Talking Point: Royal Hobart Hospital culture change can save lives

GEOFF COUSER: Simple changes to Royal Hobart Hospital Emergency would lift safety and help patients faster

EFFECTIVE: Senior inpatient specialist staff being rostered on-site after hours would provide clinical leadership and support to junior staff, assist with clinical decision making, reduce adverse events and improve patient flow.

I’VE been a staff specialist in the Emergency Department at the Royal Hobart Hospital for nearly 20 years.

In that time the department has grown in size and complexity, and I and my colleagues have been driven by the principle that we’re here for the patients and we endeavour to deliver the best care possible around the clock.

From the time I started in 2000, the Emergency Department has always had specialists present in the department between 8am and midnight seven days a week.

This was once regarded as “extended hours cover”, but no one would disagree with the proposition that this sort of senior staffing model is now, in 2019, anything less than expected. It gives me great comfort to know that should a patient present to the emergency department needing immediate urgent care, that there will be an experienced and qualified clinician present immediately to provide care.

The people of Tasmania should be reassured that despite reports of a struggling system, excellent care will be provided to those who require it.

I’d like to make the point that we didn’t start working like this because any government directed us to.

We did it ourselves because we recognised that our junior colleagues, nursing staff and ambulance colleagues deserved that level of support.

We did it ourselves because we recognised that it was the right thing to do. Above all we did it for our patients who deserve the best care possible any time of the day or night. Which brings me to the point of this piece.

The public hospital system is in trouble. It is overcrowded and suffering from chronic under-capacity.

This situation is demonstrably causing adverse outcomes.

It has become an accepted truth that an overcrowded emergency department is the canary in the coalmine of an overcrowded health system. There are almost daily calls for the Government to “do something” or for the Minister to resign. There are undoubtedly things the Government could and should be doing.

However, that’s not the whole story. This was highlighted in the recent Auditor-General’s report into emergency department services in Tasmania.

It makes for sobering reading.

The report critically examines issues such as ramping, length of stay, patient flow — all issues that impact upon emergency department performance and subsequently patient care and outcomes.

Importantly, the Auditor-General highlighted that many of these problems “reflect the impact of longstanding cultural and process barriers within hospitals”.

In that these problems arise from within, the solutions must come from the people within the RHH and the broader system.

As an emergency department we have addressed what we can do in isolation.

We have changed our work pattern to have even more senior staff present in the department after hours in an attempt to mitigate against such adverse outcomes in the face of such difficulties.

We have implemented and supported an overcapacity protocol to spread the risk more evenly across the hospital.

We have advocated for additional staff in other units to improve review times and processes.

Cardiologists have redesigned their services and processes so a patient suffering an acute heart attack will receive specialist-led care 24 hours a day.

Trauma and retrieval services are undergoing a similar redesign — all led and delivered by senior specialist staff.

However, as highlighted in the report, other barriers must be overcome so that optimal patient care can be provided.

We as a hospital community must take ownership of the challenges facing us.

This must be driven by a conscious acknowledgment that we, the staff, are here for the patients.

They are the reason we practise this vocation, and, to put it bluntly, they also pay our more than adequate wages.

How we work and what we do must have their wellbeing at the forefront.

It’s time for all clinicians in the hospital to examine their work practices and similarly redesign processes and systems so that patient safety and wellbeing comes first.

We cannot just keep on calling out for the government or the health department to fix things from above.

A number of changes challenging longstanding cultural practices and attitudes could be rapidly implemented that would lead to marked improvements to the functioning of the RHH and hence the wellbeing of patients.

Here’s one example: currently, in some inpatient units, the management of patients after hours is left to junior staff who are often overwhelmed by the sheer number and complexities of patients.

Senior inpatient specialist staff being rostered on site after hours would provide much-needed clinical leadership and support to those junior staff, assist with clinical decision making, reduce adverse events, and improve patient flow.

It has been proven in many jurisdictions that senior staff present at the beginning of the patient journey reduces length of stay and improves outcomes. This one change to a longstanding culture of working largely “in hours” would make immediate and demonstrable improvements to our patients’ wellbeing.

Solutions to the problems facing the health system are complex, but as health practitioners we must recognise that many of the problems are due to how we practise; conversely, many of the solutions lie with us.

It’s up to us to get on with it and do what we always claim to do: act in the best interests of our patients.

Dr Geoff Couser is a senior staff specialist at the Royal Hobart Hospital. The views expressed in this piece are his and are not written on behalf of any institution or organisation.