By Farrah Tomazin, Aisha Dow and Melissa Cunningham
The Victorian hospital system is facing an emergency crisis of its own.Credit:Dylan Coker
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It was the type of tragedy that should never happen in Melbourne. A young mother was rushed to the Werribee Mercy Hospital by ambulance but instead of getting the critical emergency care she needed she was forced to wait.
The 27-year-old had recently given birth when she suffered from a suspected postpartum hemorrhage – a serious but treatable condition that can lead to excessive blood loss and a severe drop in blood pressure. By the time she was accepted by the hospital, reportedly more than an hour after arriving at the emergency department, she could not be saved.
The death in June last year, confirmed by The Age this week, is one of a number of “adverse events” being reported. The system, according to the people who work within it, is struggling to cope with unprecedented demand during the global pandemic.
An Age analysis of performance data has found that virtually every part of the service is deteriorating: from ambulance response times and access to mental health beds, to dental waiting lists and the number of hospital patients receiving urgent treatment. Patients are arriving sicker after putting off care or having their surgeries delayed due to the pandemic.
Nineteen months since Australia recorded its first coronavirus case, those delivering healthcare at the front line are warning of a looming catastrophe as staff shortages and workforce burnout further strain the sector.
Emergency medicine physician Dr Simon Judkins says when he turns up to work now he finds ambulances waiting out the front as paramedics are forced to stay on to oversee patients because they are unable to offload them at overrun emergency departments. Hospital waiting rooms are full of people waiting hours for care while others lie in stretchers in brightly lit emergency corridors waiting for a bed.
“It’s Groundhog Day,” he says. “These are the sort of things that used to be the exception to the rule, but there is a grave concern from emergency doctors that this is almost like a new normal.”
All around the country are signs of a health sector under stress.
In Sydney’s hotspots, ambulances and hospitals have been so stretched that coronavirus patients now need to be triaged in makeshift units at Westmead and Blacktown hospitals.
Western Australia, which has been COVID-free for months, announced this week it would postpone about half of elective surgeries amid fears the state would be overwhelmed in the event of a fresh outbreak.
In Victoria, 32-year-old Christina Lackmann was found dead in her Caulfield North apartment in April after it took an ambulance more than six hours to respond to her triple-zero call.
And the young woman who died at Werribee Mercy had been delivered to an emergency department operating at capacity and under extra pressure due to new precautions introduced to safeguard against coronavirus.
A Safer Care Victoria review has since found there were a number of significant factors that contributed to the death, on June 17 last year. New department guidelines – outlining a maximum 20-minute wait time for patients entering an emergency department – issued the day before had not yet been implemented.
Planning is now underway for a new emergency department and improved ambulance bay access at the western suburbs hospital, after the review also highlighted the “physical limitations” of its ED.
“Both the COVID-19 environment in which Werribee Mercy Hospital and Ambulance Victoria staff members were operating, and related recent changes to protocols for receiving patients by ambulance, which were instigated by the Department of Health, were significant factors in the event,” a Mercy Health spokeswoman said.
‘Literally like a traffic jam’
Ninety per cent of patient transfers from ambulances to hospitals are meant to happen within 40 minutes, according to the statewide target. Paramedics are waiting at hospitals more than 6000 hours per week above that target, according to a source close to Ambulance Victoria.
The phenomenon of ambulances waiting to offload patients is known as “ramping”.
One crew of paramedics recently spent their entire 14-hour night shift waiting at Sunshine Hospital, according to the source. And there are now times that crews are being sent to hospitals simply to relieve their colleagues whose shifts have come to an end as they wait for their patients to be accepted by the hospital.
Victorian Ambulance Union state secretary Danny Hill described his members’ working conditions as “almost dystopian”. Some paramedics were forced to eat meals inside ambulances that had just transported COVID patients, or at service stations without proper facilities.
“Their working conditions are atrocious,” Hill says.
Paramedics are so overworked some are being forced to eat meals at service stations during shifts, says the ambulance union.
One paramedic, who did not wish to be named for fear of losing his job, said emergency wards these days were “literally like a traffic jam”.
“There’s absolutely no space for social distancing, people are cramped, and pretty much as far as the eye can see down the corridor you might have 12 or 13 ambulances and stretchers. It looks like Victoria Market on a very busy day,” he says.
“Being ramped for two or three hours wearing the full level of PPE – the plastic gown, your mask, your glasses – it is unconscionable in my view. The material doesn’t breathe, so you sweat, you’re dehydrated, and once you finally catch your breath and clean yourself up you have to go back out again. It’s so exhausting.”
In dire straits
Judkins, a former president of the Australasian College of Emergency Medicine, wonders how much more the system can take. He recalls a time early last year when he heard Australia’s then chief medical officer, Brendan Murphy, telling reporters that to manage the pandemic hospitals would need to open their “surge capacity”.
“I remember saying at the time ‘what surge capacity?’ because hospitals across Victoria were already running at full capacity,” he says.
Dr Simon Judkins says many hospital workers are tired or on leave after a demanding year.Credit:Jason South
Ask any doctor working in a Victorian hospital about the past 18 months, he says, and they will tell of patients who have become seriously unwell while waiting too long for care.
”Whether that’s due to sepsis or a delay in [treating] their stroke or a delay in their cardiac care … there will be stories from every emergency department across the system,” he said.
“I have no doubt that when we look back on this there will be a significant number of what we would consider to be preventable deaths.”
But COVID exacerbated the health crisis. It didn’t start it. Australian Medical Association state president Dr Roderick McRae says Victoria’s healthcare system had been in “dire straits” long before the pandemic hit.
Hospitals have been underfunded for years, he says, leading to bed and staffing shortages. Problems with the federal government-administered National Disability Insurance Scheme and aged care have not helped – patients are stuck in wards waiting for mandatory assessments to enter both systems, locking up hundreds of hospital beds every week. The latest figures show the Commonwealth only puts in 36 per cent of the total cost of public hospitals, while the state pays 57 per cent.
Other patients, meanwhile, including those who are suicidal and psychotic, spend days waiting to be admitted through emergency department cubicles.
Victoria now has more patients than ever before and they are sicker. Emergency departments treated 479,719 patients in the last quarter, an increase of 34 per cent over the same period last year. And people who deferred having a check-up during lockdowns are now experiencing more complex or critical problems.
McRae says: “We’ve seen the population in Melbourne double in the last 10 to 12 years and the bed numbers and hospital services just haven’t kept up. The pandemic has just further exposed every hole that was already there.”
‘Hot’ wards and short shifts
Since the end of the second wave, Victoria’s COVID caseload has been relatively light, but its mere existence presents a serious challenge. Virus exposure in a single hospital can filter across the entire health system. If staff are furloughed and patients diverted to neighbouring hospitals, it adds to demand on workers.
This played out at the Royal Melbourne Hospital last week, when 450 staff were forced into isolation after a COVID-infected man, who wasn’t tested before surgery, sparked an outbreak at the Parkville facility. As authorities scrambled to contain the cluster, emergency staff were put in place and ambulances diverted to other hospitals for all but the most serious cases.
A nurse at the Royal Melbourne Hospital, who spoke to The Age on the condition of anonymity as she was not authorised to speak publicly, said staff were frustrated that the patient had not been tested before his surgery or even in the days afterwards.
“How can a patient be in the hospital for 10 days infecting staff and they haven’t even been screened for COVID? It just defies logic and belief. It has caused a huge amount of anxiety among staff.”
The nurse said the trauma ward at the hospital had been a deemed a “hot” ward, leaving dozens of staff working in a suspected COVID ward without any warning. “The anxiety levels are so much higher this year than they were last year because there are many young nurses who are seeing younger people get infected and come to hospital,” she said.
Across Victoria, managers say they are struggling to fill shifts, partly because nurses have been deployed to every corner of the COVID frontline as contact tracers, vaccinators and testing centre staff. Health unions warn of unprecedented rates of double shifts and dangerous levels of burnout, including in maternity wards, where women are being reportedly discharged early from hospital only to return with complications.
Australian Medical Association president Dr Omar Khorshid is reasonably confident that every COVID patient who needs an ICU bed or ventilator will get one. But he said he wasn’t seeing any preparations to be able to continue normal healthcare at the same time.
“What I’m more worried about is all the other healthcare that gets stopped or pushed aside in order to look after COVID patients. And that is what we’re seeing right now in Sydney, we’re seeing it in Melbourne, we’re even seeing elective surgery cancellations in Perth, prior to any COVID because the system is so full,” he said.
Patients are raising concerns about the quality of care. Box Hill resident Julie Rowland*, an 84-year-old widow, was last year one of thousands of Victorians sent a taxi instead of a paramedic to transport her to emergency as part of an Ambulance Victoria overhaul designed to free up vehicles from taking on non-urgent cases.
She was alone in her home at a Box Hill retirement village one night when she started to panic that she was having a stroke. “I couldn’t use my fingers properly, I couldn’t speak properly and I was having trouble walking,” she tells The Age.
What followed would be laughable if it wasn’t so serious. At first the taxi driver struggled to find her address, then he had trouble finding Box Hill Hospital, only a short distance away. Once they arrived, nobody helped her get inside.
“All I could think about was: what if something had gone wrong from here to there?” she told The Age. “What if I’d had a stroke? What was the cabby going to do when he didn’t even know where the damn hospital was?”
The mental health toll
Melbourne psychiatrist Dr Killian Ashe says there has been an “extremely concerning” increase in people, especially children and young people, presenting to emergency departments with self-harm and mental health distress. A growing number use drugs and alcohol to cope.
Some in the midst of a crisis spend two or three days waiting in emergency departments because no mental health beds are available.
“Services are so saturated, both public and private,” he says. “It really should very rarely come to a person having to present to an emergency department, but unfortunately now it almost always comes to that.”
The problem is exacerbated by a severe shortage of mental health workers and beds. Some nurses have become so burnt out they’ve opted to leave mental health wards and take jobs helping with vaccination and testing.
”Striving towards the best vaccination numbers and keeping people safe from COVID is an awful necessity,” Ashe said. “But this mental health pandemic that’s coming with it is carrying more morbidity and mortality now, arguably, than actual COVID itself.”
Psychologists are also feeling the pressure as they try to help a growing number of young people who often have to wait months for a referral. Calls to the child counselling service Kids Helpline increased by 30 per cent in the first six months of this year compared to the same period last year.
“Children’s needs aren’t being met … and you’ve got all these desperate parents really wanting support for their kids and getting frustrated because they feel like they can’t get the help that they need,” says Rebecca Thomas, co-founder of Shine Bright Psychology, which caters for school-aged children. “That puts a lot of pressure on psychologists as well because we have this huge influx of work that we just can’t keep up with. We simply don’t have the workforce.”
Child psychologist Rebecca Thomas says the pandemic’s mental health toll will last for years.Credit:Eddie Jim
No simple fix
As demand for health services soars, the question is whether the system can withstand the pressure. And as state and federal leaders squabble over national cabinet vaccination targets to ease lockdowns, what must be done to safeguard hospitals once Australia eventually begins opening up?
The Andrews government has invested $759 million to recruit more than 300 paramedics and registered nurses, to implement a new transport service for patients who do not require urgent care and to boost triage and telehealth. About 350 medical staff have also been recruited from overseas and will be deployed across 30 health services from October.
But Danny Hill argues the health system “needs to work like an ecosystem” – you can’t unclog one part without fixing another.
“You can double the amount of ambulances but if you don’t have the beds on the wards for patients to move into, and if we don’t have enough allied health people to discharge patients, then it won’t work.”
Psychologists and mental health services have also asked for additional resources, while Australia’s leading doctors’ groups are demanding state and federal governments commit to establishing an emergency plan to avoid the system “grinding to a halt” every time new COVID cases emerge.
This plan could mirror emergency medical responses already in place to handle natural disasters such as bushfires or floods, says emergency medicine specialist Dr Sarah Whitelaw. Once hospitals have hit a certain threshold or a certain percentage of staff have been furloughed, it would trigger a statewide response so entire hospitals are not shut down.
Prime Minister Scott Morrison with Health Minister Greg Hunt.Credit:Alex Ellinghausen
Cognisant of the challenge, Prime Minister Scott Morrison has promised to “bolster” the nation’s hospitals and make sure the system has the “resilience” to cope. He is yet to explain how. The government has sought urgent advice from intensive care doctors about what happens after the country hits a vaccination rate of 70 per cent or more and starts easing restrictions. At that point, doctors expect already stretched hospitals will experience a huge and sustained boost in demand from a COVID-19 pandemic of the unvaccinated.
A national working group has also been convened to address issues highlighted by the pandemic which include national funding arrangements, reforms to care models and workforce fatigue – but the jury is still out on what it might achieve.
“It’s not going to be an easy, simple fix,” says Andrew Hewat, assistant secretary of the Victorian Allied Health Professionals Association.
“The workforce has been run too lean for too long, well before COVID. The pandemic has really just exposed the vulnerabilities of the system.”
With Rachel Clun
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