IF there aren’t enough hospital beds to transfer admitted patients into from emergency departments (EDs), moving patients out of ambulances faster won’t solve the problems faced by Australia’s hospital system, says an expert.
Research published in the MJA today shows that ambulance offload delays are associated with increased risk of death and hospital re-attendance. In 2018, it is estimated that there were around 70 preventable deaths and 225 preventable re-attendances for the 51 000 patients with chest pain transported to hospitals via ambulance.
Experts say with five code reds – people being told not call an ambulance unless they are in a serious emergency and instead make their own way to hospital – being declared in Victoria this year alone, the problem is now significantly worse than when the pre-COVID-19 study was conducted.
The study examined adults with non-traumatic chest pain between 2015 and 2019. It included 213 544 people with chest pain transported by ambulance to Victorian EDs in that period, excluding patients with unstable conditions being rapidly transferred into EDs. The authors reported that longer offload times were associated with greater 30-day risks of death and ambulance re-attendance. The overall median offload time increased from 21 minutes in 2015 to 24 minutes during the first half of 2019.
“About 51 000 people with chest pain were transported to Victorian EDs in 2018, and in 70% of cases the offload time exceeded 17 minutes. Offload times of 18‒28 minutes were associated with numbers needed to harm of 769 for death and 238 for re-attendance within 30 days; for offload times greater than 28 minutes, the numbers were 357 (death) and 115 treated patients (re-attendance). This is equivalent to about 70 preventable deaths and 225 preventable re-attendances by patients with chest pain,” the authors wrote.
But, according to Victorian emergency doctor and member of the Australasian College for Emergency Medicine’s Health System Reform Committee Dr Simon Judkins, since the study was conducted, the problem has become much worse.
“This [study] is pre-COVID, up to 2019 – an overcrowded, stretched public hospital system and overcrowded EDs caused increased morbidity and mortality,” he told InSight+.
“Now take that pre-COVID situation and make it worse. Of course, you’re going to see an increase in mortality and morbidity across all patient groups,” he said.
Victoria has a key performance indicator to transfer 90% of patients from ambulance to ED within 40 minutes. All Australian states and territories have different targets which all fall around the 30-minute mark. According to the Australian Medical Association’s latest ramping report card, no state has managed to hit those targets.
However, the MJA study found that even those transfer targets aren’t enough to save lives.
“As we found that mortality increased with times beyond 17 minutes, this target [30–40 minutes] may be less appropriate than aiming to complete transfers within 15–20 minutes,” the authors wrote.
Dr Judkins doesn’t believe that setting a new target would solve the problem.
“If you make it 15 minutes, it’s not going to fix it because you need to have somewhere to offload patients to,” he said.
“We’ve seen during COVID … we created ambulance offload spaces within the hospital system, where we can free up ambulances and get them back out into the community where they should be.
“But what actually happened … you have these areas within EDs that aren’t properly staffed. So, you have undifferentiated ambulance patients, waiting for hours and hours. Instead of being with an ambulance crew, they might be with a paramedic trainee, or a member of the nursing staff, and they don’t actually get any investigations done.
“So, it’s not solving the problem, it’s just creating a bigger queue in front of the hospital,” he explained.
Dr Judkins said it is the hospital access that needs to change.
A 2021 study in New Zealand found that mortality was higher for patients who arrived at times when there was more than 10% hospital access block.
“[The study] says that if 10% of your beds are occupied by patients who are waiting for admission for over 8 hours, and you turn up to that ED, whether that be on an ambulance with chest pain or any other condition, that … your chance of dying increased by 10%,” Dr Judkins explained.
“What actually is needed is a whole system reform to allow us to run the hospital system at 90% capacity so there is always a bed for a patient to go to when they turn up to the ED,” he said.
What does that whole system reform look like?
Ultimately, there needs to be changes in every area of health care, not just the ED.
For example, Dr Luke Dawson, who led the Victorian Ambulance offload delay study, is also researching the current pathways of care for patients with chest pain to hopefully divert low risk patients before they make it to the ED.
“[We’re] looking at different ways to monitor chest pain outcomes, and new risk stratification processes, which is kind of leading into this trial we’re starting with ambulances,” he told InSight+.
“By using point of care blood testing in ambulances, along with a risk score to see whether some might be diverted rather sending to hospital, that might have impacts on reducing overcrowding and costs. But chest pain is only about 10% of the ambulance attendances,” he explained.
According to Dr Judkins, other parts of the hospital system need to change the way they manage patients.
“The cardiology unit, for example, could take ownership of accessing capacity into their wards, how can they get their patients moving through the system quicker to create capacity for the ED, the chest pain patients that are presenting at the front door,” Dr Judkins said.
There also needs to be drastic change in the way health care is provided, particularly after hours.
“We’re staffing [the ED] 24 hours a day, 7 days a week. The rest of the hospital health system seems to be still operating on an 8 am until 6 pm, Monday to Friday continuum. And if we really want to start solving those problems, we need to look at how we radically reform the health system.
“To fix this, it means that every other part of our system needs to actually change the way they behave and change the way they manage patients. To say just offload ambulance patients quicker isn’t going to fix a thing,” Dr Judkins concluded.
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