“The emergency department can’t admit patients if there’s no flow at the other end. Now everyone is involved”: Dr Sellappa Prahalath, with nurse unit manager Daryn Mitford. Photo: Nick Moir
Five days after Christmas, the emergency ward at Royal North Shore Hospital was heaving.
More than 220 patients limped, lurched and wheeled through the doors. Ambulances piled up outside. One person waited at least 18 hours to be seen by a doctor. Others not much less.
It can’t go on like this. The system will implode.
Medico
A medico observing the packed waiting room was alarmed.
“It can’t go on like this,” he said later. “The system will implode.”
The fortnight over Christmas and New Year’s Day is notoriously busy for emergency departments. Boxing Day is the busiest day of the year.
General practices, pharmacies and all the places that people usually go for minor ailments are closed, so instead they drive out to the hospitals and perch on plastic chairs among the bleeding and rasping.
These patients build up like a dam in the emergency department, which has a reduced capacity to feed them through to specialists within the hospital.
Many of the wards have closed. Doctors, nurses and administrators have gone on holidays and there are fewer beds for the patients that need further care.
Those that move into the hospital take longer to be discharged. The entire system slows down.
Mona Vale Hospital’s director of emergency, Andy Ratchford, said the predictability of the Christmas crush did not alter its course.
“Even though we know it’s going to happen, we don’t increase our staffing because we can’t afford it,” Dr Ratchford said.
“We don’t open up more beds because we can’t afford it. So obviously if you’re going to have the same number of beds and the same number of staff and more people coming in, you’re going to run into trouble.”
Patients arriving at Blacktown Hospital on Monday felt the brunt of that trouble as they waited in corridors, on stretchers and waiting room beds as night turned to day and back into night again.
One 63-year-old woman, weak from days of vomiting, waited close to 40 hours to be moved into a ward.
During that time the paramedics who delivered her to hospital needed to be relieved by another team, because they are not permitted to leave patients until beds are found for them.
Health administrators declined to comment on reports that 60 beds out of a total of 450 at Blacktown Hospital were closed over Christmas. Other sources have put the figure at closer to 40.
One staff member says while this might be reasonable in a hospital with extra beds, Blacktown has no surge capacity to cope with the straitened resources.
“Closing large numbers of beds over the Christmas period was always going to result in [delays],” the source says.
Australasian College of Emergency Medicine’s Simon Judkins says trolley blocking – leaving patients on stretchers until they can be admitted – is less an emergency department problem than a hospital problem because it cannot be fixed without everyone working together to improve flow.
A 2013 analysis by the NSW Auditor General found it was increasing. An average of 20 ambulances spend their days in hospitals instead of on the road, the report found, a figure that has tripled inside a decade.
Some emergency physicians believe more surgeons should be encouraged to continue working over the summer to open more beds for people flowing through from emergency departments.
Evening the spread of elective surgery would also reduce pressure in the flu season over winter, when it often has to be cancelled for spikes in admissions from elderly patients, Dr Judkins says.
“They do save a hell of a lot of money at that time by putting people on leave and closing theatres,” Dr Judkins says.
“The problem with what happened at Blacktown is it probably got to the point where they just closed too many beds.
“And to try and ramp up the whole hospital machine, to try to get people discharged, is just impossible because all those people who would normally be there – the social workers, the pharmacists, the physiotherapists – are all on annual leave.”
NSW Health Minister Jillian Skinner is familiar with the argument that hospitals should not shut down over summer, as she made it herself in opposition. She says hospitals use algorithms to calculate the demand and ensure they have enough staff and the problems at Blacktown were caused by an unanticipated spike in demand.
“We’ve stopped the long, long shutdowns that Labor used to implement – eight to nine weeks,” she says.
“This Christmas New Year, most hospitals shut for two to two-and-a-half weeks and that’s just normal.”
One year she invited surgeons to volunteer to continue providing elective surgery over the Christmas period, but only two took up the call.
“I’m not going to force doctors to work when they want to spend time with their families,” she says.
As the population ages, emergency department presentations are forecasted to increase 10 per cent annually.
The scale of the looming influx has forced health administrators around the world to seek new ways of alleviating pressure on emergency departments.
Most hospitals now recognise that emergency department blockages are not just a problem for the emergency department, but that the whole hospital needs to work together.
NSW Health introduced the Whole of Hospital Program in 2012, which includes strategies such as ensuring that appointments are set aside for emergency patients to have x-rays and MRI scans, so they do not wait all day for appointments, and that beds are cleaned and ready.
One study identified 24 to 33 per cent of latent capacity in Australian hospitals.
Campbelltown Hospital, which is upgrading its emergency department facilities, has reported huge improvements since it started on the program.
It now offloads 92 per cent of patients from ambulances within 30 minutes, compared with 60 per cent before it joined the program, and with 160 to 180 presentations per day, it is one of the busiest emergency departments in town.
Director of medical services, Sellappa Prahalath, said the hospital previously struggled to meet its key performance indicators.
“We wanted to get the whole of hospital involved in the process. The emergency department can’t admit patients if there’s no flow at the other end. Now everyone is involved.
“Systems were put in place which expedited flow.”
Dr Ratchford said the Whole of Hospital Program had led to a huge improvement at Mona Vale Hospital, but the forecasted increase in emergency presentations loomed large.
“Whole of Hospital can help patients get through a bit quicker, but it’s never going to keep pace with that amount of presentations.
“There are definite improvements that have come about in the last couple of years, but in a way it’s just chipping around the edges.”
The scene at Royal North Shore Hospital on December 30 was not outside the usual range for the busy festive period. It took an average 29 minutes to be seen by a clinician on that day, a further three hours to be admitted and another hour before a bed was ready on the ward.
The local health service was not able to comment on the patient who waited 18 hours.
At St George Hospital, 250 patients swung through the doors on each of their two busiest days, Boxing Day and January 2, but in a sign that patients were flowing, ambulances were waiting only 15 minutes to transfer patients.
Campbelltown Hospital fielded 218 presentations on Boxing Day and a similar number on New Year’s Day, but nearly all of them were off their stretchers within 30 minutes.
Dr Judkins says sometimes closing down beds for surgery over summer means less competition for emergency patients.
“But it’s a fine balance. If you get the mix wrong, you end up with a situation like Blacktown.”