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Health - Paramedics and Ambulances

Dr Rosalie Woodruff MP

Dr Rosalie Woodruff MP  -  Monday, 6 September 2021

Tags: Ambulances, Ambulance Ramping, Paramedics, Health, State Budget

Dr WOODRUFF - Minister, within Ambulance Tasmania, how many intensive care paramedics and how many extended care paramedics are employed?

Mr ROCKLIFF - Thank you, Dr Woodruff. I will get those numbers for you. Our new CEO, Joe Acker, was here earlier and will be here later on this afternoon, to answer question of that nature. If we can provide them now we will.

In 2021, Ambulance Tasmania increased its staffing, that’s all staff, to 627.85 FTE compared to 567.54 FTE the year earlier. That’s an increase of 10.63 percent across all staff awards.

In 2021, 541.51 FTE were employed under the Tasmanian Ambulance award, which includes paramedics and emergency communication staff, compared to 487.34 FTE the year before and I'm advised that's an increase of 11.11 per cent. But your question was around intensive care and extended care.

If we can access those numbers prior the Mr Acker returning we will let you know. Mr Acker will be back at 2 p.m.

Dr WOODRUFF - Okay. I will ask a question about ramping which you can probably can answer. Last year in budget Estimates we asked the Minister to provide data for the number of code blue events that had occurred on the ramp at the Royal. The Minister told us that data is not available. Is that still the case, and are you measuring any data which is specific to the ramp?

Mr ROCKLIFF -Ambulance ramping is directly impacted by demand for public hospital emergency departments and the capacity to admit, discharge or transfer ED patients in a timely manner. We have invested in several hospital-based strategies to facilitate ED throughput, patient admission and discharge processes and pre-hospital care strategies including the introduction of the Patient Flow Manager Electronic Information System and the creation of integrated operation centres in the major hospitals. The department's also established a statewide access and patient flow program to develop a system wide framework for integrating, delivering and monitoring programs of work aimed at improving patient access and flow across the State.

This statewide access and patient flow program has been designed to build on work already completed or underway across the state to deliver sustainable improvements in the performance of our hospitals in patient access and flow. Ambulance Tasmania also employs strategies to reduce demand for emergency ambulance responses, where it is assessed as appropriate for the medical care of the patient. These include deploying extended care paramedics who have advanced skills in patient assessment and the provision of medical care. This response may enable patients to be treated at home and avoid the need of an emergency ambulance response.

I have mentioned this a few times before, but the implementation of a secondary triage service in February this year is providing referrals or alternative care pathways for patients who call triple 0 and are assessed as not requiring an emergency ambulance response. I am advised that we do not collect code blue data in a way that links it to locations within an emergency department.

Dr WOODRUFF - We know that. The question was whether that data is now available. I asked that question last year. Does the department collect any data about how long people are being ramped or what is happening on the ramp?

Mr ROCKLIFF - I'm advised that we do collect that data.

Dr WOODRUFF - But what is the data, Minister?

Ms MORGAN-WICKS - We collect ramping data, relating to the offload delay criteria which I think is triggered at 15 minutes. This is measured at the point we go over a 15-minute period in delay of offloading a patient from an ambulance on the ramp. In relation to code blues, we obviously collect code blue information, as it relates to a particular patient. We don't segregate the data as to where the code blue has occurred, such as the physical location of the code blue on a ramp.

Dr WOODRUFF - Thank you. Minister, can you please provide a list of all data that are collected for hospital ramps, and the figures recorded against those measures for the last three years?

Mr ROCKLIFF - Statewide?

Dr WOODRUFF - By hospital, statewide. Last three years, thanks.

Mr ROCKLIFF - If you look firstly at ambulance presentations at the Royal Hobart Hospital, in 2018 19, there were 22 686; in 2019 20, 22 219; and 2020 21, 25 105.

The percentage of transfers within 15 minutes in 2018 19 was 66.3 per cent; in 2019 20, 68.8 per cent; and the financial year just gone, 66.6 per cent.

The percentage transferred within 30 minutes: 72.1 per cent in 2018 19; 75.6 per cent in 2019 20; and 74.6 per cent in 2020 21. In Launceston we have ambulance presentations: 2018 19 of 13 565; in 2019 20, 13 993; and 2020 21, 15 066 ambulance presentations. An increase there. Percentage transferred within 15 minutes: 75.1 per cent in 2018 19; in 2019 20 69.6 per cent; and 2020 21, 61.4 per cent. Transferred within 30 minutes: 81.2 per cent in 2018 19; 75.7 per cent in 2019 20 and 68.1 per cent in 2020 21.

At the North West Regional Hospital ambulance presentations were: 6929 in 2018 19; 7282 in 2019 20; 9116 in 2020 21. Again a big increase. Percentage transferred within 15 minutes: 95.4 per cent in 2018 19; 90.4 per cent in 2019 20; and 77.5 per cent in 2020 21. Transferred within 30 minutes: 98.5 per cent in 2018 19; 95.1 per cent in 2019 20; and 85.7 per cent in 2020 21.

Dr WOODRUFF - Minister, in February the previous health minister announced that the Government was going to set up a fully-fledged secondary triage program for Ambulance Tasmania. She said at the time, in a media release, that it would divert 16 000 patients to alternative service providers. Two weeks later in parliament, the minister said the service had the potential to eventually divert well over 10 000 patients each year.

Can you please clarify which of those figures is the Government's goal for secondary triage? And since the program started on 21 February, how many calls have been taken on average a week, and how many patients have been diverted away from the emergency department to another provider?

Mr ROCKLIFF - My understanding is that the patients who have been secondary-triaged and then diverted to another form of care outside the emergency department is around 600.

Dr WOODRUFF - Is that per week?

Mr ROCKLIFF - No, total. It commenced on 22 February 2021, and as of 30 August 2021, approximately 642 triple zero calls had been successfully diverted from an emergency ambulance response. Of these cases, approximately 50 per cent were in the south, and 25 per cent in the north and north west.

I saw part of that in operation when I visited Ambulance Tasmania six weeks ago.

Dr WOODRUFF - How many calls were taken in total, 642 diversions?

Mr ROCKLIFF - We successfully diverted 642 triple zero calls.

Dr WOODRUFF - Out of what total number of triple zero calls?

Mr ROCKLIFF - How about we address the issue of the 10 000 or 16 000, and then there may well be data that Mr Acker will be able to provide at 2 o'clock about the calls over those few months. Ms Morgan Wicks, in terms of the 16 000 or 10 000?

Ms MORGAN-WICKS - I am not personally aware of the 10 000 versus the 16 000 and the context in which those numbers were used by the previous minister, but I am aware that our secondary triage program was a transitional process. In terms of the 642, we're not at full implementation as yet on secondary triage. It has commenced, and we continue to add in the types of cases, triage points, that we can have transition through and be handled by the secondary triage teams.

In terms of our future demand modelling, patients who currently ring 000 and are assessed by our medical patient dispatch system as not requiring an emergency ambulance response, and are categorised as 'sick person' - or 'Card 26', as the despatchers like to refer to those - they're being referred through to our secondary triage for further assessment.

We're now looking at expanding the suitable events that we establish for secondary triage in addition to that sick person category.

When you look at the future expansion of the events, when we look at the cards, for example, and 'card' is like a category that they use in their triage system, and the potential volume, we have thousands of events that sit against those. For example, card two allergies, card three animal bites, card seven burns, so going through and looking at what are appropriate categories that may be referred through to secondary triage.

We have started with that lowest acuity category. Card 26 sick person is where we are not able to previously identify it as not breathing, other severe reaction or severe acute response being required.

We have been very pleased with the way in which secondary triage has now commenced. We are really working with the community to aid their understanding that not every call requires an emergency response.

We have closely followed the Victorian roll out of their secondary triage service. A Victorian paramedic involved in that project came over to assist us with our roll out.

With regard to our medical care plans for frequent callers, and we do have some frequent callers to Ambulance, we have a clinical nurse consultant. Medical care plans commenced on 18 June 21, who is going to be undertaking investigation of our frequent callers and to liaise with external and internal stakeholders for the purpose of developing medical care plans for them.

We do have instances where our paramedics, upon call out, take patients to a pharmacy or to a GP where we can find other care in the community to assist them, rather than coming straight through to our hospital ED environment.

Dr WOODRUFF - Minister, what is the goal? The previous minister said 10 000 and then she said 16 000, so what is the goal for this year?

Mr ROCKLIFF - First, can I table the process? You might be interested in how that is integrated and the connectivity of Ambulance Tasmania with other health and social service providers to appropriately divert patients away from emergency ambulance response when their medical care needs could be better met by another provider.

Dr WOODRUFF - Did the previous minister just pull some numbers out before the election and throw them around?

Mr ROCKLIFF - I wouldn't have thought so.

Dr WOODRUFF - There is a big difference between 1200 if we are tracking at the same numbers and 16 000.

Mr ROCKLIFF - My understanding is that the numbers would have been a result of some business cases that were presented with regard to moving to secondary triage. I will stand corrected on that.

Dr WOODRUFF - It is not stacking up with what we are seeing.

Mr ROCKLIFF - It's only six months

Dr WOODRUFF - So we are tracking for about 1280 compared to 16 000? Do you have any figures?

Mr ROCKLIFF - I welcome deputy secretary Dale Webster to the table. It is the roll out stage. As we progress further, there will be more secondary triaging and ProQA card sets will be well established.

Mr WEBSTER - The estimate of the capacity of secondary triage is based on the experience of Victoria, given that we are rolling out the Victorian model here. In Victoria, they have reduced the number of emergency call outs by about 35 per cent. If you apply that to the numbers in Tasmania, which is about 50 000 emergency call outs, that is how you get to 16 000.

In achieving that, we need to walk before we run. We are rolling it out in a way where we are looking at our community partners, making sure they are available, we are making sure that our GPs have capacity. The secondary triage model overlaps with all of the work that has been done around the emergency response centres. The ultimate goal would be to achieve the same as Victoria, that is around 16 000. We need to work up to that and make sure we are not just diverting people and there is no service.

At the moment we are growing the number of extended care paramedics within our work force which will add to our capacity to do secondary triage. We are working with general practice and practitioners around telehealth consultations, we're working with No. 34 Aboriginal Health Service, Royal Health Tasmania, The Tasmanian Lifeline, the Extended Scope Occupational Therapy as well as Community Nursing South and North. We will expand that over the next few years.

Dr WOODRUFF - Minister, access to Ambulance Tasmania drug storage was clearly a very important factor that was highlighted in the coronial inquest hearings into the tragic death of the young paramedic Damien Crump earlier this year. He died in 2016. We understand it is now policy that paramedics should not access the drug store at Ambulance Tasmania headquarters in Hobart alone. However, we also understand to access the room still only requires scanning a single access pass and these passes allow entry to the drug store even when paramedics are off shift. In the course of their work paramedics need to ensure they adhere to the rules. However, the fact remains the current security arrangement would not prevent someone from taking the same steps as Mr Crump so tragically took. Why has not access to the drug store been fixed so two security passes have to be scanned to enter the room every time?

Mr ROCKLIFF - I will ask Mr Acker to say a few words in a moment addressing the operational matters of your question. I want to commence by extending my deepest condolences to Mr Crump's family and loved ones, a coronial inquest into the death of Ambulance Tasmania paramedic, Mr Damien Crump, in 2016 commenced on the 15 March this year. Since Mr Crump's death, Ambulance Tasmania has comprehensively reviewed its medication management policies, procedures and practices with new policies and procedures implemented in early 2020.

I am advised Ambulance Tasmania is implementing an electronic medication management system, which will capture medication management from procurement to audit. The procurement process for the system is progressing, it will assist in a capture of drug register information including the procurement, administration and disposal of addictive and restricted substances. The system will also enhance drug audit capability and is designed for the mobile paramedic environment, the timeframe for implementation will be confirmed upon the commencement of a project manager and this recruitment process nearing completion.

A review of security access in stations and for medication store rooms was also undertaken. Ambulance Tasmania is currently conducting a security project. I am advised that will see enhancement of security measures and the development of a standard approach for all stations. Five Ambulance Tasmania station sites are being used as test sites to determine a blueprint for security needs, including medication rooms and site access and these sites will include Melville and Brisbane Streets in Hobart, Launceston, Wattle Hill and Campbell Town and it will go live in the second week of September.

Since 2016, Ambulance Tasmania has introduced a number of mental health and wellbeing support for staff and has implemented awareness and educational programs for supervisors and managers. I might now ask Mr Acker to say a few words in relation to Dr Woodruff's question.

Mr ACKER - You are right that we have some work to do. As the minister said we are working on a security project right now we have hired a senior pharmacist who is now reviewing all of our policies and procedures. That has been over the last month. We are also hiring a Project Manager to look at all of our security infrastructure across the state. We have about five projects underway right now to identify the best-case blueprint for our security of our station. It is important to also now our medication rooms are under a 24-hour closed-circuit television monitoring and every time the door is opened it starts recording. Although we haven't fully fixed our card-swiping systems, which we intend to do shortly, we do have very good CCTV across the state for our medication rooms.

Dr WOODRUFF - That's very good to hear. Perhaps Mr Acker could comment on whether Ambulance Tasmania will transition from a paper-based drug register to an electronic one?

Mr ACKER - We are investigating the electronic medication management system. We have an external vendor who is providing that service to us, which is the same system that is used by the THS. We intend to implement that very shortly.

Dr WOODRUFF - Minister, during the coronial inquest into the death of the paramedic, a long-term paramedic wept when she gave evidence talking about the other paramedics in the workplace opening discussing suicide plans. There was also evidence that staff with post-traumatic stress order or mental illness were explicitly not supported in the workplace and people had been managed out of the workforce if they were being, quote 'difficult' or 'caused any extra work or grief for managers'. The Workers Rehabilitation and Compensation Act was amended to include provision for presumptive PTSD for public sector workers, importantly including paramedics, which is excellent.

We have heard disturbing stories from paramedics currently on workers compensation for PTSD who have been encouraged by their GPs to undertake social and community activities. We have heard they have been filmed by private investigators hired by insurance companies to verify their claims. Minister, have you heard any reports like that? Are they true and are you concerned by them?

Mr ROCKLIFF - As I said before, since 2016 Ambulance Tasmania has introduced a number of mental health and wellbeing supports for staff. It has implemented awareness and education programs for supervisors and managers. Before I go to Mr Webster, in partnership with the Department of Police, Fire and Emergency Management, Ambulance Tasmania frontline staff have access to physical and mental health online assessments. Following the assessment, coaching assistance provided by allied health professionals and other more immediate interventions are put in place for individuals as required. Mr Acker has engaged a third party organisation, Frontline Mind to conduct an organisation-wide resilience survey that will result in recommendations for enhancements to their wellbeing programs. The Resilience Survey closed on 27 August 2021.

Pertaining to the coronial inquest, hearings were convened on 23 and 24 August, now adjourned until 9 September, at which time submissions will be heard as to the timing of closing submission and testimony from the inquest relating to other workplace drug and harassment issues within Ambulance Tasmania are currently being investigated by the Department of Health. Mr Webster, have you anything further to say on Dr Woodruff's question?

Mr WEBSTER - In addition to the work by external organisations, Ambulance Tasmania engaged with Queensland Ambulance Service and adopted a model of peer support workers. There are now 33 peer support officers across Ambulance Tasmania. They are supported by a mental health and wellbeing or human resources consultant in terms of sets of skills and things like that. That is that additional level of support, the immediate support for staff. In relation to the workers' compensation issue you raised, I would be surprised if that is a situation for PTSD given the presumption that is now in the legislation, but I am unable to comment on a particular circumstance.

Dr WOODRUFF - I had hoped you would look into that to make sure there is nothing there.

Mr ROCKLIFF - We will look into it.

Ms MORGAN-WICKS - Certainly I am not aware, as Secretary, in relation to any claims of filming. Noting Mr Webster's response in relation to the presumption on PTSD, that we automatically accept those workers' compensation applications. But certainly, if there is some information you would like to be provided to the department, I would be very happy to look into that and connect with the employee involved.

Dr WOODRUFF - Minister, do you agree there is a need for a more proactive and ongoing approach to look after the wellbeing of paramedics, including rostered check-in appointments with qualified professionals, possibly, for example, every six months?

Mr ROCKLIFF - In terms of the operational nature of that question, Dr Woodruff, before I hand to Mr Acker, could I say as part of our 2040 Workforce Plan, when we spoke about culture and ensuring people who work across our health service feel valued, enjoy the place they work, being a place they want to work in, have ensured there is aspiration also throughout the workforce and opportunities for promotion and the like, and create a better culture right across our health system, I will take on notice your ideas of what you have just outlined. But perhaps Joe would have more detail around some of the matters.

Mr ACKER - Dr Woodruff, we definitely take these situations very seriously. We are doing everything possible to support our employees and volunteers. We are also looking forward to the results of the coronial recommendations the Coroner sends out that will guide some of our changes in the future. We are also looking forward to the results of our recent resilience scan. When we meet with Frontline Mind we can start to look at what is causing the stress in our workforce and working through some important innovations to change that.

Mr ROCKLIFF - I think Mr Webster wanted to finalise an answer.

Mr WEBSTER - To emphasise, Mr Acker mentioned Ambulance Tasmania is actually part of the program run through the Department of Police, Fire and Emergency Management. All of our staff have access to physical and mental assessment processes. Following those assessments they have coaching assistance, they have allied health access. If there is a need for more immediate interventions they are put in place on an individual basis. We emphasise that program run across Police, Fire and Emergency Management applies to Ambulance Tasmania also.

Dr WOODRUFF - Minster, there are many very highly qualified and experienced paramedics who unfortunately have had to leave Ambulance Tasmania over the years or are currently on stress leave for PTSD or other mental illnesses related to the stress of the work they do for us all.

It is so important we are able to retain these people's skills within the Tasmanian health system. Could you talk about where things are up to with legislation to enable the paramedic practitioner certification process so paramedics who want increase their skills, like other health professionals can -doctors and nurses are able to get rights and recognitions under Tasmanian law - and have a paramedic practitioner training process?

Mr ROCKLIFF - I can. I request Mr Acker provide some detail on that question.

Mr ACKER - Dr Woodruff, the concept of paramedic practitioner is new to Australia. It is a very new clinical field that closely resembles extended care paramedics or sometimes community paramedics. Essentially, these are paramedics often with post graduate education that have a scope of practice to provide primary care, skills and more comprehensive patient assessment in the home or in the community.

Some of those skills would be things like administration of antibiotics in the home or suturing the wounds in the home that do not require transportation to the hospital. In Tasmania, we are considering opportunities to expand the scope of practice of our current extended care paramedics to enable some of those skills and procedures as the more comprehensive diagnostics.

For example, we have recently procured ISTAT Podgas analysers for extended care paramedics to new point of care testing in the patients' homes. The patient would not have to now go to a lab for blood testing and the paramedics could relay those results to a general practitioner or to our internal physician consultants. It is definitely something we are closely considering in terms of the expanded scope of practice for paramedics.

Dr WOODRUFF - Minister, in relation to Ambulance Tasmania staff. Could you please step through the process in place at the moment in Ambulance Tasmania to investigate allegations of sexual assault or harassment in the workplace? Something that was mentioned very strongly in the coronial inquest. I understand that the recommendations will be looked at, but just right now, what is the process in place?

Ms MORGAN-WICKS - It is not a different approach or process that we applied, Ambulance Tasmania versus an allegation of sexual harassment or assault that occurs across our health service.

Earlier today, I outlined in response to the Commission of Inquiry team that has been set up, but are also looking at our policies and procedures, that information in relation to the reporting of any concern in relation to sexual abuse or harassment, whether it is a child or involving two adults, for example in a transaction, applies equally. Certainly, following the information that has come out in relation to the coronial inquiry and the witnesses we have reached out to, people who have been attending the inquiry have also received some information and reports that are being worked through in terms of the department.

Dr WOODRUFF - Minister, Ambulance Tasmania is known around Australia for having one of the best intern paramedic programs in the country and the success of the program has led to many graduates from other states seeking work here. However, we are hearing some major changes are underway for the intern program.

Can you confirm plans are in train to transition the intern program from one that has been based on formative and scenario-based assessment training in person to interns undertaking online training, including parts with self-assessment?

Mr ACKER - We are exploring opportunities to be innovative in the way we hire casual paramedics including new graduates. Up until now we have never hired casual paramedics right from university. We have always waited until we had full-time positions available and that has not served our workforce well because we have not had a capacity to cover those vacant shifts or times of leave. We are exploring innovative opportunities to allow graduates from university to get casual employment with us that is supported through a variety of educational methodologies including online delivery and a substantial focus on face to face so the first six weeks of their induction will be face-to-face education. They will also have a driving component so we ensure that they are safe to be in practice and then it will be supported throughout their term for the same number of hours as our employees coming from university were supported previously.

We are also investing in new technology to track the skills and competencies and capabilities of our employees who are new to the organisation to ensure that they are continuing to grow in their profession as new graduates.


Dr WOODRUFF - Paramedics have told us that they are very concerned about the proposed changes to the intern training program and what that will mean for the competency of people in the service. Although some other jurisdictions in Australia have this type of training that Mr Acker has outlined for interns, we have heard that Tasmanian paramedics need to be able to treat serious and severe illness to a much greater level than other jurisdictions, particularly because remote areas make that impossible to do otherwise.

We have also heard concerns that limited on road assessment will not be able to cover off on all the critical scenarios that paramedics can confront. For example, managing trauma, overdoses and obscure conditions such as diabetic ketoacidosis. These are all critical skills that paramedics need but are not regular enough occurrences to be easily accessed on the road. The real concern is without having on the job training and having the online skills mean that people will not have access to the real-life experiences.

Can you please comment on whether these concerns are valid?

Mr ROCKLIFF - People have concerns which have been expressed to you. I have great confidence in the innovative approach that Ambulance Tasmania are looking to employ. On the specifics of your concerns, Mr Acker, would you like to talk about online training versus more practical training and the effect that that might have?

Mr ACKER - For some context, prior to my joining Ambulance Tasmania, six months ago I worked in British Columbia, Canada, but I have also been an academic. I am an adjunct professor at the University of British Columbia and spent seven years as a senior lecturer in paramedicine at Charles Sturt University. I am very well connected with the academic community in Australia.

I think that the concerns mentioned to you regarding the paramedic program that we intend to start in the next few weeks are not necessarily fair or accurate. We do know that the universities around Australia are graduating terrific graduates who are ready for practice and we need to support them in practice. Supporting them is done through a number of different ways, including infield mentorships, support and coaching as well as competency tracking. As I said, we have a tool in place to ensure that we are tracking their competencies to ensure that they have a range of experiences.

With casual employees - which I think is even better than with permanent employees - we also have the ability to move them to different stations so they can get the exposure to rural and remote communities and some of our branch stations which is different medicine, as well as working in an environment where they see more volume. Their capability to manage a range of cases will be monitored by our education and professional development department under the direction of our new Director of Clinical Services. I am very optimistic and confident that we will continue to produce excellent paramedics as they enter practice.

Dr WOODRUFF - Minister, a question in relation to Ambulance Tasmania again. Earlier you said that in order for Tasmanian paramedics to become an extended care paramedic they have to first become an intensive care paramedic. This is despite recommendations from the 2017 Clinical and Operational Service review of Ambulance Tasmania, which said that the roles should be separated and specifically said an extended care paramedic should not require intensive care paramedic training first.

Paramedics have told us that they think the uptake of extended care paramedic training would be much higher if this intensive care paramedic training wasn't required first. Why was the decision made to ignore the recommendations of that review? Do you accept that this is contributing to the very low rate of extended care paramedics who are employed?

Mr ROCKLIFF - Thank you, Dr Woodruff, for the question, it's very operational in nature. Kath?

Ms MORGAN-WICKS - We understand that this is actually an award requirement and that the recommendation of the review has been raised with HACSU, the employee organisation involved, but I might ask Mr Acker to comment further.

Mr ACKER - We agree with the recommendation that paramedics should have the opportunity to pursue formal education to become extended care paramedics without being an intensive care paramedic. The jobs are completely different. We have raised this with HACSU again, going back to the award that requires extended care paramedics to be first an intensive care paramedic. So, it is on our list of things to discuss at the next negotiations.