Finding The Fix For Broke Emergency Wards
December 2008
The much anticipated final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published on 27 November, and it makes interesting reading.
The inquiry, which was set up in response to media reports of community and clinician concerns about patient safety following two high profile incidents at Royal North Shore Hospital, undertook extensive investigation of the health system over 10 months, including visits to 61 public hospitals, review of 1200 submissions, and 39 public hearings. More than 30,000 documents were reviewed in the most comprehensive examination of the NSW health system to date.
Commissioner Peter Garling SC describes the NSW public hospital system as "on the brink of crisis" and makes 139 recommendations for improvement and modernisation in his comprehensive report. He acknowledges the crucial role of hospital clinicians — nurses, doctors, allied health professionals and clinical support staff including orderlies and clerks — in keeping the system alive.
Many of Garling’s recommendations simply describe what hospital services, if well managed, should be delivering now. These are things like supervision of junior staff, multidisciplinary teamwork, thorough documentation, handover of patient information when shifts change — and there are no surprises there. Clinicians welcome support for formalising these fundamental requirements of patient care in performance agreements.
To drive these reforms, Garling proposes four new bodies: the Clinical Innovation and Enhancement Agency to support clinicians to develop protocols for best-practice, the Institute for Clinical Education and Training to guide postgraduate training across the health professions, The Bureau of Health Information to record and report data relating to patient access and health outcomes, and NSW Kids, to oversee all measures relating to the health of children and adolescents. The existing Clinical Excellence Commission will have an enhanced role driving system quality and safety.
Recognising the breakdown of relations between clinicians and administration, Garling proposes that oversight of the reform process sit outside NSW Health, suggesting that change be driven by clinicians "from the bottom up".
More controversial are Garling’s recommendations regarding emergency departments.
The Australasian College for Emergency Medicine believes that it is the role of emergency departments to provide care to any patient believing they are in need of emergency treatment — however Garling challenges this notion, stating that treatment should be provided based on clinical need rather than patient demand. He proposes a parallel system of "Primary Care Centres", staffed by general practitioners and non-specialist doctors, to sit alongside emergency departments.
Only those patients requiring "immediate care" — meeting definitions for Australasian Triage Scale categories one, two or three — should expect to receive emergency treatment. Patients in categories four or five, who under current guidelines are deemed able to wait for over one hour to be seen by a doctor, will be redirected away from the emergency department.
This is a simplistic interpretation of the role and value of triage categories, which are a measure of urgency, but not complexity. Patients in categories four and five often do not present with simple "GP-style" problems. For example, patients with broken bones, lacerations, injuries from recurrent falls due to advanced age, or even miscarriages, may fit within these categories. Surprisingly, more complaints about misdiagnosis or incorrect treatment arise from category four than other triage categories, reflecting the complexity of this patient group.
Recognising the weakness of relying on triage categories alone, Garling allows the triage nurse discretion to treat patients in "non-urgent" categories according to clinical need, however it is unlikely that nurses will want to take responsibility for sending potentially unwell patients away prior to medical assessment.
Furthermore, there is little evidence that redirection of non-urgent patients will significantly impact on emergency department overcrowding. Estimates suggest that "GP-style" patients represent less than 10 per cent of the workload of emergency departments, and as they don’t require admission to hospital, they do not block valuable hospital beds. Overcrowding is almost entirely due to increasing presentations by complex patients requiring hospital admission who are unable to be transferred to the ward due to bed and staffing shortages.
In the short term, the only answer to emergency department overcrowding is to fund more staffed hospital beds. In the longer term, we need to think creatively about how to better manage patients with chronic and complex illness in non-hospital settings.
Creating a parallel hospital primary care system, in a climate of doctor and nurse shortages, is likely to just put more pressure on already stretched hospital staff. On the other hand, closure of selected small emergency departments, although politically unpopular, is vital to allow the building of critical mass of staff, equipment and expertise in those departments which remain open.
Garling remarks that "the safety of the patients and the quality of their care is paramount". While many of his recommendations are welcome, more work is required to get the system right. Achieving change will require strong political leadership, plus ongoing consultation with clinicians and the community.
Garling has given the NSW Government three months to respond to the document. Those of us who need the public hospital system await their deliberations.
