“ To compound that, I was also being | |||||
billed for a whole raft of tests that my | |||||
inpatient colleagues were actually ordering | |||||
. I have never ordered a mammogram | |||||
in my life; I am an emergency physician. | |||||
“ Yet, if that test was ordered as part | |||||
of that patient’ s inpatient workup, the ED | |||||
would be given the bill— and that continues | |||||
today. | |||||
“ If my neurology colleagues order an | |||||
MRI, even if the patient doesn’ t have that | |||||
MRI for two or three days, the cost of that | |||||
is attributed to the ED.” | |||||
She said it took until 2022 and a | |||||
review by Dr Paul Tridgell, a former NSW | |||||
Health executive and national expert | |||||
on hospital funding, for the bosses at | |||||
the hospital network to accept that | |||||
the source of the high costs in ED were | |||||
bound up in the accounting. | |||||
“[ Until that point ] my recurrent experience | |||||
was of going to the finance people in | |||||
the department and being told that their | |||||
accounting methodology was fine and |
what I needed to do was make sure there was never a patient in the ED who should |
PHOTO: AMBULANCE EMPLOYEES ASSOCIATION |
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be on a ward. |
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|
“ I said,‘ That’ s brilliant. How?’ What I needed was to not have the tail wag the dog. I needed the accounting methodology they were doing to actually reflect reality.
“ It was only when [ Dr ] Tridgell met
|
And there were the pressures stemming from the fact that for patients close to a mental crisis arriving in ED, there was nothing but the ED to care for them.
It was not unusual for the ED to have 20 of the 75 cubicles occupied with men-
|
“ A triage category is actually just a description of how long that patient waits before we have to commence care.
“ It doesn’ t tell me anything, really, about the likelihood that patient needs admission, the likelihood that they might
|
the bed at the same time that the orthopaedic RMO is coming down to clerk the patients and write up their medications.
“ If it’ s clinically appropriate and we happen to find a bed, I will then write an interim plan and the patient can go up to the ward.
|
Ambulances ramped at
Royal Adelaide Hospital in September
2021.
|
|
with me that I realised from his report |
tal health patients, where some would be |
die, or whether they could have sought |
“ But at the RAH, we have about 40 |
||
that I finally had some vindication |
forced to languish for days. |
care somewhere else outside of an ED.” |
assessment cubicles, and if 20 of those |
||
because I am not an accountant; I am an |
“ We communicated [ all ] this to the exec- |
She added something to which the fed- |
have admitted patients in them, I have |
||
emergency physician. |
utive of [ the Central Adelaide Local Health |
eral Minister for Health and Aged Care |
only got 20 cubicles to see a hundred and |
||
“ It was only then I understood I was |
Network ] and we also communicated that |
Mark Butler, and his billion-dollar invest- |
something patients through. |
||
|
in fact right, that we weren’ t managing this in the same way as NSW, Victoria or Queensland.”
The patient deaths
Those who have been tracking the various
|
‘ I finally had some vindication because I am not an accountant; I am an emergency physician.’ |
“ That is the cause of ramping at the RAH.
“ Those patients don’ t need resus, they’ re not well enough to be in a waiting room, they might be frail and elderly with abdominal pain, but they are not sick enough to need resus and they are not well enough to
|
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sagas around the RAH in recent years will |
be able to be managed as ambulatory. |
||||
know that ambulance ramping has been a |
to the then-CEO of SA Health and asked for |
ment in Medicare urgent care clinics, |
“ So it is, generally speaking, those cat- |
||
political hot potato for a long time, just as |
support to try to be able to mitigate the risk |
should also pay note. |
egory 3 and category 4 patients who have a |
||
it is around the rest of the country. |
and be able to manage things. |
“ There are a lot of myths around,‘ If |
50 % chance of needing admission, who are |
||
Last year, a coroner began an inquest |
“ We didn’ t have enough doctors,” she |
only the triage 5 patients didn’ t turn up, |
often frail and elderly, who experience long |
||
into three so-called ramping deaths— two |
added. |
we would be fine,’ and that’ s just funda- |
delays to accessing care on the ramp.” |
||
|
of them at the RAH during the time when Dr Brooks was the director of the ED.
Dr Brooks spoke in some detail before
|
“ We also asked the question: What is the medicolegal jeopardy here?
“ We wanted clarification and we never
|
mentally not accurate.” She said her ED was really dealing with three streams of patients. At one end, the |
The inquest deaths
The two‘ ambulance ramping’ deaths at
|
||
the select committee about what had |
got an answer to [ our ] letter.” |
resuscitation patients( 10 % of presenta- |
the RAH currently subject to a coroner’ s |
||
|
been happening.
As doctors have said for years, she stressed that the ramping phenomenon was a symptom of deeper structural
|
What do the triage categories really mean?
She said the reason the ramping issue had
|
tions) who were critically unwell. At the other end, the ambulatory stream( 40 % of presentations) whose care requirements were far less complicated, those with a |
inquest are those of Anna Panella and Bernard Skeffington.
Dr Brooks said Ms Panella attended the RAH ED in 2019 just after the time that
|
||
difficulties. |
been so difficult to discuss was because of |
single problem who were likely to be dis- |
the ED had been forced to ditch the con- |
||
But what she said is worth repeating in |
sultant-led approach to provide ongoing |
||||
detail simply because it shows how far the |
assessment of patients stuck on the ramp. |
||||
public debate is from grasping how hospitals |
“ So we no longer had that medical |
||||
work and the decisions that doctors have to |
input and we had to make a decision, both |
||||
make when resources are finite. |
as medical and nursing, that we couldn’ t |
||||
“ I don’ t think there is any clinician |
continue to have that very assertive, |
||||
who thinks delaying access to care for |
active approach to reviewing patients on |
||||
any patient is acceptable, and I think any |
the ramp at the RAH because there simply |
||||
emergency clinician— indeed, any hospi- |
weren’ t enough staff. |
||||
tal clinician— recognises the importance |
“ We didn’ t have enough triage nurses |
||||
of timely access to an ambulance in our |
to be able to allow them to go and always |
||||
community,” she said. |
visualise a patient. We didn’ t have |
||||
“ There is this stereotype that I have |
enough consultants to be able to roster |
||||
heard more than one time that emergency physicians like ramping, that we are addicted to it and various other things, and these are deeply offensive things to |
Anna Panella( left) and Bernard Skeffington. |
an additional person.“ Many of us— and this applies to the nursing leadership as well— would come in after hours and on weekends and all sorts |
|||
say to clinicians, but I have heard them |
of times just to try to mitigate the risk, but |
||||
from so many different sources.” |
the limited understanding of those out- |
charged. And in the middle, the‘ assess- |
we had to make that decision after we com- |
||
At the RAH they initially employed |
side ED of what the triage categories actu- |
ment stream’, who made up the remainder. |
municated to the executive that we couldn’ t |
||
an extra emergency physician who was |
ally meant. |
“ When I have finished my assessment |
perform [ the active approach ] anymore.” |
||
available to the paramedic crews and |
“ People take them to infer that just |
of the patient, and I have decided they |
Ms Panella’ s death occurred a few |
||
could support the triage nurses whenever |
because you had a lower triage category, |
need an inpatient admission, I [ would ] put |
months later. |
||
they were unable to offload an ambulance |
that means that you didn’ t need to have |
through an admission order, and that’ s a |
Dr Brooks said she was admitted to the |
||
in timely fashion. |
care in an ED, and that’ s fundamentally |
signal in the EMR to the patient flow team |
resuscitation room after waiting in the |
||
But the fix got crushed by the pressures, she said. |
wrong.“ We know that the highest morbidity |
to find a bed.“ Obviously, I have had a conversa- |
ambulance for nearly an hour. Her death, she stressed, was probably unavoidable |
||
Having to use a brand-new EMR that the |
and mortality is actually associated with |
tion with an inpatient colleague who has |
given she had experienced a massive pul- |
||
rest of the hospital was not using was one |
patients who are in triage category 3 and |
agreed that that patient needs to be admit- |
monary embolus. |
||
big issue sucking up staff time, she said. |
triage category 4, because they are often |
ted for inpatient care. |
“[ Preventing ambulance ramping ] |
||
So was working in a physical space that |
frail, elderly and have multiple medical |
“ We try to do as much of that in parallel |
wouldn’ t have changed the outcome, but |
||
was not fit for purpose. |
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