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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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There also needs to be a significant change in public expectation. The idea that every discomfort must be addressed immediately does not gel with the service we are able to provide. Health illiteracy is rampant. A lot of what we have to do in the ED is reassure the worried well, and do stuff for people that they should be taught to do for themselves.
The fact remains, however, that the worried well and so-called “GP-type patients” make us busy but not overcrowded. Overcrowding lies squarely at the feet of access block.
There is no easy fix to the the problem of ambulance ramping and bed block. One of many solutions is to try and decrease presentation of people to ambulance and ED. The gap between the home/community and the ambulance/hospital. In Victoria an organisation, HMS Collective Community Paramedic Service is achieving this. A multidisciplinary approach to support people to remain in their home and community. This longitudinal model of health prevention provides care to a predictable group of people who can deteriorate such as people with chronic disease, living with mental health, disability, aged care, disengaged from a GP and/or, an unpredictable group of people with minor illness or injury who don’t need an ambulance or hospital but feel they have no other option. Another important group HMS Collective supports are Carers (the forgotten health workforce). If carers become unwell, often the people they look after end up in ambulances and ED as they have no where else to go. The HMS Community Paramedics, Nurse and Support Partners provide care in the home and reconnect people to General Practice and Community Care. This team often buys time while people wait for GP appointments. In the area HMS serves, it is estimated that ambulance call out have decreased by 90 hours a week. This results in a decrease of hundreds hours of ED time. The cost saving to the Health System and Governments is estimated to be over $1.4 M a week. Unfortunately Government are not interested nor are they willing to discuss. Sadly simple innovation is often unrecognised and resisted as it is different. This model can easily be funded out of cost savings, putting no burden on budget, improving availability of ambulances, freeing up ED beds while keeping people safe in their homes/community and being redirected to Primary Care Services. See: http://www.hmscollective.com.au
As above mentions…blaming Ambulance PARAMEDICS is a complete cop out. We don’t bring people in because we don’t know how to triage accurately, we don’t bring them in because we don’t know what to do, we don’t bring them in because we don’t want to, or are scared to say no. If only the author of this comment had a clue how many people we save the ED from by leaving people at home. What an ignorant comment spoken from someone who clearly has never spent a day on road outside of their secure ED environment. Do you not realize that many patients that we bring in who you Cat as a 3, were actually fixed by US enroute to hospital…..? Isn’t it lucky we have the skill to be able to present you with a now well patient? Your insight is lazy, judgemental and ignorant. Not to mention ambulance Paramedics don’t blame the hospitals, we know your waiting room is full of people who should be at a GP, because most of our cases we attend, we tell them to go to a GP! They either listen to us, or they drive themselves to ED after we leave, or they make it soooooo god dam hard for us to leave them at home that we take them in because WE are the ones responsible for them if the very unpredictable and unlikely, does indeed happen. You try having that on your shoulders. As for this article… no offloading Ambulances won’t fix EDs but what it does do is it gets us back on road so that the person who goes into arrest in the community has half a chance at surviving it.
After forty years in public hospitals – including over thirty years as a specialist emergency physician – I now have a different perspective from working in Emergency Telemedicine. Through evaluating people by either phone or video, explaining the likely pathophysiology and providing either reassurance, specific care or (less commonly) referral, it is possible for senior decision-makers to provide much more appropriate care for so many people than lining up in overcrowded EDs, getting worried and angry.
There are a few key requirements. Ideally, the initial assessment of people seeking emergency care occurs BEFORE they reach ED. It is much harder to offer different solutions when the person has already on-site. The evaluation must happen BEFORE they have waited so they can have productive time evaluating their own progress, in an informed way, Those who are evaluating patients seeking acute care must not be risk-averse, but pragmatic and realistic. Providers need to understand the needs and concerns of these patients and validate the concern without offering unproductive tests or treatment. Importantly, we must recognise that evaluation, explanation and reassurance are just as much “doing something” as referring or ordering a test.
Good GPs do this for their patients all the time. The difference with acute care, however, is that emergency physicians have more exposure to the full range of acute conditions, including chest pain. We know that physiologically well young people with chest pain are are extremely low risk of AMI. We know that diagnosis can be deferred, that conditions evolve.
Finally, if the core acute role of ED for people with truly urgent illness and injury is truly valued, we cannot continue to simultaneously use ED to plug holes for all other health and social services, whether this is homelessness, emotional distress or concern about a potential diagnosis. Each other service needs to provide a source of reassurance or triage for its own clients when that service is not available – beyond “just go to the hospital”. People in nursing homes should not be sent to ED in the middle of the night for ongoing medical issues, or abnormal blood tests, in the absence of an acute, time-dependent condition.
None of this will change if the only people concerned about ED overcrowding are ED staff. While EDs continue to plug everyone else’s service gaps, what incentive is there for any other service to change?
Agree with James; We have seen the bed capacity inexorably decreased so that we run the hospitals at close to capacity most of the time – little surprise that we can’t expand capacity to manage surges like the current one. However, there’s another problem – we fail to recognise that ignoring exit block will stymie any strategy to fix the entry problem. Sometimes called the “back door”, rehabilitation (and other subacute) beds are needed to facilitate a significant number of patients out of the hospital back to the community. Ask yourself what has happened to them during COVID? – drastically reduced all over the country as these beds were redeployed, but not reinstated.
I’ve worked in Emergency Departments for nearly 30 years. I often hear the media and ambulance officers blaming hospitals and emergency departments. This is ongoing stupidity. There are multiple stakeholders who are to blame for ED overcrowding and associated problems. Here are two: Ambulances that transport many many people to ED who dont need to be there or go there. See your GP. Ambulance officers appear not to be capable of determining who needs transport and who doesnt. Solution – no transfer to a hospital ED unless its approved by a senior ED Consultant assigned every shift to say yes or no. Do it! No one will like it but it needs to be done. Secondly – GPs who relentlessly (for years now) fail to treat people efficiently and effectively in their practice and instead write a 2 minute (or less) letter and tell them to go to ED.
Theres your problem! STOP blaming the hospitals as the sole cause of the problem and investigate properly then find a solution. And if you cant do it, pay me the big bucks and I’ll do it!
A simple graph of hospital beds per capita since 1960 defines the problem. Over 9 beds per 1000 people in 1970 to under 4 beds per 1000 people now. Every middle manager talks of increased efficiency, blames both patients and health workers and dangles the solution. If only patients could be discharged at 7 am… etcetera etcetera. All illnesses have a psychological component that defies increasing testing. Sometimes people just need the care of fellow human beings.