Can we fix our ailing hospital emergency departments?
Airdate: 
Tuesday, September 1, 2009 - 20:30
Channel: 
SBS



Doctors and nurses say they're struggling to cope and this can sometimes lead to tragic consequences.

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Replay our online chat with experts.

According to one study, overcrowded emergency departments are responsible for up to 1,500 deaths a year, as high as the nation's road toll.
 
Join us as we hear from doctors and nurses who work in emergency and the patients who turn up there.

What every patient should know when an emergency arises.

Transcript

JENNY BROCKIE: Welcome everybody. Good to have you all here. Bryon Beggs, I would like to start with you, let’s hear the story of what happened to your mum when she sought medical care in Hobart.

BETTY SULLIVAN’S STORY:

BRYON BEGGS: She was a happy go lucky lady, full of life really - loved a joke, loved to laugh.

On the eve of her 79th birthday Betty Sullivan flu to Hobart to visit her son Bryon, on the flight she became ill and Brian tried to get her in to see a GP.

BRYON BEGGS: They just seemed to be swapped at the time. the only option was to go to the Royal, to the emergency section there.

Bryon drove Betty to the Royal Hobart Hospital where she was triaged as a category 4 patient – this means that her condition was potentially serious and she should be seen by a doctor within an hour.

BRYON BEGGS: People were coming in and getting really frustrated that they couldn't get to see anybody - people getting angry with the staff. Some up and left out of - you know, disgust but others opted to try private hospitals elsewhere. It was just a very frustrating time. Yeah. And all that time, mum was sitting there, it was her birthday, and she didn't complain.

Eventually the doctor came and said "look, our hands are tied we can't do anything you are welcome to stay and wait but all the cubicles out the back are full and after nine hours of waiting there, yeah, we were just dumbfounded.

He took his mother home. A day later, her condition worsened. Bryon's GP advised him to take his mother back to the emergency department.

BRYON BEGGS: I got down there, wheeled mum in, saw the same triage nurse that was on two days before and she said, 'Oh, Mr Beggs, I'm sorry, the waiting times are going to be similar to what they were when you were last." And I thought ' I'm not putting mum through that again."

In desperation, Bryon paid for his mother to see a doctor at a private hospital - they diagnosed her with an infection and sent her home. The following day, her condition deteriorated. This time, Bryon called an ambulance which took Betty back to the emergency department at the Royal Hobart. On this third visit, she was seen immediately.

BRYON BEGGS: I said "how are you feeling mum?" she said " I'm feeling retched, absolutely retched - my legs, my legs." With that she started having a heart attack.

Betty was left in a critical condition and the family decided to take her off life support.

BRYON BEGGS: Mum died. For that last part of her life, not to be cared for and made comfortable as soon as she could have, or should have been, is a real tragedy. A real tragedy.

JENNY BROCKIE: Bryon, three visits to emergency before your mum was finally treated. Where do you think the fault lay in that situation?

BRYON BEGGS: I don't really know. I know the staff were doing what they could with what they had. It seemed to me that they were under staffed at the point in time, the coroner has since said that. It was just a frustrating time for everybody - patients and staff.

JENNY BROCKIE: And of course a very discomforting time for all of you but for your mother especially?

BRYON BEGGS: Yes, for sure.

JENNY BROCKIE: The coroner said that - even if your mum had been seen, it couldn't have changed the outcome. And I know the hospital says it has improved triage and increased staff since it happened, the coroner's report came out relatively recently -a couple of months ago I think. Do those changes at the hospital address your concerns about what happened?

BRYON BEGGS: It's hard for me to say unless I'm faced with the same situation again which I won't be, not with my mum. It's difficult to say.

JENNY BROCKIE: But for you the system clearly wasn't working?

BRYON BEGGS: Yes, it was very lacking to make mum comfortable.

JENNY BROCKIE: Jordan, you are 15, and your mum recently took you to Fremantle hospital with a letter from your GP, saying you had acute appendicitis. What happened when you got there and how long did you wait.

JORDAN CANDLISH: We got to Fremantle hospital at about 4.30 in the afternoon and we got through emergency and went into like the waiting area, just past emergency and we were waiting there, it must have been nine hours before they look at the sheet and said I was too young to be operated on so I was transferred to another hospital and was operated on there, by that time the appendix had bust and spread through my stomach.

JENNY BROCKIE: So nine hours to find out that you couldn't be treated in the hospital. What sort of state were you in during those nine hours?

JORDAN CANDLISH: I was lying on a bed and couldn't move because of the pain I couldn't do anything. I was just waiting, hoping that someone would come soon and no-one ended up coming.

JENNY BROCKIE: Nine hours is an awfully long time to be in that sort of pain. Susan, you're Jordan mum and you were with him. How badly ill was he by the time he did finally get to a surgeon?

SUSAN CANDLISH: By the time he was seen by a surgeon he was uncomfortable and in a lot of pain and discomfort but we couldn't believe he had been left so long without being attended to. It was obvious he needed an operation to remove the appendix.

JENNY BROCKIE: And the appendix had bust?

SUSAN CANDLISH: They had perforated apparently by that stage and by the time he was operated on, it was quite a messy situation the surgeon said. There was quite a lot of contamination and they were perforated and gangrenous and he was in a bad way.

JENNY BROCKIE: How did you feel about that experience?

SUSAN CANDLISH: I felt frustrated, just sitting there waiting. We weren't sure how long it was going to be. I asked a nurse here and there and they couldn't really give me an answer and said the surgeons weren't available - they were either in theatre or you don't see them around. We thought well, someone has to see him.

JENNY BROCKIE: Of course, you were waiting just to go to another hospital as it turned out and you didn’t know that.

SUSAN CANDLISH: In the end, after nine hours when we were told we were at the wrong hospital, we should be transferred and we were transferred, that way it was just ridiculous.

JENNY BROCKIE: Mike, you are a specialist emergency physician from WA which has some of the longest waiting times in the country in emergency for patients in emergency. A nine hour wait to get the information you are at the wrong hospital. I mean, how often does that sort of thing happen?

DR MIKE CADOGAN, EMERGENCY DOCTOR, WA: Certainly, it's not a frequent occurrence. But to have people come to the triage desk, that's the place where we would initially make did some diagnosis of someone being too young or to actually be at my hospital and need to go to a children's hospital. I guess you know, without going into the individual facts, trying to get somebody through the triage system, given appropriate treatment and care and then make the ongoing referral as part of what we have to do on a daily basis.

JENNY BROCKIE: And those long waits – something like a nine hour wait -is that happening frequently?

DR MIKE CADOGAN: Yes, we certainly are - we have extensive waits for a number of different reasons. It can be waiting for the specific specialist on call to come and see them. It can be trying to get through the emergency department. It can be waiting in the waiting room to get into the emergency department. There are a number of different levels which we’re blocked.

JENNY BROCKIE: Where do you put people when they are just waiting – what happens to them?

DR MIKE CADOGAN: We have extended the actual departmental area into it was into corridors but that became a fire risk - now we have opened up separate areas where we are seeing them closer and closer towards the front and now the nursing staff go out into the main waiting area in order to start the triage process and start the treatment process out there now.

JENNY BROCKIE: How long - how often would you say those really extensive waits are happening in the system?

DR MIKE CADOGAN: Daily.

JENNY BROCKIE: Daily.. How often, how many times a day, how many people a day would be waiting for those extended periods?

DR MIKE CADOGAN: On a daily basis we - every day we will have somebody waiting for more than 6 hours to actually either be seen by a specialist or patient team or actually be admitted into a hospital setting.

JENNY BROCKIE: Margaret, a couple of months ago, your 92-year-old mum Lillian, was taken to Westmead hospital in Sydney in great distress after she suffered hallucinations. How long was she waiting on the ambulance trolley before she even got into emergency?

MARGARET DONKIN: Well Jenny, we got to the hospital at 6.30 at night. At quarter to three in the morning, mum was strapped on - which they have to be - strapped on the trolley, of course, seeing the ambulance and with dementia, she thought it was police and she thought she had done something wrong, 'why am I being arrested," all that sort of went on. Quarter to 3, she finally went to sleep on the trolley in the morning.

JENNY BROCKIE: So she was still on the ambulance trolley from 6o’clock the night before?

MARGARET DONKIN: At one stage, there were 6 trolleys in the corridor, it was only a very narrow corridor there. She was strapped on - they have to do that. She went to sleep to quarter to 3 in the morning. The ambulance man said to my sister and I, why don't you go home and get a couple of hours sleep. We left there at 3.30 on Monday morning - she was still on the trolley and we got back at half past 8 the next morning and they were just assessing her in a bed in the emergency ward.

JENNY BROCKIE: That must have been hugely distressing for an elderly woman.

MARGARET DONKIN: That was terrible, the poor old thing, because she thought they were police and when she wanted to go to the toilet, they had to help her because there was only little nurse on. So it was really sad.

JENNY BROCKIE: Of course the ambulance officers are tied up for all that time if she is not getting into the hospital.

MARGARET DONKIN: They have to stay, and that’s it – the Parramatta boys took her there, nine o'clock, they sent in a couple of ambulance men from Lane Cove and then at 12 o'clock they sent some in from Ryde station to relief.

JENNY BROCKIE: Barry, you had a similar situation, yes, with your elderly mother. How long was she waiting at the hospital with the ambulance crew.

BARRY THOMSON: We arrived by ambulance at about seven o'clock, in the morning. She didn't actually get to a bed until after one o'clock in the afternoon. For the whole time she was quite distressed because gurneys are not very comfortable.

JENNY BROCKIE: Again, how many other ambulance crews did you see there doing a similar thing, staying with the patient which they have to do until they get admitted?

BARRY THOMSON: Up to 6 at one time. The ambulance officers were extremely frustrated. They passed their frustration on to us. They indicated that at the time, 50% of the local ambulance service was tied up waiting at the emergency access there but what was more frustrating was the fact that the ambulance officers were our primary care, nobody from hospital was offering care because while we were in the care of the ambulance, that's who was looking after us.

JENNY BROCKIE: Steve, you represent Victorian ambulance workers and these incidents happen in New South Wales but I wonder, how often your members, your ambulance workers are in this situation where they are tied up hour after hour after hour at hospital because you can't get into emergency.

STEVE MCGHIE, AMBULANCE EMPLOYEES AUSTRALIA: This would be a daily occurrence in particular metropolitan Melbourne and some of the major regional hospitals as I say it would happen daily. We have recently acquired data from the ambulance service over the months of May, June and July, and it happened on 997 occasions over that 90 day period, that ambulances were waiting in line for a minimum of an hour and up to 3 hours and up to 11 ambulances at once. We have seen this becoming an increasing problem.

JENNY BROCKIE: What does that mean for the service you can provide as an ambulance service or the ambulance service itself can provide to other people who need an ambulance?

STEVE MCGHIE: Obviously what it means is there is a greater unavailability for ambulance responses and ambulance crews to respond to the next emergency. While on average there is about 11 hours a day where ambulances are tied up waiting at hospital to off load their patients - that 11 hours of ambulance resources is taken out of the system, so it just means that a ambulance crew has to come from a further distance away to that next emergency which means it's a longer response time and it could be detrimental to the outcome of the patients condition.

JENNY BROCKIE: I want to balance things up a bit at this point because I know a few people have had a few good experiences in Emergency, Michael, your one of them aren’t you - did you have a good time"¦.

MICHAEL OSBORNE: I just think waiting 6 hours to get my hand fixed up when it was a self inflicted injury was quite acceptable.

JENNY BROCKIE: Six hours"¦. I didn’t think you waited six hours – so you think that was acceptable?

MICHAEL OSBORNE: I had x-rays within that time and at the end of the day I was reprioritised - I saw they had an ambulance with a high speed roller and within the time I had actually arrived - they got treated first obviously and I was quite happy"¦

JENNY BROCKIE: So you were quite happy with how you were prioritised and dealt with?

MICHAEL OSBORNE: They assessed me well enough and I was treated in due course.

JENNY BROCKIE: Chad, what about you?

CHAD MCCARTNEY: Well, I was extremely happy with the process because my friend was taken straight from Kings Cross to St Vincent's hospital, that was like within ten minutes and we were seen straight away. So - we were out within half an hour so we didn't have like a long wait at all.

JENNY BROCKIE: OK, so just to get the whole picture here because I know that some people have excellent experiences going to emergency departments. Clare, you are an emergency doctor at a big teaching hospital in Sydney where Kevin Rudd recently dropped by to hear, 'warts and all about the problems with hospitals" his term I think, what did you tell him about emergency?

DR CLAIRE SKINNER, EMERGENCY MEDICINE REGISTRAR: The thing I wanted to convey and I am a trainee emergency doctor is that people who work in emergency departments, I mean doctors and nurses but we don't think of people like clerical staff who work there as well, we don't do it for money or for glory, we do it because we actually deeply care about our fellow human beings. We work in a system that is often not properly resourced, so we don't have the beds we need, we don’t have the staff we need, we don’t even have the physical equipment we need and that means that often we are made to feel like meat in the sandwich. It's a very awful thing to take someone who really, really cares about something, and wants to do it well and compromise their ability to do it.

JENNY BROCKIE: It's interesting though, because in all the stories we are hearing, we are not hearing any anger towards the staff in the hospital – no., not angry with the staff, but angry with what? The system – the way the system operates at the moment. I think it's fascinating, given that some people like you, Bryon have been a very traumatic episode but you are not angry with the staff?

BRYON BEGGS: No way, no way, no.

DR CLAIRE SKINNER: But it leads to tremendous stress and burn out in the staff to constantly be forced to say no to people who need their care and I think that is important.

JENNY BROCKIE: Dianne, you are a nurse practitioner at a big children's hospital. Is Emergency any better there?

DIANNE CRELLIN, EMERGENCY NURSE: I would love to be able to say, clearly we are much better at managing our patient load but I think that's probably not reasonable to say that. We are certainly under- I think-many of the same pressures that adult and mixed departments are under and increasingly so. Once upon a time when I first started in Emergency which was a while ago, it was some years ago - we didn't have the bed access problems that adult departments did. We didn't have the problems in terms of space and resource in our department. But increasingly, that's not the case for us. We have extended waits for our patients as well. I absolutely concur and I think it would resonate with most paediatric emergency clinicians with the issues that you've raised so far in particular, just how frustrating it is, not to be able to provide the service that you would like to be able to provide.

JENNY BROCKIE: We will get on to some of the causes of this in a moment.. Before we do, Drew Richardson, I know you have done a study looking into how patients are affected by overcrowding in Emergency departments - A very recent study -I gather - Some results that have just come in yesterday. What have you found?

DR DREW RICHARDSON, ANU MEDICAL SCHOOL: There is no doubt that waiting times like this are a sign of an overcrowded department and our studies and others like them show that if you present to an overcrowded department, you are 30% more likely to die. You have about 30% higher mortality if you present to an overcrowded hospital.

JENNY BROCKIE: Why don't we let you have a little cough"¦ Is there a doctor here who could take care and while you are having a little cough - Bob Wells, I will talk to you and ask you as a health policy analyst, what you think all this says about the health system in general because the emergency department is like the front door of a hospital isn't it, it's where you go in first and where you see problems. What does it tell us about the bigger picture?

BOB WELL, AUSTRALIAN NATIONAL UNIVERSITY: It clearly shows there is a big problem. In many ways, emergency departments are the canary down in the coal mine and once the canary gets sick, you know it is time to really do something serious. I think there are problems both of resourcing - clearly and I hear that from around the country, there are resourcing problems in the emergency departments. There are problems then of getting patients who have to be admitted into the hospital because they are crowded as well. Most of the big teaching hosptials are running at over 90% occupancy, so there is no capacity there to spare and then there are pressures coming from the primary care end, where we have a shortage of GPs, we’ve got reduced access after hours to general practices, so people who might have otherwise be quite happy to go along and see a GP are now feeling that they can’t or can’t afford it and so they front up to the Emergency Department. So I think all that puts pressure and I think another factor is of course is the increasing expectations in the community – that whatever illness you have can be dealt with and whatever age you are – that illness can be dealt with. So we have much more expectation from the community, that every health problem can be fixed and of course that is not the case.

JENNY BROCKIE: How are you going Drew"¦. Better? Let’s get back to your study because you got to the very critical point of saying that you were 30% more likely to die in an overcrowded Emergency department.

DR DREW RICHARDSON: I am afraid that is true, I’m pleased to say that the mortality after coming to Emergency department is low, but, obviously there is a mortality and if you present to an overcrowded department it has been shown in different centres in Australia and around the world, you are more likely to die than the same sort of patient who comes when it is not overcrowded.

JENNY BROCKIE: And how would you describe the system at the moment in Emergency departments?

DR DREW RICHARDSON: I would describe the system as critically overcrowded, everywhere around the country there is evidence that our departments are struggling under the load.

JENNY BROCKIE: And your figures show that the number of people dying as a result of this is higher than the national road toll, is that right?

DR DREW RICHARDSON: That’s right. The estimate is about 1500 deaths a year due to overcrowded departments. This is figures from the period 2002- 2004 and that roughly corresponds to the road toll each year at that time.

JENNY BROCKIE: Tonight Insight is looking at Emergency departments and what is causing the problem in so many of them. People are saying that they have had good experiences even if they had to wait - there is quite a bit of talk about waiting. And again, goodwill towards the doctors and nurses which I think is very interesting. Carol. I know that you suffered a heart attack, 3 weeks ago, you were seen by a doctor at Wollongong hospital pretty quickly. They decided to admit you in a cardiac ward, what happened then?

CAROL HAMILTON: I had to wait 28 hours to get into that cardiac ward.

JENNY BROCKIE: 28 hours you were in emergency.

CAROL HAMILTON: Yeah.

JENNY BROCKIE: Waiting for a bed. There wasn't a bed in the ward?

CAROL HAMILTON: There wasn't a bed. There wasn't a bed in the whole hospital.

JENNY BROCKIE: Anywhere?

CAROL HAMILTON: Anywhere.

JENNY BROCKIE: So that's 27 hours you were in emergency that somebody can't get into an emergency bed as well because you are sitting there waiting for a move.

CAROL HAMILTON: Yes.

JENNY BROCKIE: Sally, I know that you have views about this and I know that you head up a group responsible for training and accrediting emergency doctors as well as running an emergency department at a big teaching hospital in Sydney. What causes those blockages, is it just about beds?

DR SALLY MCCARTHY, AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE: It is about available beds, the problem for us in emergency, is that whilst we can treat patients and get them stable, we need to move them on into the hospital. Almost 40% of our workload now is looking after patients who have finished their emergency phase of care and who should be in a bed within the hospital. It's like I mean, talking about frustration amongst staff, it's like sending staff to work with their hands tied behind their back because we really don't have beds to treat our new emergency patient on, when all our beds are full of patients who should be elsewhere in the hospital. We are not set up to deliver the ongoing specialist care that patients need and this includes all groups of patients, they can be intensive care type patients or coronary care, as we’ve heard or mental health patients and all groups of patients who require specialised care and they end up waiting in an overcrowded emergency which is lit 24 hours a day, it’s very busy, it's noisy, there's lack of privacy, it's - it's an unpleasant place to be when you are at your sickest.

JENNY BROCKIE: And the categories of people who are presenting at Emergency - What types of people do you think are causing a lot of that build up and demand?

DR SALLY MCCARTHY: It's really not the patients presenting to emergency. The Australian public are pretty smart about where to go for care. They select themselves pretty accurately in terms of requiring hospital intervention. So that we hear a lot about lower triage categories of patients – categories 4 and 5 - you know, should

JENNY BROCKIE: There are five categories in triage, yeah?

DR SALLY MCCARTHY: Yeah, the reason is it is the Australasian triage scale, and it sorts patients according to their clinical urgency, so it is to guide us, so if we didn't have a queue, we wouldn't need to triage, we would just see everybody when they presented but because we have got our demand in excess of our ability to see patients when they come, we have to sort out people who need intervention quickly and those who can safely wait a little bit longer.

JENNY BROCKIE: Drew, I know you have looked at this and we are talking now about causes and we hear all the time - more beds, more beds but what else is going on?

DR DREW RICHARDSON: Well we surveyed every major emergency department in the country at 10 o'clock yesterday morning, so far, 71 have sent us their figures from those. At that time, there were 448 patients all around the country in emergency departments, who were simply waiting for an inpatient bed and had been there more than 8 hours. At that time there were only 427 patients around the country actually waiting to see a doctor.

If it weren't for the people unnecessarily waiting for beds there would be no wait to see a doctor in our Emergency departments. Furthermore, there were 79 patients just like the one we heard who waited more than 24 hours for a bed. There were 3 who had waited more than 60 hours - 2.5 days for a bed. That is not what emergency departments are for.

JENNY BROCKIE: Is that getting worse or has it always been this bad?

DR DREW RICHARDSON: It's been getting worse for years, it’s much the same this year as last year but it's been getting worse over the last decade.

JENNY BROCKIE: Roger, you ran one of Sydney's busiest emergency departments, familiar.

DR ROGER HARRIS, INTENSIVE CARE DOCTOR, NSW: Yeah. You have no idea. I guess just listening to all of this brings back a lot of not so fond memories but I trained as a specialist in emergency medicine like many of my colleagues here and invested 10 years of my life training in that specialty, only to be in many ways, crushed by it.

JENNY BROCKIE: What do you mean crushed by it?

DR ROGER HARRIS: Well, many of the words that I've heard used here, like hands tied behind your back is a very familiar feeling - being trained to do a job and to look after patients but trying to do it in a system that didn't work. So, feeling all the time that you were seeing people on chairs, that really needed to be in beds or seeing people on ambulance trolleys, who needed to be in rooms. It was a very difficult job to do. It was just pick up on something that Clare said earlier which was about being the meat in the sandwich, it was a revelation to me when I actually decided to leave emergency medicine, took a big pay cut and made a big life change and decided to go and retrain in another specialty which was intensive care and when I went back as a trainee as a more junior doctor, I left as a very senior emergency physician, I went back as a more junior doctor in Intensive Care, but felt much more valued because now all of a sudden people asked me for help. I didn't feel like I was part of the problem, I felt like I was part of the solution and it made a huge difference to the way I felt about being back in medicine.

JENNY BROCKIE: That's fascinating for me. Paint me a picture of what it was like for you sitting in that job in that emergency department? Just describe it for us. Take people there.

DR ROGER HARRIS: I guess you can imagine a department that was as we have heard overcrowded. That the facilities were inadequate for the number of people who were there, that you were apologising continually to the patients because they did have to wait long or had not received the sort of care I wanted to give them. That I was apologising to my staff, because of the pressure they were under. And the way they were working. Then, when I rang my other colleagues, like I now would have been ringing myself in my new job, I was apologising to them because I was now delivering more work to them. I felt very undervalued and it was a difficult thing.

JENNY BROCKIE: What happens now when they call you? When the emergency department calls you?

DR ROGER HARRIS: I tell them to get lost..

JENNY BROCKIE: How interesting? Why do you tell them to get lost?

DR ROGER HARRIS: They don't let me do that I can guarantee you. They remind me exactly who I am.

JENNY BROCKIE: How do you deal with it when you are on the other side.

DR ROGER HARRIS: It's very difficult. I am often torn because the resources that are put into something like intensive care and the operating room where I work are completely different to what is put into emergency. I just don't understand why that is. We have heard the emergency patients described as vulnerable, they are very sick patients often.

JENNY BROCKIE: And a lot of them need to go to intensive care – some of them do.

DR ROGER HARRIS: Many of them are elderly and they are complex medical problems and yet we don't put the resources at the front door and get it right at the start. In somewhere like the operating room or intensive care, there's a huge amount of more resources and I just don't know why we aren't putting more resources at the front door. I don't think any other business, no other organisation would operate the way health operates.

JENNY BROCKIE: Peter, Nugus, you are a sociologist. You have spent nearly a year looking at the inner workings of emergency departments. What is the relationship like between doctors in Emergency and other parts of the hospital and how do these different areas work together? Do they work effectively together?

DR PETER NUGUS, SOCIOLOGIST, UNSW: Well, at an individual level, the relationships between doctors from the emergency department and inpatient departments are pretty cordial and professional generally speaking but there is a power imbalance between doctors in the emergency department and doctors in inpatient departments, a source some of the some of the problems that have been talked about tonight is actually the way the hospital is organised. It's organised according to particular organs of the human body. The good thing"¦ and there's specialised knowledge that comes along with that. The benefit of course is that we get advanced treatment and for a modern society that's is what progress is all about. The down side is that there's a mismatch between the way the hospital is structured and the complex older patients who are increasingly presenting to emergency departments. An inpatient specialist will always have more power knowing more about their particular organ and when they are under pressure because we are not talking about individuals being good or bad, when they are under pressure, it's easy for them to say, I am sorry, that's not my problem, the Renal problem is more pressing than the heart problem, so emergency clinicians find it's harder to sell these patients.

JENNY BROCKIE: That is one thing I am interested in - I have spent a bit of time in hospital emergency departments recently, the systems, I am just interested in whether you all think the systems work, the people from a patient perspective or from somebody with a patient, I have to say they look arcane sometimes or they look really old fashioned, you are all nodding your heads. Do you think that's the case, Peter. Do the systems work? Are they efficient, do they work well?

DR PETER NUGUS: Look, I think a lot of people talk about efficiency and I believe that you can deliver quality care but also try and be efficient as well. There is a big emphasis on bringing in new rules and policies can say whatever they like. You can have a policy to say well okay, 8 hours, 4 hours, half an hour, get them out but in the UK for instance, we have seen where they said nurses can't put patients on trolleys but what nurses in at least one department did was take the wheels off the trolley and said 'what trolley?" basically so policy has to fit with what staff are doing in their day-to-day work.

JENNY BROCKIE: I suppose I am not talking so much about policy, records and communications and whether, we live in a very kind of technological world. I wonder, Clare, you are agreeing with that. Do you think the systems that are operating could be part of the problem as well?

DR CLAIRE SKINNER: I think it is and to take this down to a basic patient safety level, quite often a patient will come to the Emergency department and their GP knows them well and now we have no access in the Emergency department, to the records that the GP keeps. We have no access quite often to the medications that they are on.

JENNY BROCKIE: So you are often starting from scratch?

DR CLAIRE SKINNER: We are starting from scratch and most people who present to Emergency have a history and patients are often frustrated because they think that we have access to the things that are on the computers of the GPs. And then there are things like ordering a CT scan or ordering blood tests are often done on pieces of paper and those pieces of paper might go missing and we rely on a system of Chinese whispers to communicate information throughout the hospital and then things don’t happen and people are surprised.

JENNY BROCKIE: Mike, do you agree with that?

DR MIKE CADOGAN: Certainly, the IT infrastructure we’ve got is ridiculous for the health system that we have in place. The ordering of pathology tests, radiology tests, the actual communication of information for example ECGs, if somebody comes in with a cardiac condition, they have had an ECG three months before, it would be lovely to see that ECG that they had three months before. We have got the electronic capabilities to do it, we just have nothing in place.

JENNY BROCKIE: And how does that all effect patient care?

PROFESSOR FRANK DALY, EMERGENCY DOCTOR, WA: It is very deleterious for patient care. We are alluding to a problem whereby hospitals are very much vertical heirarchy of professional groups. They are very very good at what they do but they are not very good at communicating with each other and that communication can be verbal, written or even electronic. But the patient does not see that at all, the patient comes ...


JENNY BROCKIE: Oh but the patient does see that, the patient does see that sometimes.

PROFESSOR FRANK DALY: .....horizontally, the patient comes through the organisation in a different orientation, they come across all those silos and so a lot of the problems occur when you have interface - so there are communication problems, delays and errors occur whenever you get people trying to cross those barriers that are being put up in hospitals, and that is why we have to change the system a bit.

JENNY BROCKIE: And what does all that mean for patient care?

PROFESSOR FRANK DALY: It means increased medical errors, it means delays, it means delays to surgery, it means inceases in length of stay and the increase in mortality that Drew alluded to not only just occurs in the Emergency department, it's not just people dying in the ED, it's dying throughout the hospital addmission. So it has a roll on deletirious effect all the way through.

JENNY BROCKIE: Talking about mistakes, Paul, I think you are interested in the issue of mistakes. Tell us your story because you hurt your neck 3 months ago.

PAUL CURTIS: Yeah, I accidentally broke my C7 in a head collision with one of my young friends. I was taken to the local hospital and I was examined by the nurse at the front and told to go sit down and sat there for 2.5 hours.

JENNY BROCKIE: Undiagnosed of course.

PAUL CURTIS: Undiagnosed, actually said to them, I've had a major head collision, had swelling at the back of my neck, had a bit of neck pain, had some pins and needles, and went in - I was in with the dock for like, not even ten minutes. Noticed there was swelling on my neck. Said, you will be fine. Go home with a Panadol. I actually reported back to the hospital on Monday and they X-rayed me and then they see - scanned me and I had had a broken neck and I was very close to becoming a paraplegic because a bit of bone had broken off my neck and nearly severed my spinal cord.

JENNY BROCKIE: You requested the scan, is that right?

PAUL CURTIS: On Friday night, I requested about asking for an X-ray and the guy said he didn't think it was necessary to wake the guy up to get me to X-ray. He said if I have any more pain to come back to hospital.

JENNY BROCKIE: What do you put that down to? Is that just a - a serious error, is that just an error, a big mistake or was the system stretched at the time. How did you view it? What happened?

PAUL CURTIS: I think it just can be brought down to funding, that you know, this hospital was not very busy. There was about five people in the emergency area. So, I probably would like to bring it down to funding, to see these hospitals have more funding and that a person should be on call 24/7, if a doctor is going to request an X-ray.

JENNY BROCKIE: Susan, I wonder how efficient the hospital seemed to you and how much confidence you had in the doctors that you saw when you went through your experience with your son?

SUSAN CANDLISH: We initially saw a student doctor, so Jordan had already been diagnosed with acute appendicitis. So another examination, was sort of verifying that and then an emergency doctor verifying that but there wasn't anything - no one was really acting on it. I did find that it seemed a bit disorganised in the department where there was no answers, no communication back to the patients or the people waiting.

JENNY BROCKIE: Kate, you are a senior doctor in Emergency in regional New South Wales, I just wonder what you think about the levels of experience with doctors in emergency. Clearly there are some very fine young doctors but do you think that emergency needs more experienced doctors?

DR KATE PORGES, EMERGENCY DOCTOR, NSW: I think there is a skill mix imbalance in our emergency departments. Everyone is well intentioned, the most junior doctor, the medical student is obviously well intentioned but the skill mix is wrong and we have a pyramid where there are a lot of junior doctors and one or two senior doctors trying to oversee them. Often in the regional centre, you won't have a senior doctor so you will have junior doctors trying their hardest but just not having the supervision there. As we are struggling with doctors throughout our work force at the moment, and have got a lot of oversees trained doctors working in our hospitals, English may not be their first language, that creates another problem with communication, understanding patients issues, communicating back to patients. If patients are seen by senior doctors early in their hospital stay, have their fears allayed, the kind of process of emergency explained - the experience for them is often a lot better. It's never going to be pleasant. Who wants to be in emergency department but it can be better by having that senior doctor see you earlier.

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JENNY BROCKIE: Tonight we are talking about hospital emergency departments, how sick they are and how we might be able to fix them. Some interesting things coming through on Twitter. People being worried about miss diagnosis given how stretched the system is. Complaints about repetition for the doctors, a lot of patients are saying that they get sick of being asked the same questions over and over again by different people in emergency and a mismatch of skills. There are concerns that they might not be seeing the appropriate person for what their problem is when they front. Does that sound"¦. nodding your heads a bit "¦what do you think, Roger can you understand people having those concerns?

DR ROGER HARRIS: Yes, I definitely. I mean, they will get asked the same questions time and time again. I guess it's until they give us the right answers, perhaps but some of it is to do with the fact that obviously they do see the emergency doctors and then they will often see other specialists or other teams throughout the hospital. Everybody wants to hear the story for themselves and take a history is what we taught at students. So it may seem repetition to the patient but it's pretty important to us.

JENNY BROCKIE: I wonder how much that might get back to systems too, whether some of those things might be able to be improved where you tell the story once and then it becomes available to everybody throughout.

DIANNE CRELLIN: I think although it is repetitive to ask the same questions, I think there is no doubt that at times, patients will reveal little bits of the story that they didn't see as being relevant on a previous occasion. It's only when you start to get a bigger picture that you can actually make an accurate diagnose. I think while it is frustrating to be asked the same question, there is method to some extent in that madness I think.

JENNY BROCKIE: OK. Bryon, I want to ask you about the G P situation because I know that you before you took your mum to emergency, you did try to get into a local doctor. You couldn't, yeah.

BRYON BEGGS: Yeah, that right because they were weren't seeing any new patients and my partner phoned the doctor's rooms and spoke to someone and got an appointment for mum to go and see a doctor.

JENNY BROCKIE: Clearly a problem with access to a GP in that situation.

BRYON BEGGS: Yes, there was.

JENNY BROCKIE: Delia, in Bryon’s situation, his mum was seriously ill, you work as triage in a Queensland hospital and I wonder, whether you are seeing people often who just can't get to a GP and probably shouldn't be in an emergency department, is that the case.

DELIA O’BRIEN, EMERGENCY NURSE, QLD: I think yes, that is the case. Specifically in the area where I work, it's a low socio economic area, we particularly if they are keen to go to a GP, we actually have a list of bulk billing GPs in the area that they can phone but often you will get when they come, that they have tried two or three doctors, they are not taking new patient, they can't get an appointment. So it does occur.

JENNY BROCKIE: Mike.

DR MIKE CADOGAN: Yeah. Totally agree. The way things are going now, we are moving doctors out to the front of triage so we have got a four minute interview area where we can see people right at the front and so we can deal with a lot of these people who have come in because they can't get access to the GPs, they can’t get access to bulk billing and the quickest and most efficient way and sometimes they are directed by their GPs is to come into the emergency department.

JENNY BROCKIE: The Federal Government says that it has committed $275 million, to build 35 of the GP super clinics across the country which they say will bring together, GPs, nurses and specialists. Bob, what do you think about that idea, I think just yesterday the Tasmanian government said a lack of access to GPs was causing problems in emergency, are these super clinics going to fix that?

BOB WELLS: No one thing will fix it. I think they are a good initiative. I know there are problems around the way it has been implemented in some locations but I think the concept of a place where primary care resources are concentrated and the full range of primary care resources that will enable the patient to be cared for rather than just looked at for 20 minutes or 20 seconds whatever it is, and then sent off somewhere else is a good thing. Over time that will help.

JENNY BROCKIE: Sally, do you think it will help emergency departments?

DR SALLY MCCARTHY: There is a couple of things the research tells us one is the most common reason that patients come to emergency, are felt by emergency clinicians not to require the services of a an emergency department is because a GP has sent them there. It really touches on the issue of what a GP can do in their surgery and that short consultation time and the ability to observe the patient or to provide treatments. However you provide that, that can be either be provided in the emergency department or one can duplicate a system but the problem for emergency departments as we have already discussed is really not the patients sitting in the waiting room, although I understandably that's a problem for patients sitting there, but for those sick patients needing to get on a bed. It's the patients who are ready to go into the hospital ward.

If I might just also raise a point, touching back on the differences between the emergency department and other areas of the hospital in terms of resourcing, we talked about intensive care, emergency is the only place in an acute hospital where there is an unending number of patients welcomed into affixed capacity area. There is no other part of the acute hospital like that. There's no expectation that other specialists and other clinicians in other areas can look after an endless number of patients appropriately so we don't expect the surgeon to operate if someone else is on the operating table.

JENNY BROCKIE: But the government thinks that the GPs super clinics will help that situation. Do you think they will sort of problem?

DR SALLY MCCARTHY: No. Will the GP super clinics be able to manage the admitted patients waiting for a bed as Drew has said - there's more patients waiting for a bed within the hospital than there are waiting for care in all the emergency departments. Until we fix that, you know, it won't make a great difference. There are a number of things around the edges and access to GPs is vital for the community, of course.

JENNY BROCKIE: Steve, you are with the AMA, you are also a Brisbane GP. What do you think about the super clinics? Are they going to address this?

STEVE HAMBLETON, AUSTRALIAN MEDICAL ASSOCIATION: No, they are not. There has been a long-term under investment in general practice and that certainly needs to be addressed. In we are training less GPs today than there were in 1984 when I graduated. We are still not catching up – we still have not got the message that we need to do better primary care in the community. But again, the patients we have heard about tonight are not GPs style patients that are causing the problems. People are still going to have heart attacks, people are still going to have appendicitis.

JENNY BROCKIE: And elderly people too, I know this is a big issue, yeah.

STEVE HAMBLETON: We have got an ageing population, we have an increasing burden of chronic disease, and we can manage that better in the community that’s true but they are still going to need hospital services. The fact is it's just an under investment in beds in hospitals. They are the engine room of our health system, we trained in the engine room in our health system and the beds should be at 85% capacity. We don't have capacity in our hospitals, now if there is a flu pandemic as we have just seen, we were running at 100%. We can't increase bed numbers.

JENNY BROCKIE: We did a show on that not long ago actually and that very much came through, yeah..

STEVE HAMBLETON: We had to cut back on elective surgery. We have problems in primary health care and we can do get better, but super clinics is not the right solution.

JENNY BROCKIE: You have worked in a clinic?

STEVE HAMBLETON: I have, my clinic is in fact a super clinic. I've got multiple services, at least 10 doctors, X-ray, radiology, we have got Allied health professionals and we do the very best we can. What the government should be doing is investigating in existing general practice surgeries to increase the services, not competing with them with new surgeries.

JENNY BROCKIE: You were open 24 hours and you cut the hours back because you weren't getting the patients?

STEVE HAMBLETON: Yes, we were. After 11 o'clock at night, quite rightly, people feel they are acutely ill, they present to a hospital.

JENNY BROCKIE: They have to do that regardless?

STEVE HAMBLETON: Well they are, because often they’re very sick and can’t wait till the next day, they feel that the right place to go is to the emergency department. It may well be correct.

JENNY BROCKIE: Frank you are aiming to move 98% of patients through emergency departments in WA within four hours can you do it?

PROFESSOR FRANK DALY: Yes, we can. You ask the question. We can.

JENNY BROCKIE: Is it realist though?

PROFESSOR FRANK DALY: It is realistic. It's a program to redesign the whole of the hospital journey for the patient, to improve the quality and the experience of their journey. It sounds - the name sounds the four hour programme sounds like it pertains to haste, it sounds like it's just about the ED but it's about the whole hospital journey. The tension that you've actually alluded to, the idea that we have got this really important taget, it's not the solution, it's the idea that we have to rebuild the whole hospital system to achieve it. Unless you have that really tough target, you can't get people to really think differently about what they are doing. You have to have a fundamental change.

JENNY BROCKIE: Is it about more than just more beds though? Because we hear the more beds argument a lot. Is this situation that's emerged about more than that?

PROFESSOR FRANK DALY: We will never keep up by building new beds. It's as simple as that. If we do build new beds, we have learnt from experience, that if you fill them up with patients again, they still suffer the same problems and delays. You don't improve the quality of their care. So, in some areas, you do need specific capacity but the most important thing is to redesign the way the hospital works. In fact, there is capacity in our hospitals but we can't access it. There is lots of latent capacity through system inefficiency and system problems and part of our aim in Western Australia is to access that latent capacity.

JENNY BROCKIE: Sally, what do you think?

DR SALLY MCCARTHY: I agree, the question is it's all about available beds, it's not just about bed numbers, Australia has under invested in beds in the last 15 to 20 years and we are below the OECD average. We do need an increase in bed numbers but we do need along with that, a major increase in efficiency.

JENNY BROCKIE: Peter, I am just interested in asking you as an outsider who spent quite a bit of time in hospital, what advice would you give patients who end up in emergency? We have got quite a few people in the room who have. What advice would you give them?

DR PETER NUGUS: It can be difficult for patients to influence an expert system which is really what they are going into in the health system but there are some things that patients can do. Patients can ask questions. Patients need to know that there are a common series of phases through which they go in emergency department care, through the emergency department, into the hospital or to be discharged directly from the emergency department. The first phase is that they are assessed, part of that is the triage process we have talked about, on a scale of one to five in terms of urgency. Then there is the process by which a diagnosis is put forward and that often involves tests being conducted and a physical examination.

JENNY BROCKIE: What sort of questions should people be asking along the way?

DR PETER NUGUS: They should be asking what stage am I at? What are these tests going to show? What is the diagnosis that you've got for me, will I be admitted, what will it depend on? Those are the sorts of questions that can be asked. If patients ask those questions, it can make clinicians accountable to patients and I think it also passes over some responsibility to patients as well to be involved in the decision-making because as we have heard energy clinicians are rationing their time across a lot of patients, they often can't get all of the information about the social circumstances that are very relevant to making those decisions.

JENNY BROCKIE: Roger, they are asking you those questions if you were back in emergency and you stretched. How do you make this work? How do you make that communication work? Because people at home watching think will be thinking how will I deal with it when I have to go there next time.

DR ROGER HARRIS: I think asking any sort of questions of the system is very appropriate because I think one of the things that frustrate patients most is lack of information. You know, asking sensible questions like where am I in the system? What is happening?

JENNY BROCKIE: Where am I am up - how long will it take?

DR ROGER HARRIS: Not being silent is actually very important for the patient.

JENNY BROCKIE: We have to wrap up. Do join us on-line. You can keep talking to go Sally, Clare and Peter, if you just go to our website. There is some information there on the government's GP super clinics and on Western Australia's Four-hour rule.