Hunter health alert: do or die

It was just another busy Wednesday night at John Hunter Hospital emergency department.

Among the dozens of sick and injured waiting to see a doctor were Waratah pensioners Barry and Joan Alcock.

Like so many elderly patients who attend the state’s busiest emergency department, Barry Alcock had suffered a fall at home.

After watching in horror as her 80-year-old husband’s head “bounced off the lounge room floor”, Mrs Alcock called triple-0.

Not wanting to make a fuss, the couple waited patiently for more than seven hours on February 22 to see a doctor.

The next day, Mr Alcock was admitted with a brain haemorrhage and spent three days lying in a hospital bed, unable to understand what was happening around him.

Alarm bells sounded for Mrs Alcock, but on Sunday she was reassured and told she could take her husband home.

“He was in that much pain, he couldn’t stand up properly and he kept asking why it was hurting so much,” Mrs Alcock said.

“He was complaining about his back all the time. I specifically asked and they told me he had no broken bones.”

Weeks later, Mr Alcock’s general practitioner discovered every rib on his left side was broken, some twice, and several ribs on the right were as well.

“I knew there was something wrong, but I’m not a medical person so I couldn’t make them take notice,” Mr Alcock said.

“If this has happened to me, there is no doubt other people have suffered as well. I would not like anyone to have to go through that pain.”

General manager of the hospital Michael Symonds apologised for the family’s distress and said fractured ribs could be difficult to diagnose and no fractures were detected when the X-rays were reviewed.

Mr Symonds said it was the hospital’s goal to provide the best care to all patients and it was the family’s wish that Mr Alcock be cared for at home following ‘‘appropriate hospital treatment’’.

IN the past few weeks there have been several cases of patients and staff speaking out about failures in care at John Hunter Hospital.

The causes of these system failures are, of course, different in every case, but each has a common thread.

The Hunter’s health system is under pressure – it is over-stretched and under-resourced.

Staff who spoke to the Herald from John Hunter, Calvary Mater Newcastle and Maitland hospitals detailed “increasingly stressful”, “dangerous” and “difficult” conditions that contribute to compromised patient care.

A senior doctor said he knew of scenarios in which errors of significant magnitude had been made in Hunter emergency departments that had been largely related to workload.

The Australasian College for Emergency Medicine estimates 1500 people die each year due to overcrowding in casualty.

Nurses said at times they were forced to care for up to eight patients at once in John Hunter’s emergency department, while the patient-to-nurse ratio on the wards was one to four.

Health officials responded by pointing out the increasing demands on the system and said staff ‘‘worked to safe workloads”.

As chief executive officer of Hunter New England Health, Michael DiRienzo takes a practical view of failings and complaints.

“We use complaints as opportunities to look for improvement,” he said.

“I am not saying we get a lot of complaints ... individuals who take the time to write to us or ring us up, it’s not so much about the clinical treatment, it’s about the care aspect and we take the issues very seriously.”

For decades state government efforts to deal with hospital overcrowding have failed, with wait times for beds and surgery stretching out to days in the Hunter.

Across the Hunter New England Health network emergency department attendances rose from 369,009 in 2009-10 to 377,699 in 2010-11, equating to a jump of 23 patients a day.

In the year to March, 68,330 patients attended John Hunter’s emergency department, a jump of 2511 people, or almost seven a day when compared to the previous year.

John Hunter had an official bed occupancy rate of 97per cent at June, well above the internationally accepted benchmark of 85per cent for safe and efficient care.

DIRIENZO said with no room to expand John Hunter, it was crucial to look at other alternatives, including boosting care options in the community.

He said improvement required a “whole-of-system approach”, including further investment in home support services, initiatives to reduce the need for hospitalisation and access to nursing home places.

In the past few years, 24 extra beds have been opened at Belmont Hospital to act as a “relief valve” during times of “saturation” at John Hunter.

A report on the 20 largest NSW hospitals published in the Medical Journal of Australia last year found a correlation between lack of beds and how well emergency departments run.

There is no doubt emergency departments are political dynamite.

John Hunter’s staff medical council chairman Dr David Williams said it was the first place to show strain on the system.

Williams said people could not get in the front door of John Hunter, because all too often patients were occupying emergency department beds while waiting to be transferred to wards.

‘‘Access block’’ is mainly caused by elderly patients, who once admitted to a hospital bed, find themselves stuck there because they can’t go home and there is a lack of suitable nursing home accommodation – a federal government responsibility.

Williams said overcrowding was so acute that ‘‘people are jumping into warm beds as soon as the last patient leaves’’.

FATALITIES and failures in care are rarely reported publicly because of patient confidentiality and bureaucratic bans on doctors speaking out.

‘‘It’s our jobs on the line if we talk publicly about problems with patient care,’’ said one Hunter emergency doctor.

Another said the system was struggling with inadequate staff levels and was only held together by the goodwill and commitment of the workers.

Symonds said there was a need to better educate the public about other options for treatment outside of the emergency department.

Big picture health reforms, where community care is co-ordinated and hospitals are a last resort, is the stuff of dreams for administrators, patients and staff.

The latest vision for Australia’s healthcare system, introduced on January 1, not only promises better care, but also suggests it is possible to do it by halving wait times in emergency departments.

The $500million reform push to cap emergency department wait times was initially met with widespread criticism from doctors fearing it would put pressure on them to move patients before they had been stabilised.

Under the new guidelines hospitals must transfer, refer or discharge emergency department patients within four hours.

There will be annual incremental rises in the number of emergency patients treated within four hours, rising to 90percent by 2015.

The target for hospitals is 69percent this year, up from 62per cent achieved last year.

According to the latest Bureau of Health Information Hospital Quarterly report, Hunter New England achieved 71per cent between January and March.

But Belmont, the Mater, John Hunter and Maitland hospitals all failed to reach the target and were between 46per cent and 66per cent.

Symonds admitted achieving 90per cent would be a “stretch”.

He said a range of “whole-of-hospital” initiatives were being put in place to increase performance.

“It is a target, it’s a stretch we need to get to,” he said. “It’s a whole-system reform that needs to take place in order for us to achieve that benchmark.”

Some initiatives include:

?Bolstering the number of senior staff in the emergency express area to ensure a rapid flow of low-acuity, or GP-like, patients.

?Improving the function of wards to ensure people are discharged or transferred efficiently.

?Increasing discharge of patients at weekends.

?Promoting programs to help people avoid the emergency department and access treatment at home, via GPs or in nursing homes.

?Using information technology to ensure better patient flows throughout the hospital.

There are no plans to employ more doctors in the emergency department.

“People think if we bolster staff, patient flow will improve, but that’s not totally accurate. There are many, many other factors at play,” Symonds said.

WITH the strain on the system already so great, many fear there is little hope of ever reaching the 90per cent benchmark.

Hunter doctors said without more workers and beds they were unlikely to meet the targets which could jeopardise the region’s chances of receiving a share of the incentive-based funding that was built into the new scheme.

Over four years from this year, NSW will receive $96.9million in funding from the federal government to help it achieve the four-hour target, plus $72.5million for capital investment in emergency departments.

But a further $63.6million is contingent on annual improvements against the four-hour threshold.

President of the Royal Australasian College of Surgeons Dr Ian Civil warned there were some bitter pills to swallow in accepting the four-hour rule.

Civil said it could lead to hasty decisions that endangered lives and there was little evidence it worked.

“The UK recently withdrew the four-hour rule,” he said.

“A six-hour rule is in place in New Zealand and has similarly failed to deliver improvements in patient care. By stressing promptness of care without providing additional radiology, ward and operating room resources, the rule runs the danger of compromising quality of care.”

But others, including the Australian College of Emergency Medicine’s NSW faculty chair, Associate Professor Richard Paoloni, said major reform to improve emergency department performance was “long overdue”.

Paoloni said many doctors had been reassured by the experience in Western Australia, which pioneered the four-hour practice.

Research published in the Medical Journal of Australia in February found the introduction of the rule saved 80 lives in three West Australian hospitals in 2010-11.

It was found the four-hour rule had led to a whole-of-hospital approach that appeared to have encouraged better communication between the emergency departments and wards with “an increased appreciation of each other’s problems”.

Paoloni said because the system linked performance and financial reward, it had “upped the ante to make real change”.

He said work practices in emergency departments had not evolved as demands on the system had increased.

The traditional apprenticeship model of teaching junior doctors in emergency departments by allowing them to make an initial assessment of a patient and then reporting to senior staff would no longer work.

“The educational process used to precede the decision to accept patients to wards,” he said.

“The educational part of the process will have to shift to the wards. It is going to take a massive culture change and it’s not going to happen quickly.”

Paoloni said it required reworking the entire system throughout the hospital, to minimise unnecessary delays and steps.

He said the biggest issue was the health bureaucrats’ decision to introduce the change so quickly.

“It is a huge thing that touches on decision-making processes, educational issues and safety,” he said.

“It is going to take time to introduce but it is long overdue and it needs to happen,’’ Paoloni said.

‘‘Nobody will change unless they are driven to change.”

The chair of the Australian Medical Association’s NSW Hospital Practice Committee, Associate Professor Brian Owler, said there was no doubt things could not stay the way they were.

Owler, who sat on the expert panel to review the four-hour guidelines, said access block and overcrowding was associated with increased morbidity, and patients were fed up with extended delays.

“This is the biggest reform we have seen in decades,” he said.

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