Rack ‘em and Stack ‘em

When does your ambulance journey end? Is it when the ambulance arrives at the emergency department, or when you are finally allowed to decant the patient into an ED bed? Clearly, the practice of keeping patients in an ambulance until a bed is available, suggests that ED personnel think it is the latter. A new report now suggests banning the practice.

Now it is true that refusing to allow ambulances to unload is dangerous and produces worse patient outcomes, but before Tony Ryall produces a government fiat banning the practice let me remind him of a couple of facts:

1. The reason why the ED staff don’t want to unload the patient from the ambulance is because they CAN’T. They are not engaging in the dubious practice of “gaming” the triage system by refusing to unload the patient until the doctor is ready (thereby improving the waiting time statistics). This might be the case in some British hospitals, but, in NZ hospitals, nobody gives a toss about statistics because government has not yet been stupid enough to try to pay us according to our waiting times.
2. The reason why the beds are full has been discussed by me before. But a brief recap is in order.  The reason is simply that there are not enough beds in the hospital. This is not rocket science, is it? You either need to make your ED bigger or you need to make your hospital wards bigger. There is probably a reasonable amount of bed block being cause by the arcane and lengthy processes of finding funding for elderly care, but, in general, you still need more beds. This is because of two things – a larger population and a hospital rebuilding program that persists in making hospitals TOO SMALL. I’m sure treasury has saved you some money this way. Now you are going to pay for it. 
3. Before you bring down the big bad banning hammer, may I ask you to do a bit of research? Find out exactly what patients have been held back by our triage nurses. I’m betting that none of them have been critically ill. I’m willing to lay down good money that they are mostly things like moderate fractures and vague abdominal pain – stuff you don’t want in your waiting room where you can’t monitor them, but nothing in serious jeopardy. You see, unlike your MoH advisers and your DHB boards, I trust the judgement of ED triage nurses. I think the ambulance backlog is merely an annoyance to ambulance control. I suspect no patients are endangered at all.

I don’t mention the latter point as an excuse to continue this practice. Sooner or later, a triage nurse is going to stuff up and seriously harm a patient. My point is that the situation is not so urgent that it does not merit a considered response. Mr. Ryall should forgo his banning instincts and look at ways to increase bed numbers in hospitals as fast as possible.

Otherwise, before long, we will be treating patients out in the street.

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