Zen & the Art of ED Management

There has been a lot of discussion this week regarding pressure on the Emergency Department at Flinders Medical Centre in South Australia.

Rack 'em and stack 'em!

I have a ‘soft spot’ for Flinders. I worked there as a junior resident and then registrar in the late 90s/early naughties and like to think that I learned a bit. The Consultant staff were excellent and engaged in training. The nursing staff were fantastic. And the work was great fun - I certainly enjoyed the immediacy of emergency/critical care but was seduced away to rural medicine by the lifestyle advantages and variety that this work offered. More importantly, the one thing that affected my decision not to complete training in ED/ICU was the lack of control over factors in my work (some might say that dealing with Country Health SA is similar, and you would be right, but more of that in another post).

The big issue for the ED is ‘access block’ - the inability to efficiently deal with emergency patients because there are insufficient beds in the ED..because there are patients waiting for beds ‘upstairs’ ie: in medical and surgical wards. And why are there no beds? Because the medical and surgical wards are either run at 100% capacity leaving no room for ‘surge capacity’...and/or that medical beds may be clogged with patients awaiting discharge to home, nursing home or country hospital.

Because there is no slack in the system, the clogging of ward beds filters back to the ED causing access block. And when the ED is full, the unhappy situation arises when ambulances cannot handover their patients because the ED is full and ambulances are ‘ramped’(literally wait on the ramp outside the ED). And tying up ambulances waiting outside EDs means there are not enough ambulances to deal with emergencies in the community.

Ramping has been a common phenomenon at Flinders Medical Centre in the past few weeks. Last Friday I was at an EMST course at Flinders and heard that the Director of ED, Dr Di King had resigned after being called into the CEOs office and asked to guarantee that ramping would not occur.  Of course this is impossible - Dr King has no more control over this than anyone else - the solution lies with the CEO and Minister of Health, not the ED Director. And so Di resigned, putting more pressure on a beleaguered Health Minister.

Yesterday Dr Dave Teubner came out and said it was safer for people to remain in an ambulance than to be seen in the ED. Dave is a passionate ED doc...he is not some hopeless academic, but a chap who really gives a damn. He is of course correct - it is better for people to be at least in an ambulance with oxygen, suction and a paramedic than lost in a corridor in the ED, unobserved and awaiting assessment or treatment with access to neither.

In essence, the whole idea of a well run health service should be to ensure that care is escalated with every referral. It is frankly dangerous to have care take a step downwards from ambulance to ED, as is the case at FMC when under bed pressure.

This is a concept that is a particular hobby horse of mine - the idea of ensuring there is never a ‘therapeutic vacuum’ or ‘inertia of care’. Every single thing we do should improve patient care, not stall it or even detract from it.

Certainly people admitted to an ED should see an increase in the level of care delivered to them. And so on...every single doctor, nurse, paramedic is doing his or her utmost to make this happen.

But the system seems to conspire against us.

And of course this is not just about ramping in the ED. It also applies to rural medicine, to the operating theatre, to in-patient care and to discharge.

Like many people working in health, I get hot-under-the-collar bemoaning failures in ‘the system’ where things could (and should) be better. Particular bugbears include 

• lack of equipment to manage a difficult airway in rural EDs and theatres
• lack of ownership of equipment and emergency training for rural staff
• cost-shifting between State and Commonwealth coffers for ED patients
• lack of discharge summaries from people who have been admitted and discharged from metro hospitals

...and so on.

What can we do to improve things?

Well, political pressure is one - I would imagine that Dr Di King’s resignation has served to highlight the issue locally and perhaps prod the Health Minister into action. 

More so, we can engage and try to make things better. I’ve been revitalised in the past few months by some of the information coming through the blog-o-sphere, with concepts of relevance to my practice that one is not going to get from a textbook or clinical placement. So I’ve done a survey on difficult airway equipment for rural GP-anaesthetists. I’ve offered to run some small group scenario-based sessions for nursing staff at the end of each of my anaesthetic lists and whenever I am on call for A&E. And I’ve been developing a web-based repository of emergency training for local use...how to set up the oxylog, where to find and use the rapid rhino kit for dealing with an epistaxis, a dump mat for RSI etc.

Another new idea is borrowed from the UK - a ‘one minute wonder’ fortnightly update on topics of relevance for our multiskilled rural nursing staff - basically a single A4 poster explaining how to find/set up/use a piece of ED equipment - displayed on the wall above the iStat machine to give people something to read whilst waiting for the iStat or Troponin reader to do it’s stuff.

Small things, but they might make emergency management in the bush easier.

Of course, the astute reader would wonder why these initiatives are not flowing ‘top down’. It would seem intuitive to have a minimum standard of airway equipment in rural hospitals, to have standardised ED kit and protocols, to train staff in equipment use beyond the token annual ALS refresher.

But this doesn’t happen. Change takes time, there needs to be initiative and drive, and solutions need to be appropriate to the local situation.

Anyone else got any pointers to drive change and improve emergency management in rural areas?

Advances in Trauma?

Well I’ve just got back from an EMST Refresher course in Adelaide.  This is the first time I’ve taught on a refresher course and it was nice to meet other experienced faculty as well as (mostly) rural doctors doing this refresher course. The Provider courses that I usually teach on are not usually so filled with rural doctors - more junior RMOs doing EMSt as a requirement for surgical training ANZCA no longer has EMST as a requirement for their trainees).


EMST is very much an entry-level course, but is well suited to the needs of rural doctors who often have to manage trauma as a solo doctor with limited resources. It should be borne in mind that over 40% of major trauma originates in rural Australia, so there is real bang for buck in getting effective trauma care delivered to these patients, whether y rural GPs or aeromedical services.

On this Refresher course, the hands on scenario-based skills stations seemed well received. I also had an hour after the MCQ to talk about ‘Trauma Teams and Advances in Trauma’ - a golden opportunity to chat about things like human factors in trauma team dynamics, as well as to draw on experiences from the group about well-run and not-so-well run traumas.

But what about ‘advances in trauma’ that are not covered in the EMST Provider course? Well, I reckon they can be broken down by category and it was this approach I used to guide discussion in the 30 minutes or so available to me for each group:

AIRWAY

Videolaryngoscopy as an adjunct for difficult intubation

Ketamine for trauma intubation

Difficult Airway Society algorithms

Andy Heard’s excellent youtube videos on CICV

Cliff Reid’s notorious ‘propofol assassins’ rant

Weingart/Levitan’s paper on preoxygenation

BREATHING

Finger thoracostomy

Ultrasound for evaluation of pneumothorax

CIRCULATION

Minimal volume resuscitation

C-ABC and tourniquets for catastrophic compressible haemorrhage

Tranexamic acid, CRASH II trial & applicability to rural Australia

Managing major traumatic bleeding in rural hospitals (big shout out to Casey Parker’s excellent blog on this at Broome Docs)

We didn’t get as far as DISABILITY but I daresay that discussion of hypertonic saline in head injury would have come up...

The discussion really made me think just how knowledge-hungry the rural doctors I met were, but how hard it was for information to be disseminated to these guys.   It cemented my belief that a  rural masterclass course would have a willing audience. There’s lots of new stuff to discuss in trauma alone, but add in other (non-trauma) areas of interest to the rural proceduralist and you’d have a gutsy, useful, evolving course with enough content for 2-3 days. I could rant about this for ages...

All I could do was relate my own experience in past year or so, and the value of internet-based learning and discussion which has re-vitalised my own enthusiasm for learning. Big shout outs to the rural docs for the education resources below :

Minh le Cong’s retrieval resources for ACRRM members at www.rrmeo.com and his new PreHospital And Rural Medicine (PHARM) blog at www.prehospitalmed.com

Cliff Reid’s excellent blog at www.resus.me

Casey Parker’s excellent Broome Docs, the central repository for all things relevant to the rural proceduralist

Those UCEM rascals over at Life In The Fast Lane

Scott Weingart's EM-crit blog

Common themes amongst the rural proceduralists I spoke to remained

• difficulty accessing medical equipment (videolaryngoscopy, infusion pumps and fluid warmers were common ‘wish lists’)
• difficulty with triage and training for nursing staff in rural hospitals
• desire for cross-training with RFDS/Retrieval service in terms of infusion regiments, SOPs and equipment

In Country Health SA, there are nominated rural doctors as ‘consultants’ in each of the areas of emergency medicine, anaesthetics, obstetrics & surgery. According to CHSA, their role is to :

• be responsible for providing clinical system advice and broad support to rural resident medical practitioners in country South Australia, in their identified area of expertise
  
• act as a point of contact for clinicians in country regarding system issues, as related to their specialty area, and participate in problem resolution
  
• participate in the development of policy and procedures that guide clinical practice in country. In addition, the Chief Consultants will work with the Chief Medical Adviser, Country Health SA and other country health staff related to decision making and policy setting as related to their speciality area 

With the exception of obstetrics, for which there seems to be a proactive rural proceduralist, it is hard to point the finger firmly at any positive attempt to address the above issues by present incumbents. In fact the rural doctors I spoke to (those with EM or anaes skills) were not aware of any initiatives in past year or so by the CHSA EM or Anaes consultants.

Which is a shame, as it seems these rural docs were struggling with similar issues in their own institutions, but lacking a top-down approach to streamline equipment, protocols & training. Rather they were having to push for equipment/training by dealing with local DONs of the hospital, usually being rebuffed as 'no money' in CHSA. It seems that my problems on Kangaroo Island with equipment/training are the same as those in Port Lincoln, the Riverland, the South East etc...and we are all trying to fix in our own manner, which mostly comes down to enthusiasm for a particular issue at any one time. No wonder things are fragmented.

Meanwhile not a week goes by without another meaningless diktat arriving in rural doctors email from CHSA detailing the latest policy. Useful stuff...for example I've learned that dabigatran can cause bleeding (well, duh!)...and that I probably should not inject chlorhexidine down an epidural catheter. I only wish the same regard for safety was applied to trauma management and crisis management in theatre or the ED of rural hospitals...

Phil Tideman of iCCNet has revolutionised how cardiac patients are cared for in rural South Australia, with an initiative over past decade to place point-of-care troponin, proBNP and iStat machines into all rural EDs, as well as standardised protocols for management of ACS/STEMI & heart failure patients relevant to rural practitioners. Whilst I am not a huge fan of centralisation of services, such standardisation in equipment and protocols has had demonstrable benefits for these patients...similar with obstetrics under Steve Holmes' wise guidance. Why not extend the same to trauma, emergency and theatre patients by assessing needs of rural doctors and addressing their common issues?


A simple issue, like availability of difficult airway equipment or new advances like tranexamic acid could and should be addressed by these consultants.


Perhaps it’s time for some new blood in CHSA to represent the rural proceduralists in SA?

Obfuscation & the 'Blame Game'

Well, I was not expecting that the letter in my last post would be referred to in 'The Weekend Australian' in follow-up to a previous report. Thanks to Dr Scott Lewis of Wudinna for telling me.

Oh dear.

There seems to be confusion about the issue of ED patients being charged fees in rural SA hospitals. It's something that has been an issue locally every since I have been on Kangaroo Island, and my colleagues tell me has been going longer still. I refer to the fact that patients presenting with serious problems (examples might include assessment after a car crash, a suspected fracture/dislocation, a forensic medical exam after sexual assault, repair of a complex laceration) are forced to pay the attending doctor, whilst they would receive the same service for free in a metro ED or interstate.

This is counter to the Australian Healthcare Agreement and the letter which is referred to in the Weekend Australian support this. The practice has been longstanding in South Australia, and I reckon arises over confusion over what is an emergency and what is a GP-type service.

The Australian college of Emergency Medicine have recently issued a media release that dispels the myth of triage 4/5 patients being 'GP-type' attendances, and highlights concern for such cost-shifting between State and Federal coffers.

Me? I am just fed up having to charge people for conditions that are more serious than your usual GP attendance, more so when they have been referred to the ED by another GP or a GP after hours service like HealthDirect. Don;t get me wrong, I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

Today I received an email from the Rural Doctors Association of South Australia, which appears to cling to paragraph G21 of the Australian Healthcare Agreement, which allows for medicare billing in the specific circumstance of "eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor" (my emphasis underlined).

The RDASA email states:

There has been a lot of email traffic and concern from you about the article appearing in the Australian over the weekend inferring that charging patients for after-hours services in publicly funded hospitals was contravening the National Health Care reform document. 

Please be assured that the RDASA Executive have taken immediate action on this issue, writing to Minister John Hill referring him to section G.19 of that Agreement and the assurances from CHSA that the current arrangements are acceptable to the Federal government. We have sought written confirmation that:

·         Doctors can bill Medicare for triage level 4 and 5 after-hours consultations that occur at public country hospital facilities

·         Doctors will not have to pay back any money to Medicare for money already collected

Maybe I am being thick, but it seems unfair to use clause G21 to then slug rural patients for services that would receive for free in a metropolitan ED or interstate.

RDASA seem curiously quiet on this issue of equity and I fear that this approach may be regarded as more about preserving doctor's incomes than in equity for their patients. Given that many of these patients are genuinely in crisis or not-medicare compensable (particularly in a tourist location like Kangaroo Island), I would much prefer to be paid by the Hospital for my services rather than bulk bill or chase bad debts. After all, the Hospital called me as the A&E doctor for the hospital, not the patient as part of a prior arrangement or agreed private service.

Anyway, here's my letter to the RDAA on this issue. It will be interesting to see what eventuates.

Comments, as always, welcome.

Paul Mara

President

Rural Doctors Association of Australia

10 May 2012

Dear RDAA

You may be aware of the recent ‘Weekend Australian’ article regarding billing of public patients attending public emergency departments in South Australia (http://www.theaustralian.com.au/national-affairs/state-politics/warning-for-states-on-hospital-charges/story-e6frgczx-1226347278031). Last month I received a letter from Minister Plibersek’s office (attached) which supported my concerns regarding the practice of charging public patients in public EDs for non-admitted services. This letter was posted on my blog site and subsequently referred to by The Weekend Australian without my knowledge. 

I have been seeking clarification on this matter since 2007 from the South Australian Health Department, as there exists significant potential for cost-shifting from State to Federal Health budgets. Specifically, patients who attend the Emergency Department are annoyed at having to pay fees for non-admitted attendances in rural areas.

I should clarify that these fees are being charged not just for GP-type attendances, but for ED attendances that require the resources of a hospital and can chew up considerable time for assessment and treatment. Many of these patients have been referred to a rural ED by GP-after hours services such as HealthDirect, and are not typical of GP attendances in metropolitan areas. Examples might include the assessment of car crash victims after a rollover, forensic medical examination after sexual assault; urgent mental health assessment of patient brought in by Police; the assessment, X-ray, manipulation under anaesthetic and plastering of fracture/dislocation; repair of complex laceration etc. These are services that Country Health SA has in the past deemed ineligible for admission and hence cost-shifted to Medicare by refusing to remunerate doctors on the A&E roster.

On questioning this in the past, South Australian doctors have been directed to clause G21 of the Healthcare Agreement which states:

"in those hospitals that rely on GPs for the provision of medical services...eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor"

The most recent (indeed, only) contract between rural doctors in SA with Country Health SA goes further, to state :

“after hours GP services and non-admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from medicare). For the avoidance of doubt, Country Health SA shall not be liable to pay any fee for such services”

This statement in our contract neatly ties both emergency attendances and after hours GP services under the same umbrella, ie: to be charged to Medicare. This is at odds with legislation.

I understand the RDASA has recently written to the RDAA on this matter. From the email to SA members, the issue has been obfuscated by confusing triage 4/5 patients with GP-type attendances, an assertion that is not reflected in either the National Healthcare Agreements or current contracts in SA. Indeed, the Australian College of Emergency Medicine gave recently issued a media release on this very issue, dispelling the myth that “ED triage 4 or 5 patients = GP attendance” and highlighting the concern for State to Federal cost-shifting by such ploys (see http://www.acem.org.au/media/media_releases/GP_Patients_ED_attendances.pdf).

I am concerned that this issue disadvantages rural Australians In SA who may defer ED attendance for potentially serious conditions due to fear of fees. I am concerned that the SA Health Department is promulgating an interpretation of the Australian Healthcare Agreement which is at variance with other States and which both Medicare and the Federal Health Minister’s office have told me is not allowable. I am concerned that genuine GP after hours or private arrangements (where I am more than happy to charge a private fee) are being used as a cover to defray State health costs.  For the record, can I ask for your assistance to clarify with the Health Minister and RDASA:

1. that the Australian Healthcare Agreement states that eligible public patients are entitled to free emergency care in a public ED,

1. that the South Australian Department of Health is responsible for provision of emergency medical services in both metropolitan and country areas,

1. that the contract between rural doctors and Country Health SA is to participate in on-call services for Emergency Medicine (A&E), not GP-after hours services,

1. that whilst clause G21 does allow for rural doctors to charge privately (with Medicare rebate) this is only in the situation where patients “request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”. Many patients who present to the ED have either been referred there by a GP or an after hours service (HealthDirect) or else have needs that require ED attendance. They have not requested treatment by their own GP nor is their a pre-existing prior arrangement with the doctor on call for the A&E roster for the State Health Department.

1. that in situations where a patient elects to be treated privately by their own GP then clause G21 applies and Medicare fees are allowed,

1. that the assertion that triage 4/5 patients are to be billed under Medicare is not supported in the Australian Healthcare Agreement and indeed is counter to advice from the Australian College of Emergency Medicine who dispel this myth in a recent media release and state “It is in the political interest of state governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.”

1. that the situation as it stands in South Australia is at odds with arrangements interstate.

I would be grateful for your clarification on the above points. To my mind it is vital that rural Australians are not disadvantaged when attending the ED with a genuine need. Similarly there may be concerns from rural doctors that such Medicare-billing is not supported and there needs to be clarification that such practices are allowable in certain circumstances (eg: as part of a GP after hours service utilising the local hospital premises, ie: private arrangement, ongoing care). I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

I am sure you would agree that it is important for rural doctors to be seen to uphold the same standards in each State and to ensure that neither patients nor doctors are disadvantaged.

Sincerely

Dr Tim Leeuwenburg

Kangaroo Island, South Australia www.ki-docs.blogspot.com

Country Emergency Department Fees

Well I've just received a letter from the Federal Health Minister which seems to broadly confirm my suspicions that the charging of fees for country patients attending a public hospital ED is incorrect.

You may need to click and open separately to view

Of course there is a grey area in what is a 'GP after hours' type attendance and what is an emergency attendance - and with that comes the potential for massive cost-shifting from the State (charged with providing free public emergency treatment) and the Commonwealth (providing Medicare compensable services).


Country patients are caught up in this, as in South Australia they have been charged fees for attending the ED in rural hospitals. Now historically there was an arrangement (not defined in a contract, but in an agreed schedule of fees for paying doctors called SARMFA) that allowed a rural doctor to charge a private fee in circumstances where a patient requested private treatment by a particular doctor, or where care was provided in the country hospital as part of ongoing care or prior arrangement.


This seems a sensible compromise to allow rural doctors to attend patients at the hospital both in and after hours for GP-type consultations or private care. Example might be an agreement between doctor and patient to meet at the hospital after routine consulting for a review of an eye injury, utilising the hospital's slit-lamp. or arranging to be seen for a skin excision or to administer intravenous therapy.


All well and good.


Then in 2010 a new contract (in fact the first time a written arrangement about rights & responsibilities) between CHSA and rural doctors came into being. This is a good thing and it was hoped that would create a level-playing field with rural doctors getting equivalent deals, rather than the hotch-potch of 'local deals' that saw some doctors getting lucrative locum rates for being oncall, others struggling to balance the impact of providing oncall work for the hospital with their private practice.


The negotiating teams of both AMA and RDASA invested a lot of time and effort into getting the 'best deal', but as time wore on the AMA walked away from the offer whilst the RDASA recommended to their members on a temporary basis, expecting a new and better deal to be negotiated by the end of November 2011.


My concern has been that, for the first time, there is a contract that is explicit about the charging of fees. Whilst the SA Health Minister acknowledges that CHSA are responsible for the provision of public emergency services in the country, there is a catch. The contract specifies that only ADMITTED patients are entitled to free treatment - non-admitted patients are to be charged by the attending doctor.


This seems to fudge the previous arrangement designed for private services or ongoing care between patient and treating doctor. Instead, people who present to a rural ED in South Australia are charged fees unless they are admitted....and yet patients with similar problems who go to a metro ED are provided the service for free.


The Health Minister says this is because rural hospitals do not have a salaried medical officer on site. Fair enough. I'd just argue that if the Hospital feels they need to call in a doctor, that that doctor is paid for their services - and the patient does not.


Of course, if the patient presentation is trivial (a GP-type attendance) then it would be appropriate to divert them to a GP-after hours service or to GP clinic the next day - and Medicare or private fees would apply.


It's all down to definition. What is an admitted patient? The bean-counters take the view that a patient has to be present for > 4 hours, although occasionally this requirement can be relaxed for certain things (type C attendances, a definition derived from mostly day surgery units).


So we have a position now enshrined in a contract, where rural patients may be charged for things like reduction of a fracture, IV fluids, X-rays, assessment after a car crash, mental health emergency in a country ED...on the basis that these are 'GP services'. These are things that a GP in the city may well refer patients to an ED for.


Medicare advisors tell me this is illegal and that doctors should not charge for such non-admitted ED services where patients attend a public ED. The Dept of Health & Ageing letter suggests the same.


The only explanation from CHSA is that this is allowed because of a 'longstanding arrangement for treatment of private patients as part of ongoing care or prior arrangement by a specific doctor'. 


I am all for this - when such care is agreed and is genuinely private. I have no qualms charging a private fee for my private GP services. 


Seems hard to explain that all this to the carload of NSW tourists who have crashed and seek assistance at the local hospital only to be saddled with a bill. Or the patient with a fracture-dislocation that requires X-ray/reduction/plastering...and many more examples.  Understandably some patients refuse to pay on the basis that they are attending an ED. CHSA insists that the doctor charges Medicare..who say that this practice is illegal...and CHSA doesn't answer this query.


So, where are we at now?


There have been two extensions to the rural doctors contract (which was to expire 30/11/11) so far...the current extension ends in just under four weeks and still no contract offer available for perusal.


In an effort to address this anomaly, RDASA had proposed that triage 1-2-3 patients are to receive free treatment. Seems fair, although it does ignore the issue that triage is just about treatment priority, not complexity and is ill-suited to decisions about whether ED attendance is appropriate or not. There is a myth that triage 4/5 patients are 'GP-type' presentations, when in fact these patients are often elderly, complex and require admission or the services of an ED not a GP (minor fractures, plastering, X-ray etc). ACEM have issued a media release on this which is informative.


Despite that, I'm still struggling to get paid for attending a triage 1 call in...with CHSA insisting the patient be billed under Medicare.


So, there you have it. 


- A contract that seems to be in breach of the National Healthcare Agreement.
- Cost-shifting fees onto patients who are already rurally disadvantaged. 
- And only a few weeks to go until the most recent contract negotiation expires.


Really, is this any way to do business? It seems that Country Health SA hold both rural patients and the medical workforce with a lack of respect. I despair, because this sort of thing does little to encourage recruitment and retention of rural doctors to South Australia.


I guess there's no votes in the bush.