Almost 14 years ago, Southern’s then orthopaedic clinical leader David Gwynne-Jones was so fed-up he made a presentation to the district health board.
He did not mince his words. Then, fewer than half of the hospital’s patients requiring acute surgery received it within the ideal time, with some having to fast for most of several days while they waited. Ideal times range from two hours to 48, depending on the condition.
He estimated hundreds of bed days were being wasted by people waiting for operations. And, although about half of the surgery done at the hospital then was classed as acute, only one operating theatre was dedicated for acute work.
Over the years there has been scrutiny of myriad issues at Dunedin Hospital, including acute care.
However, it has proved easier to diagnose the problems than comprehensively solve them.
Retired intensivist and general surgeon Mike Hunter, who was involved with a plethora of quality improvement projects, has said while these accurately established what was wrong, real change did not occur basically because of a lack of funding. Better processes were rate-limited by the facility, by staffing, or both. The dreaded district health board deficit loomed large in decision-making.
Although two acute theatres are now in play much of the time, it is difficult to tell how much has changed and how well planning and funding for this aspect of care is accounting for the increasing demand coming from an ageing population.
Since we no longer have district health boards holding public meetings, commentary on such issues is less visible, but sometimes they come to our attention through Health and Disability Commissioner reports when something has gone wrong.
Sadly, that was the case this week when an HDC report emerged of a 2021 case of a fit and well 74-year-old woman who waited more than 90 hours to have surgery for her broken leg when it should have occurred within 24 hours. During surgery she suffered a stroke and a pulmonary embolism and died a few days later.
She said lack of theatre resources at Dunedin Hospital continued to be a chronic problem and it was her sincerest hope her mother’s premature death could serve to highlight, and bring change, to this serious resource allocation issue through the assistance of the HDC.
Commissioner Morag McDowell acknowledged limited access to operating theatres at Health NZ Southern has been an ongoing issue for many years. Timely treatment for older patients with femoral fractures was particularly important for reducing the risks of morbidity and mortality.
She found the failure to reassess the patient’s acuity, and lack of systems for that, indicated a lack of appropriate response to the clinical risks created by limited access to acute operating theatres.
This represented a service-level failure that could and should have been avoided.
Improvements since this 2021 case are a work in progress. Changes have been made to the way acute and elective surgery demand is managed daily so that if acute demand requires additional theatres, elective surgery is postponed.
Undertaking additional lists at weekends is possible when there is concern about delay to a "specific group of patients", although this is dependent on staff availability and access to post-surgery care.
HNZ recruited and trained staff to be able to double the amount of acute operating theatres over weekends from last November.
There has been some extension of acute theatre hours, but this only started in mid-2023 and is not expected to be fully implemented until the end of this year. It is dependent on recruitment of anaesthetic technicians and anaesthetists.
Ms McDowell will be requiring several updates on the improvements in the coming months.
Since the existing hospital, with all its limitations, has to function for years yet before the new hospital is completed, adequately addressing this ongoing issue in the meantime will be vital.
