shelf; Manley helped herself to a pair of socks during the night. To use the bathroom, she dragged her IV pole in her johnnie past strangers.
"I'd like to get a bed because I think it's a better healing environment," she said.
Several studies published last month in the Annals of Emergency Medicine showed that the more crowded the emergency department, the more likely pneumonia patients are to wait to receive antibiotics and the more likely patients in pain are to face delays in getting pain medicine.
Manley got the medication she needed, and initially doctors and nurses were around often, taking blood and attaching EKG leads to monitor her heart. But as night turned into morning, she saw less of staff, as they moved onto a new wave of more urgent patients. Nurses forgot about her EKG monitors, and when the sticky pads began to irritate her skin, she asked someone to remove them.
She thought about letting her 3-year-old son visit. But she didn't want him witnessing the open suffering in the ER. Maybe once she had a room.
Each time a nurse turned into Bay 28, Manley's hopes for a room upstairs rose - and fell. The nurses came for other reasons. "No one said anything about when I'd get a bed," she said.
Tense juggling acts
Earlier that morning, soon after arriving at work, Kathleen Gottbrecht sighed as she looked at the tiny squares on her computer screen, each representing an emergency department patient. It's "a sea of red," she said.
Yellow squares indicate a patient has been assigned a bed upstairs. But at 7:40 a.m., she counted 22 red squares, meaning those patients, including Manley, were waiting for beds.
"The ED is full and there's no place to put them," said Jennifer McIntyre from the other end of an oval table in the nursing administration office on the 14th floor, where the triage nurses were meeting to prepare for another day of speeding access to beds and matching patients with the right units. Expansion of the triage team two years ago helped reduce average ER stays for patients admitted to the hospital to 8.4 hours this September, from 11.6 hours the same month last year.
In addition to waiting ER patients, eight patients in other hospitals had requested transfers to Mass. General. Nine patients in the hospital had been unexpectedly wait-listed for surgery, meaning they were filling valuable beds. And in the coming hours, dozens of patients would come out of the operating rooms needing beds.
Economic pressures in the 1990s forced some hospitals to close and others to cut beds. Mass. General, like other hospitals, worked to reduce the number of days patients stayed in the hospital. And the advent of minimally invasive surgery meant many patients could go home the day of their operation. But at the same time, new treatments requiring inpatient stays have been developed, and are being heavily marketed, and the number of elderly has increased. Overall, the number of overnight patients at Mass. General has grown 8 percent in the past five years.
Beds are mined like gold.
Gottbrecht and her colleagues struggle to balance the sometimes-competing needs of sister hospitals, ER patients, surgery patients, surgeons, and staff. The priority is to get unstable patients, or those who have waited 24 hours or more in the ER, into beds. But often the decisions aren't clear-cut.
On the morning of Aug. 23, Gottbrecht finished her meeting in the nursing administration office and pulled on a hip-length white coat with her name embroidered in blue cursive letters. She rode the elevator to the first floor and walked a long corridor lined with empty gurneys and wheelchairs for the daily 8 a.m. meeting with ER doctors and nurses.
"I hear the bed situation is kind of grim upstairs," said nurse Raymond Bisio. He urged Gottbrecht to give a lung cancer patient who was in pain and needed a blood transfusion the first available bed.
Because Manley was stable, her name didn't come up.
"We don't promise anything" to patients, said Maryfran Hughes, nurse manager of the ER. "Because we would say you're getting the next bed and then someone [more urgent] comes in."
Gottbrecht told the ER staff that she hoped to have better news at noon, as units began discharging patients scheduled to go home, but privately she worried. On her next stop, at the admitting office, she discussed her concerns with Benjamin Orcutt, the patient access manager, who sent an urgent text page to 100 nurse managers, unit coordinators, and physician leaders across the hospital.
"Overall Capacity Alert," he typed. "24 patients in ED awaiting placement. 96% adult med/surg. Please expedite and advise admitting of all discharges."
Now, it was Gottbrecht's turn to wait.
Some days, Gottbrecht and her colleagues have to put ER patients on the back-burner. On the morning of Sept. 26, Gottbrecht studied transfer request forms left in her inbox and knew she faced a dilemma.
A woman who had received a lung transplant at Mass. General became ill over the weekend. The Mass. General ER was full and closed to ambulances, so her local hospital rushed her to Brigham and Women's Hospital. She had been waiting three days to get into Mass. General, where doctors were familiar with her history. Complicating matters, she needed her own room.
"It's our duty to get her in here," said Gottbrecht, sitting at a desk in the admitting department. "But she's being cared for."
Orcutt told her another very ill man on her list was a patient of a particular surgeon. "Let's make sure he gets in - five minutes ago," Orcutt said.
The surgeon specializes in gastrointestinal cancer, a targeted growth area for the hospital, but one without its own unit, Orcutt explained. So admitting staff pay special attention to these patients.
Then there was a woman at an out-of-state hospital whose son-in-law was a doctor at Newton-Wellesley Hospital, a Mass. General partner. The community hospital wanted Mass. General nurses to check with the son-in-law about the type of unit she would be assigned, but Gottbrecht felt the decision should be based solely on the clinical evidence.
"Oh no, we won't be checking with him," Gottbrecht told fellow nurse Margaret Ramage. "We're the triage nurses at MGH!"
Part of Gottbrecht's job is to help staff on the floors understand when the situation is urgent, and to use negotiation or otherwise help free up beds faster. She has short blond hair, and laughs and chats easily, but she sometimes has to hold a firm line. "The answer right now is no," she responded when Ramage asked about a transfer request.
She started punching numbers on the phone.
She called the head nurse in the trauma unit, which had four open beds reserved for trauma patients, explained the hospital was desperate, and asked her to take a transfer. Searching on the computer, she saw that an open bed on Ellison 12 was not clean. She called a janitorial team and asked them to head up there immediately.
Finally, near the end of the day, Blake 6, the transplant unit, unexpectedly discharged a patient who required a single room. Gottbrecht immediately snapped it up for the lung transplant patient waiting at the Brigham. "Today was a good day," she said.
A month earlier, the day Manley waited, most of the transfer requests were from patients without a Mass. General connection or a life-or-death issue. They did not get in, including a woman on "comfort measures only" at a community hospital. "There is no real point in bringing her here," Gottbrecht said quietly.
The packed ER was her focus that day. Aside from the triage nurses, Mass. General has taken other steps to ease the ER backlog. The hospital opened an observation unit to monitor ER patients who are not expected to need hospital care longer than 24 hours. Gottbrecht, Orcutt, and others helped develop the computer system, called CBeds, that tracks beds in the huge hospital, so the triage nurses and admitting staff can see vacancies quickly - and so ER staff know as soon as patients' beds are ready.
These changes, the denial of transfers that day, and the urgent page from Orcutt, eventually freed a bed for Manley.
The wait ends
At 11:26 a.m., on a computer at the nurses station outside Manley's cubicle in the ER, the small red square labeled Bay 28 suddenly turned yellow.
Soon her husband, Morgan Stebbins, bounded into the room. "You got a bed!" he said.
Perhaps as a cosmic reward for her wait, Manley hit the jackpot of rooms - a single on the mahogany-appointed floor known as Phillips House that overlooks the Charles River. But the wheels can turn slowly at a large hospital. By the time Manley's room was cleaned and ER staff had time to discharge her, it was 3:02 p.m. Then an orderly wheeled her stretcher into the elevator. A lime green plastic bag stuffed with her clothes rested at her feet.
Manley just wanted to close her eyes.
"I was exhausted, physically and emotionally," she said later.
A long road lay ahead for Manley - she would be in and out of Mass. General over the next three weeks and finally undergo surgery for a blood clot in her intestine, which is what caused her pain and nausea.
After meeting her new nurse, she fell asleep in the quiet room - 17 hours after she arrived in the ER.
Liz Kowalczyk can be reached at firstname.lastname@example.org.