Western Australia’s hospital crisis resulted in tragedy on April 10 when 7-year-old Aishwarya Aswath died after waiting in the Perth Children Hospital’s (PCH) emergency department for two hours to be seen— twice the recommended waiting time.
Aishwarya was brought to emergency after she became unwell with a fever the day prior and did not improve after rest and paracetamol. Despite repeated pleas that their child be seen to urgently— Aishwarya’s mother recalls approaching the triage desk four or five times— Aishwarya did not see a doctor until 15 minutes before she died.
Everything about the event is horrific and deeply upsetting. The thought of watching your loved one deteriorate before your eyes, while those who might be able to stop it are just metres away, is devastating. While hospital staff may have failed to recognise the severity of Aishwarya’s condition, the fact that she had to wait an hour longer than the clinically recommended time for her triage category was an entirely avoidable factor in her death. It is a direct result of a chronically underfunded health care system which everyday puts patient’s lives at risk.
As a junior doctor working in an emergency department, the news of the tragedy resonated strongly with me and my colleagues. Many of my recent shifts have seen us struggle through a waiting room full of people who have been there hours longer than they should be, with ambulance ramping like never before and hospital wards over capacity. Many children with fevers have had to wait more than two hours to be seen. And it has been like this for months. Which is why, when Health Minister Roger Cook insists that the health system is performing “extremely well under pressure” and blames this pressure on increases in demand for mental health treatment and stricter cleaning protocols, it is baffling and offensive to an overworked and emotionally fatigued health care workforce. Particularly when our unions have been raising the alarm about the threat of resource shortages to patient safety since before the onset of the pandemic.
Contrary to Cook’s assertions, the state’s hospital system is overwhelmed, and the coalface of this has been emergency departments. Presentations at emergency departments have grown 12 percent over the last five years, twice the rate of population growth. In a system that had already been running near capacity, this has resulted in extreme levels of ambulance ramping and a ballooning of hospital wait times.
Figures from the Australian Medical Association (AMA) indicate that emergency department wait times are on the rise across the country. Western Australia was significantly worse than the national average, with less than half of all “urgent” (a triage category) patients treated within the recommended 30 minutes.
Dr Peter Allely, a leading Perth-based emergency physician, highlighted what this means for people when in March 2020 he described the ordeal of an elderly patient who had fallen and broken her hip, “The hospital was so full that I had no space to see her. She was stuck in the waiting room— in agony— for five hours.” Dr Andrew Miller, president of the state AMA, relayed accounts from paramedics of “sick babies waiting hours to be seen by an [emergency department] physician”. These stories have been a common theme of the health professions’ cry for help well before the death of Aishwarya.
Ambulance ramping, a major risk to patient safety, has reached unprecedented levels. Ramping refers to the situation where a lack of physical space in emergency departments means ambulances are unable to unload patients for urgent hospital care, therefore paramedics remain at hospital entry points or driveways and continue to provide care until space becomes available. Ramping delays the assessment, diagnosis and treatment of patients while tying up paramedics. This poses a risk to patients being ramped and hinders the ability of ambulances to respond to other emergencies.
Ambulance ramping exceeded 3,000 hours for the first time ever in September 2020, a record repeatedly broken over subsequent months and reaching nearly 3,700 hours in February of this year. This is more than five times larger than five years ago. As a result, response times for ambulance services to get to cases have increased. The proportion of priority one (which are life-threatening emergencies) attended to by an ambulance within 15 minutes has fallen from 93 percent in May last year to 81 percent since December.
The extended wait times and ambulance ramping in emergency departments are manifestations of “access block”, where there are not enough beds in hospitals to meet the demand for patients waiting in EDs. This has gained attention in the media recently after a series of “code yellows”— called when hospitals have zero bed capacity— were announced on several occasions at Perth’s major hospitals, sometimes affecting two of the three major hospitals at the same time. The implications of access block for patient safety have been well documented. A patient is 10 percent more likely to die if they present to an emergency department that is access blocked. Dr John Bonning, president of the Australasian College for Emergency Medicine asserted in a media release in January this year “Unless urgent action is taken there is the very real risk that somebody will die. This is an enormously distressing situation for emergency clinicians and responders, and the community should not accept it.”
For many who work in this area, the cause of the crisis appears obvious— a shortage of hospital beds, and not enough nurses and doctors to staff them. According to the latest statistics from 2017-18, Western Australia has the lowest number of public hospital beds per capita of any state in the country, at 2.31 beds per 1,000 people. According to the AMA, the state is short the equivalent of another major hospital, and requires 500 more beds urgently.
For the existing beds, there are not enough staff to take care of them. Nurses at PCH emergency department had written to their union in March of this year detailing horrendous working conditions with dangerous nurse to patient ratios becoming the norm. There was one account of a night shift in which just eight nurses were responsible for 93 patients.
Nurse colleagues across various departments have spoken of similar trends, with an additional push for junior nurses to take on more senior roles without adequate support in order to bridge staffing shortages. This has led to a situation where nurses are anxious that they cannot deliver adequate care to all their patients. Much of last year many junior doctors were unable to access their annual leave and worked excessive amounts of overtime to keep up with the increased demand. This has led to a situation where many in the workforce are burnt out, and an increasing number of doctors, paramedics and nurses are considering leaving the profession.
The current hospital crisis is a crisis of not enough beds and not enough staff, brought about by decades of underfunding. Average annual per person health funding growth over the decade to 2017 is just 1 percent, compared to an average growth of 2 percent across other states.
Despite this, the government refuses to acknowledge inadequate funding as the reason for the hospital crisis. Cook insists there is no crisis, only an increase in pressure on hospitals caused by a lack of GPs, an increasing mental health demand, and changes in the day to day running of hospitals due to COVID-19.
The claim that emergency departments are being overwhelmed with non-urgent cases that should be seen by GPs has been a frequent and tiresome refrain of successive state governments responding to the health resources, and it is a lie. The fundamental issue driving the crisis, that of access block, is not caused by patients who should see their GP, as these patients do not need a bed in emergency nor admission to hospital.
Nor is it the result of the surge in mental health related presentations. Mental health patients needing urgent review are waiting months for an initial assessment, meaning that many patients are forced to turn to emergency departments for help. This obviously exacerbates the situation of access block, however the government blaming the current hospital crisis on this is disingenuous. The same government is directly responsible for the underfunding and understaffing of community mental health services; something clinical psychologists, social workers and occupational therapists from eight services took part in industrial action over recently.
The “post COVID world” referred to by Cook is again not a factor in the fundamental issue of access block— extended cleaning procedures and separate respiratory streams in emergency may slow things down, but they do not block beds. A decline in international medical and nursing recruitment has exacerbated understaffing, but in a context where many of the state’s nursing graduates are not offered employment in the state, this is an issue of the government’s own making.
McGowan’s government has continued the trend of deliberately ignoring the primary issue of hospital funding, by putting the blame for an overwhelmed system on issues relating to demand. This obfuscates governments responsibility. As a result, cracks in the system have now burst open even without the disaster of COVID-19, something our hospitals would not have coped with.
The lack of beds and understaffing in the state has caused patients to wait too long for the medical attention that they need – be this in an emergency department, in a hospital bed waiting for a doctor or nurse, or at home waiting for an ambulance to arrive. Health care workers are acutely aware of this. They understand that without urgent funding, people will die. This is one reason the loss of Aishwarya has been felt so strongly— the avoidable circumstances surrounding her death resonate with our experience of an under-resourced health care system.
Whatever issue may exist about the failure to identify a very sick child, Aishwarya waited an entire hour longer than the recommended maximum time for the triage category she was assigned. The difference that hour might have made is yet to be clarified. But to have missed that opportunity, and to work in a system where missing that opportunity is now risked on a regular basis, is enraging. And it is the result of a health care crisis the government is refusing to acknowledge exists.
The words of Aishwarya’s grieving father— “This should not happen to any child in this country”— ring painfully true to healthcare workers. We need more beds and more staff. And we need them now.