Most non-urgent elective surgery in Adelaide’s public hospitals was cancelled last week and some patients transferred to neighbouring regional hospitals after SA Health faced its busiest day (so far) this winter.
In the post below, Professor Jon Karnon asks what could have and should be done better to both prevent and manage demand, with the implications not just on numbers of patients but for quality of care.
Professor Jon Karnon writes:
In South Australia, this last week has seen what seems to be an annual winter crisis in which hospital emergency departments are overrun. The larger numbers of presenting patients is mainly driven by increased rates of flu in the population. Flu is a particular concern for older people, for whom it can be life threatening.
To deal with the extra demand, non-urgent elective surgery is being cancelled, and some patients are being transferred from metropolitan to country hospitals to free up beds.
Non-urgent surgery, such as knee and hip replacement surgery, has the longest waiting times and so the further postponement of surgery will be particularly distressing for these patients. However, the cancellation of non-urgent elective surgery means that the cancellations should not affect the long-term health of those affected.
Perhaps more importantly, the quality of care for patients presenting at the emergency department may suffer. With increased numbers of patients, doctors may have less time to assess patients. This can lead to inappropriate clinical decisions. Patients who should be admitted to an inpatient bed for observation and treatment may be more likely to be inappropriately discharged to home.
Could the crisis have been handled better?
It is difficult to predict the time at which the crisis will occur each year, and the size of the crisis – just how much extra demand for hospital beds will there be?
There are tools that predict the number of people who are likely to present at hospital. If the increased demand could be predicted earlier, there may be more options to deal with the situation. Leave rosters could be reviewed, flu awareness programs for health professionals and the general public could be stepped up, and emergency department protocols for handling flu presentations could be disseminated.
We might think that the health system should be able ride the crisis by opening extra beds and employing extra staff to cope with the increased demand. This extra capacity would allow the system to expand so that patients with emergencies continue to receive high quality care, and elective surgery is not cancelled. But it may not be in our best interests to have the capacity to expand the system so that everything carries on as normal.
Hospitals have a set number of general beds, and some additional flexible beds, which can be opened in times of crisis. This year there were not enough additional beds to meet the extra demand. The problem is that maintaining extra capacity costs money, and when there isn’t high demand that money could be used to treat more patients. To do more elective surgery.
In planning capacity, hospitals aim to operate at around 90 per cent capacity, such that around 10 per cent of the general beds are available for unexpected spikes in demand. The aim is to balance the costs of maintaining beds that are not used, with the need for spare capacity to cope with increased demand.
Could the crisis have been avoided?
There are three contributing factors that may have reduced the size of the crisis.
1. Improved prevention of flu
The main cause of the increased demand for hospital services is increased rates of flu, and we vaccinate people against the most common strains each year. Could we have done a better job in vaccinating people, particularly those at greatest risk of serious complications?
This year pharmacists were able to vaccinate people directly, which should have increased the uptake of vaccinations. So, why was the crisis larger than in other years? Were people not getting vaccinated, or was the vaccine less effective than expected?
If people were not getting vaccinated, how might we increase vaccination rates? Should the government offer incentives to get vaccinated?
2. Reducing inappropriate presentations to the emergency department
Most people in South Australia are now familiar with Dr Hendrika Meyer, who has fronted a major awareness campaign on the appropriate use of emergency services. How effective has the campaign been – are we seeing fewer inappropriate presentations?
There is little evidence on the effectiveness of such campaigns, and researchers have suggested we need to better understand why patients use emergency services. This will help us to meet genuine needs and reduce inappropriate use.
Alternatively, could we develop incentives to discourage inappropriate attendances at the emergency department? Maybe charging a similar fee to that paid to attend a GP, for patients presenting with symptoms that could be managed by a GP?
3. Better manage patients in the Emergency Department
The organisation of the emergency department could be improved, including how it connects with other parts of the hospital and with GPs.
Some years ago, Flinders Medical Centre went through a major redesign of their emergency services, which resulted in major improvements.
We recently looked at how different hospitals handled patients presenting with chest pain. We found significant differences in the numbers of patients who were admitted to hospital, and how long they stayed in hospital. This variation indicates scope to improve services at least at some hospitals.
We should not expect the health system to stand still. Processes that were efficient five years ago, may not be efficient now. Ongoing monitoring of the health care system should identify areas that might benefit from a review and improvement process.
South Australia is currently in the midst of the Transforming Health initiative. Major changes include a move to concentrate emergency services in three hospitals. The aim is to provide high quality care for all patients at all times of the day. Careful attention should be paid to how the new system will deal with winter crises, including efforts to reduce the size of such crises when they occur.
Professor Jon Karnon is from the School of Population Health at the University of Adelaide and President of the Health Services Research Association of Australia and New Zealand. He tweets at @jonkarnon and @hsraanz.