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Auckland Regional Emergency Medicine Specialists Meeting

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Some reflections on ED complaints

Ever since Robyn Stent's Canterbury Health inquiry in 1998, which followed several patient deaths in the Christchurch Hospital ED (which must have suffered more external inquiries than any ED in the country), HDC seems to have had a special focus on emergency departments. I supposed that reflects a number of things: first that the ED is a hospital's public face to the community, and so we pay it more attention than the wards. It's also seen as the safety net, where miracles are performed in emergency situations. The public gets fed images from TV programs like Casualty and ER, where CPR always works. So when mistakes happen - as they inevitably do - people can be unforgiving.

Other factors also come into play. Usually your relationships with patients and families are one-off. So there is no longitudinal relationship over time (such as we have with our GP), which research shows is usually protective against complaints. And because it's an emergency, patients and families are not emotionally prepared for the possibility of a disastrous outcome. The outpouring of grief that follows a tragedy can fuel a complaint - especially if a patient and family experienced a long, uncomfortable wait, and feel they got minimal attention from busy, harassed staff.

I have learnt quite a lot about emergency departments over the years. Many people have tutored me over the years (including Bhavanni Peddinti, and Peter Freeman), or have shown me around their own EDs (like Lee Allsop in Tauranga, John Bonning in Waikato, Bob Butler in Hawke's Bay, and John Chambers in Dunedin). I think you do an amazing job, often in very difficult conditions. When I did a couple of nights shifts with Bhavanni when he was still at Middlemore, I was struck by the complex, multiple co-morbidities of the patients, the sheer busyness, the great teamwork, the quality of the handover, using an electronic screen, the impressive IT support, and the well designed facilities. I know that not all of you work in such conducive surroundings.

Over the years, I've had to inquire into tragic cases at many EDs. North Shore, Tauranga, Wanganui, Hutt Valley, Wellington, Nelson, Canterbury, and Dunedin spring to mind - and no doubt there are others that I am forgetting. Atul Gawande, the Boston surgeon and writer (I recommend his book Complications: A Surgeon's Notes on an Imperfect Science) talks about the anatomy of failure. He writes, "Though we traditionally associate significant improvements in health care with the big breakthroughs in transplant surgery and gene therapies, much of the biggest gains are likely to come from close attention to the detail of failure."

Of course, if the lessons are to be worth heeding, inquiries must be rigorous, and their recommendations need to be sound, evidence-based, and (if they are to be applied elsewhere), able to be generalised across the sector. I record my indebtedness to HDC's expert advisors, including Mike Ardagh, Chip Jaffurs, Shameem Safih and Garry Clearwater, and to Peter Freeman who has reviewed a number of cases lately, providing a College perspective.

If clinicians and organisations are to learn from inquiries, the reports need to be well publicised and circulated, and there needs to be time for quality. We also need effective mechanisms to ensure follow-up of recommendations, something HDC takes seriously.

Reassurance for communities that improvements have been made is also important, so long as it is justified. We care about our local hospitals and their emergency departments, and we want to know that problems are being fixed. With its unusual mix of inquiry and public watchdog roles, HDC can help provide some independent assurance, once an inquiry has established the facts and determined accountability. That has been important following cases such as Dean Carroll's at Christchurch Hospital.

Overcrowding and staff shortage have been key themes in HDC's recent ED inquiries. In the Wanganui Hospital case (about the 19-year-old snowboarder who was discharged prematurely with an undiagnosed spinal injury), I accepted that Whanganui DHB had a shortage of doctors. But I noted: "That, however, does not excuse the district health board from its duty to provide an emergency department that has sufficient staff and robust systems to withstand fluctuating demands and ensure that good communication occurs between staff and with patients."

Long waits in ED, and holding patients in corridors and other informal ED spaces, is disrespectful and unsafe. Such practices are an indictment on our health system. In my North Shore Hospital inquiry report (released on 1 May 2009) I described overcrowding as the most serious problem and most avoidable cause of harm facing hospital systems. Overcrowding largely results from hospital access block, and the primary solutions lie outside ED. A whole-of-hospital approach is needed and concerted action both at Waitemata DHB and nationally.

Thankfully we are starting to see a concerted national response. It's an exciting time for emergency care in New Zealand. The pressures you work under are unrelenting, but I sense a tremendous energy to improve services. We need clinical champions, but also support from CEOs - the sort of leadership we've seen from Geraint Martin at Counties Manukau with the "releasing time to care" initiative. We now have a national strategy with support from the Ministry of Health, and a new target that 95% of patients will be admitted, discharged, or transferred from ED within six hours. This recognises that ED length of stay is a proxy measure of access block. Sponsored by the Quality Improvement Committee, DHBs are developing process improvement models for ED and inpatient management as part of the "Optimising the Patient Journey" project.

We certainly need coordination at a national level, with an emphasis on keeping patients' safe and improving their journey from home to hospital and hopefully home again. The national conference organised by the Midland DHBs at Taupo last September was a great example of the leadership and planning ahead that we need. And the same is true of tonight's Auckland Regional Emergency Medicine Specialists meeting.

Let's open it up for questions and discussion.

Ron Paterson
Health and Disability Commissioner