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Health – Ambulances and the Emergency Department

Dr Rosalie Woodruff MP

Dr Rosalie Woodruff MP  -  Monday, 23 November 2020

Tags: Ambulances, Emergency Department, Ambulance Ramping, Bed Block

Dr WOODRUFF - Minister, how many patients have had a code blue event while they've been ramped at the Royal Hobart Hospital this year?

Ms COURTNEY - I will ask the CMO to respond to that.

Prof LAWLER - I don't have that data in front of me. The challenge will be that the recording of code blue information, that is when a code blue is activated, is not tied to the location of an individual within the ED. Our ramping definition is based upon the time they enter and leave a particular definition in the ED. We can certainly provide information on how many code blues occur on patients in the ED, but tying that to whether they are currently on the ramp or not is troublesome.

Dr WOODRUFF - Isn't that critical information, to understand the impact of access to ED on patient outcomes?

Ms COURTNEY - Obviously we want to minimise ramping at our different sites to the fullest extent possible. It is not a good outcome for patients no matter their level of acuity and it also provides a lot of challenges for our paramedic staff. We are very focused on a range of solutions that both the secretary and I have talked about at our different sites.

The RHH was obviously part of the former minister's access solutions meeting to ensure that we do have capacity in the emergency department to minimise ramping as much as possible. The CMO has provided an answer in terms of the detail, but I recognise we want to minimise any ramping at out hospitals because of patient safety.

Dr WOODRUFF - I had another part of that question, minister.

CHAIR - I've actually gone to Ms White


Dr WOODRUFF - Minister, the protocol for clinical management of patients affected by ambulance patient off-load delay in the Royal Hobart Hospital Emergency Department guides the clinical management of patients as they have been moved between ambulance and the Emergency Department. The document states that once Emergency Department staff have taken any treatment of a patient on the ramp, that patient then becomes the responsibility of the Emergency Department. In reality, this doesn't always occur. Doctors may be administering medication, for example, for a femoral nerve block, before being forced to move on to another case and so a patient can be left with the paramedics once more. Doctors, nurses and paramedics all report feeling confused by where their responsibilities start and end, and frustrated that this THS protocol doesn't reflect the reality on the ground.

Do you think this protocol is working properly? Do you accept it seems to be an unfair situation for frontline health workers to be facing this confusion? Do you also accept, following on from what Mr Lawler said earlier, perhaps we can't collect the data on code blue stats properly because they're not easily attributable due to this confusion?

Ms COURTNEY - Thank you for the question. Given the operational nature I ask Professor Lawler to outline the detail. We are very focused on having solutions that can resolve the challenges around bed block and ramping at the hospital. I acknowledge the stress ramping puts on our paramedics and hard-working ED staff, and also our patients who are having to wait. I will get Professor Lawler to talk through the response from an operational perspective.

Prof LAWLER - I will make a slight distinction between this and the previous comment around the difficulty in obtaining a linkage between code blue and ramping. That isn't so much a confusion over governance and responsibility; it's because we collect these things in two different systems that don't necessarily align. I understand exactly what you're saying around the confusion of treatment; in fact, that prompted the development of the protocol.

The protocol discussed a number of issues. It's a recognition that the ramp - or the area where patients who are in offload delay - are looked after is a very busy area. It has paramedics providing ongoing supportive care until the patient is offloaded into a formalised treatment space. There is also the need to undertake an early assessment for a number of of a number of including triage and recognition of deterioration. This protocol was extensively consulted and developed between the key stakeholders, the emergency department staff, and the paramedics.

There's a recognition that while there is some attraction to saying no treatment can start until a space is available, or as soon as treatment is started handover has to occur, it also recognises there are circumstances wherein treatment has to be started, purely for humane purposes. You mentioned a femoral nerve block. The provision of adequate analgesia is absolutely key - as I mentioned earlier, the provision of antibiotics in patients with sepsis.

There is a number of instances wherein treatment has to commence. There is a recognition that an overriding priority has to be getting a patient to an appropriate treatment space, and also to free ambulances up to provide operational responsiveness to the community. That's always in the minds of navigating - the nurse navigator, the nurse coordinator, the treating doctors - but there is also a difficulty in navigating the challenges between having a patient in a space where they can be formally treated, versus holding off on treatment which may either influence the ultimate course or even just provide needless pain and suffering.

This is also, at the point of care delivery, a matter of consultation and negotiation between paramedics, between nurses, and between doctors. This is a protocol that provides what should occur. There is also the real time response to that with a patient who requires treatment sometimes in a space that is not optimal.

Dr WOODRUFF - Surely, a protocol is meant to deal with real time situations. Doesn’t what you just said indicate there needs to be some clarity in the protocol, a change in the protocol to reflect the real-life circumstances so everything is crystal clear and accidents and terrible situations can be avoided.

Prof LAWLER - The process in negotiation and collaboration of the document has highlighted a number of those issues so I don't believe that we are in a situation where there is widespread confusion or widespread ambiguity. There is a recognition this is also about a conversation and a discussion that occurs between health professionals to provide the best level of care for the patient.

Dr WOODRUFF - Minister, I still don't understand why the THS and Ambulance Tasmania don't have code blue records. Both bodies are required to keep records. Why can't we get the information about the number of code blue events on the ramp at the Royal Hobart Hospital?

Ms COURTNEY - I appreciate the question. Information on a patient's journey through an entire system is part of what we're looking at through our investment in a digital strategy for our health system. We know that it's not only for patients being cared for within the THS; we know we have challenges that we can face. That might be within AT and the THS. It also might be between the THS and somebody's GP in the community.

We also want to make sure we don't have duplication of procedures or tests, as we transfer patients through a hospital, and through different facilities. We want to make sure that information is correct and timely. That will deliver better outcomes for the patient but ultimately, and I think that's the point you are going to, it will give us the information to drive better decision making. At the moment the systems don't give us the detail of the information we need. It is why Medtasker has been rolled out successfully in the Royal Hobart Hospital. It is why we are working with the clinicians in the North and the North West about the rollout of it there to be able to support them.

I think Professor Lawler had a further comment to make.

Professor LAWLER - I don't think the fact that we can't pull a quick data picture of how many code blues occur on a ramp should be taken as representation that we don't keep records on these things. We are able to provide information on ramping numbers, and every code blue that occurs within the ED or within the hospital is recorded and charted, and documented through standardised processes.

The challenge we have is that there are not flags within our patient tracking system, that say this patient had a code blue. We keep code blue records within our digital medical record. That is where we keep our clinical accounts, but they don't link up. I believe it would be highly atypical, if it occurs at all, that there are flags within a system around the country that enabled you to rapidly pull out from the system, this patient had this code blue on this location, in an emergency department. It is not to say that because we don't have that data, that we are not having adequate and competent recording and documentation of those events.