The exasperation expressed by Prof Robin Gauld at the weekend about what appears to be the lack of progress in improving patient flow from the Emergency Department through Dunedin Hospital is understandable.
A perusal of our files over more than a decade shows a plethora of stories with depressingly familiar themes. Basically, there are cramped facilities at the ED where stressed staff are dealing with too many people, some of whom end up staying too long because they cannot be moved into ward beds quickly. In 2010, the irrepressible campaigner for improvements to ED, clinical leader John Chambers (now also an elected member of the Southern District Health Board), likely irked management by resorting to poetry to air his frustrations.
It would be difficult to estimate how much time and money has been spent on projects trying to address the issues. There was the controversial idea of having a GP stationed in ED, advertising campaigns about keeping the ED for emergencies, GP vouchers given to attendees who do not need emergency treatment, other moves to encourage more treatment of people in the community, several studies analysing who is attending ED and what happens to them, and various patient flow improvement attempts.
We had "Putting Our Patients First" back in 2008, a pilot programme which introduced the lean thinking concept used by Toyota to reduce waste, increase efficiency and hopefully save some money in the process.
That had limited success. Its clinical leader, emergency specialist Dr Tim Kerruish, raised concerns that its gains would be scuppered by a lack of vision by the then Otago District Health Board and the culture within the hospital.
After that there was the catchy "Six Hours — It Matters!" project, its title a reference to the then-Government target for 95% of all ED patients to be seen , treated and discharged or admitted within six hours and reflecting the hospital’s struggle to meet this.
A new 10-bed observational unit opened in 2012 eased the situation a little, but not for long.
Now we have the "Valuing Patients’ Time" project which management is concerned is not making enough headway in the EDs in Dunedin or Invercargill.
We know issues within our health system are often more complicated than they might seem at first glance, and in this case poor facilities, and the ageing population with increasingly complex conditions, are major factors. But is one of the problems that the DHB is not resourcing enough beds to cater for the demand? What part, if any, is the current state of the hospital culture playing in this? Are people genuinely working together to solve problems or are there pockets of poor behaviour?
There are plans to improve the ED facilities, including a Medical Assessment Unit close to the existing ED, to offer care for those often-older patients who have complex conditions which are difficult to treat in the ED. This is part of a move to more generalist admitting, where generalist physicians assess patients holistically, also considering their social circumstances, and bringing in sub-specialists as necessary. Some of these patients may be admitted while others might be supported to return home.
There is already an MAU, but it is on the seventh floor and it is considered having one close to ED will be more efficient.
Plans are being drawn up for it now, but even if all proceeds smoothly, it sounds as if it could still be a couple of years before it is completed.
In the meantime, what will happen? Will clinicians jump to chief executive Chris Fleming’s call to ease the situation by discharging more patients before lunchtime to free up beds and to provide early senior assessment in ED, and will that have a major impact?
History would suggest we might need ED assistance ourselves if we were to hold our breath on that.
