Sick Royal Adelaide Hospital, sick system

Not much is going right at the flagship Royal Adelaide.

Ambulances ramped outside Royal Adelaide Hospital.

Problems at the $2.4 billion Royal Adelaide Hospital — once the world’s third most expensive building — continue to plague ­patients, health practitioners and politicians almost 15 months after its delayed opening.

Despite ongoing efforts alongside frontline health workers, South Australian Premier Steven Marshall and Health Minister ­Stephen Wade know there is no quick fix.

Attempts to ease chronic overcrowding are likely to continue for several months, if not years.

Capital works could be announced early next year, with smaller-than-required resuscitation rooms and a chaotic emergency department the likely first targets of any redesign.

Corporate advisory and restruc­turing group KordaMentha is moving in to slash costs.

Design flaws and health budget blowouts, inherited by the Liberals after they won government in March, are being investigated by a range of consultancy firms. A culture of overspending within SA Health, now under the Liberal-backed leadership of Chris McGowan, is also under the microscope.

Having opened in September last year — 17 months late and $640 million over budget — the RAH has suffered problems from day one. But when 18 ambulances spent several hours “ramped” outside the 800-bed hospital on ­November 5, it was symptomatic of a health system in crisis.

Ramping occurs when an ambulance is forced to park outside a hospital because there are no free beds to treat a transported patient. It became so routine at the new hospital that a “privacy fence” was erected at the RAH by SA Health in June in an effort to protect patients who, until then, were in full view of the public on one of Adelaide’s busiest intersections.

Although the problems were not new, there had been an expectation that the issues would peak during the winter flu season and settle in time for the traditionally quiet pre-summer period.

Yet the situation at the RAH, the state’s flagship acute hospital, appears to be worse than ever and steadily deteriorating.

Ambulance Employees Association general secretary Phil Palmer has called for “heads to roll” within the SA Health bureaucracy.

Australian Nursing and Midwifery Federation chief executive Elizabeth Dabars says frontline nurses are “now officially beyond breaking point”.

SA Salaried Medical Officers Association industrial officer Bernadette Mulholland says the “frustration is palpable among the clinical workforce — they want to find solutions”.

Sensing a crisis that is getting out of hand, the Premier has moved to reassure the public. “The current situation with ramping at our emergency departments is completely unacceptable,” Marshall says. “The new government is working as quickly as we can to fix up the mess that was caused by the previous Labor government.”

Yesterday the Premier left it to Wade to deliver more bad news in announcing the appointment of KordaMentha to help make health savings of more than $270m. This came after the firm detailed a culture of inefficiency and overspending in the Central Adelaide Local Health Network, which has responsibility for the RAH. Yesterday Wade described the network as a “basket case … crying out for dramatic change”.

Treasurer Rob Lucas says anticipated savings from moving to the new hospital have not been achieved, and costs in fact have increased. Under a “turnaround” plan announced yesterday, Korda­Mentha will be paid $18m to help deliver the first stage, with savings of $41m expected by the middle of next year, $101m to be recovered in 2020 and $134m the following year.

Key priorities include improving the efficiency of care and increased financial controls.

KordaMentha already has found that patients at the RAH stay longer than national benchmark times. There now will be attempts to avoid unnecessary hospital admissions.

South Australians have been bracing for the poor diagnosis.

While the community appeared to accept some teething problems during the hospital’s first peak winter period, images in the media this month of 18 queued ambulances and reports of stressed medical workers, including one who was assaulted, have stirred public emotion.

At the root of the problem is a lack of capacity and inefficient patient flow — not only at the RAH but also across Adelaide’s metropolitan hospital network, which includes Flinders Medical Centre in the south and Lyell McEwin Hospital in the north.

It is the first year that the system is without the Repatriation General Hospital in Adelaide’s inner south, which saw a net loss of 100 beds. The closure of the Repat last year was part of Labor’s failed Transforming Health policy.

A key policy of former premier Jay Weatherill, it was widely condemned as being more about transferring services than establishing new ones.

Labor abandoned the policy before the election because of its toxicity, but by then much damage had been done. The Liberals have promised to reopen the Repat and are expected to announce plans for the site early next year.

This is the crux of the problem. Nothing is going to happen anywhere near as fast as what is needed. While some extra hospital beds have been opened across the health network in recent weeks following crisis talks between government and unions, all sides know that only long-term solutions will remedy the ramping.

Yet no one knows exactly what those solutions are, let alone when they will start to have an effect.

The design of the RAH, kept confidential during its planning phase under a contentious public-private partnership, has been blamed for the ramping and emergency department overcrowding. This month there were more than 100 patients in the 71-bed emergency department at times.

The RAH was the first major Australian hospital to offer single overnight patient rooms. During the design stage, planners and ­bureaucrats were determined to revolutionise patient flow models on a large scale without the need for facilities such as discharge lounges.

Frontline medical workers were told by bureaucrats the key to the success of the new “flow model” was the timely movement of patients directly to their spe­cialty care areas. When Palmer learned of the approach, he wrote to SA Health in late 2015, warning it was “fanciful”.

“The premise is that a feature of the new RAH’s new ED is fewer patients going through it as a result of more direct admissions, but when that fails our members will find that the consequent access block will result in ramping,” Palmer said in a letter to senior health bureaucrat Todd McEwan.

Palmer this month said country hospitals such as Murray Bridge, 80km east of Adelaide, were contributing to the ramping by transferring patients to the RAH when it was already over capacity.

Wade says the scheduling of inter-hospital transfers, which account for about 10 per cent of all admissions, needs to be improved.

According to Palmer, the AEA received an undertaking from the Liberals that they would take “tangible steps to address ambulance ramping and strengthen the surge capacity of individual hospitals”.

“The proposed timeline of July this year is well behind us, but ramping is getting worse, not better,” Palmer says. “It must be stopped.”

The prevalence of ramping is increasing pressure on doctors to free up beds as quickly as possible, which the Australian Medical Association fears is resulting in adverse outcomes for patients and, in turn, the broader health network.

Chris Moy, state vice-president of the AMA, says the decision to discharge a patient should be based on the patient’s health and not because an ambulance is waiting at the door.

He says doctors may get a “tick” for an efficient turnaround of a patient. But he warns such an approach, in some cases, is leading to three or four short stays instead of a single, more comprehensive, admission.

“This is particularly the case for older people … it’s better to have more time to problem solve than facing an imperative to ‘hurry up, hurry up, get them out’,” Moy says.

“We have a new hospital but a new hospital is not a magic wand for efficiency. We hear a lot about efficiency but ‘efficient’ has crept into the language as ‘cheaper’. Is that really what we want?

“How about we take a longer view and do it better — better for patients, and better for the system?”

Mulholland says ramping is “incredibly frustrating because we’re in November now”.

Her members are becoming increasingly anxious about their workplace environment.

“We should have an expectation that we’d start to see at least some minor drop,” she says. “We are triaging, trying to get the right people through … but what if we miss something in all of the enormity of what’s coming through the door? It’s unbelievably stressful for everyone involved.”

In July, the Australasian College for Emergency Medicine said conditions at the RAH were deteriorating, putting patients at an increased risk of complications, errors and death.

“It is unsustainable to have hospitals operating at 100 per cent capacity every day. It leads to poor patient outcomes and staff burnout,” ACEM president Simon Judkins said.

A week later, emergency departments of the RAH, Flinders, Queen Elizabeth Hospital and Modbury Hospital were all stretched beyond capacity, leading doctors to warn that “dangerous overcrowding” was endangering the lives of patients.

A discharge lounge — overlooked in the initial design — had by then been introduced to the RAH.

It is seemingly having little ­impact.

Wade is under no illusion that the system will be fixed by addressing capacity issues only.

Capital works at the RAH are likely to occur at some point next year, including within the emergency department, which is the focus of a logistics company employed by the government.

“We’re not averse to investing in capital to help the hospital work better,” Wade says.

Flow from the emergency department has been hampered by faulty technology within the hospital’s mental health unit.

An unworkable duress alarm system stems from a wiring fault, meaning 10 mental health intensive care beds sit idle, resulting in several emergency beds being filled by mental health patients.

A recent example involved 11 mental health patients spending more than 24 hours in the RAH’s emergency department awaiting specialised beds.

At one point on November 17, there were 24 mental health patients in the emergency department waiting for beds.

Stays of more than 72 hours in the emergency department are common for some mental health patients.

“I’m extremely frustrated that it (the duress alarm) hasn’t been resolved by now,” Wade says.

“We’ve had a series of time­frames that have been missed and the private operator is in no doubt that it is a very high priority for the government … I’m still being told it’s imminent.”

The AMA says the establishment of an independent clinical data analytics body would be a “game changer”. Located in an academic environment free of political influence, Hoy says it would provide better data and understanding of what was going on across the network and where to best deploy resources.

“We have had too many bad decisions based on bad or badly understood data,” he says.

Hoy also wants to see those delivering care engaged more in finding solutions.

“People are pretty fatigued with external consultants coming in to provide answers,” he says.

“And although there may be short-term solutions to some of the immediate issues, we need to embed long-term solutions that will see us into the future.

“We are very ready to have those conversations.”

Together with the AEA and Salaried Medical Officers Association, the nurses’ union has had plenty of conversations with Wade and senior health bureaucrats in the hope an urgent circuit-breaker can be found.

After the most recent meeting, Dabars ramped up the rhetoric around industrial action.

“The current situation is unsustainable,” she said.

“We’ve made it clear to the minister that our members will no longer accept another all-talk, ­no- action scenario — they’re at tipping point now.”

As for when the public should expect ramping to be replaced by a fully functional health system, Wade is vague.

“I heard one of my predecessors say that with health, you wake up in the morning and you know there’ll be a crisis, you just don’t know which one,” he says.

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Nurses demoralised

Nurses have had enough.

That’s the message from union boss Elizabeth Dabars, who says her members, particularly those within emergency departments, are at a tipping point.

Patients’ lives are at risk and some nurses are considering careers elsewhere because of burnout.

One nurse recalls a mental health patient who waited 100 hours in the emergency department for a specialised bed. The patient was unable to go outside because there were no staff members available as an escort.

The patient was in a cubicle without windows for the duration, unable to tell whether it was day or night.

“It was noisy. The PA system goes off every 15 minutes. The lights never turn off,” the nurse says.

Another incident involved a 95-year-old man who was forced to wait six hours in the back of an ambulance for a bed to become available within the emergency department.

He soiled himself because nurses were unable to transfer him to the toilet inside the emergency department in time. The man, who had no family with him, was cleaned up and returned to the ambulance to continue his wait.

“Regrettably, nurses are reporting that the government’s recent initiatives are doing little to ease the enormous pressure on our hospitals, in particular the RAH,” Dabars says.

“Patient safety is clearly still at significant risk.”