Salaried Doctors

By Dr Stephen Parnis

There have been many issues introduced as part of the National Health Reform process over the last few years. Many relate to funding arrangements, and seem quite removed from our daily clinical work. The introduction of the four-hour rule, however, has the potential to cause considerable change to the way many of us practise medicine.

This rule is a directive from State, Territory and Federal Governments that 90 per cent of patients who present to Australia’s Emergency Departments be seen, investigated, stabilised, and either transferred to a ward or discharged home within four-hours of arrival. And it’s coming your way soon.

Most people are aware that hospital and emergency department overcrowding is one of Australia’s most serious problems in health care. Good evidence tells us that this leads to about 1500 deaths in Australian hospitals per year, which could be avoided, comparable to the national road toll.[1][2][3]

We also know that the main cause of access block and ED overcrowding is a combination of major increases in emergency admissions and ED presentations with almost no increase in the capacity of hospitals to cope with the demand.[4]

So the aim of the four-hour rule - to reduce hospital overcrowding – is a laudable one. The key question, however, is whether there are the resources allocated to make such a monumental change possible. At this stage, I’m sceptical.

Western Australia has grappled with the four-hour rule in recent years, and the nation can learn a great deal from their experience. The messages are mixed, but the bottom line is clear – major innovation simply cannot take place without dramatic improvements to capacity, both in staffing and physical infrastructure.

This is not an emergency department issue, but one that affects the entire health system, and manipulating one facet of this complex beast inevitably affects other areas. For example, a higher priority to emergency patients is likely to delay access to elective surgery, and vice versa. Increased time pressures to see and treat patients demand better staffing numbers and seniority – if this does not happen, the likelihood is that safe working hours are discarded, junior doctors are compelled to work beyond their levels of experience, unstable patients are prematurely transferred to an unsuitable destination – and the risk to the patient becomes unacceptable.

I’ve seen these games played before. Data manipulated to satisfy the Health Department target, short stay beds used for patients who should be in wards, and clinical indicators of care (e.g. MET calls within 24 hrs of arrival from emergency) overtaken by the time based target. Even the potential for bullying of medical staff to push the patient out is a consideration!

Innovation and increased capacity are inseparable partners for improving healthcare. Governments and administrators need to hear this message from all of us.

[1] Fatovich DM. Effect of ambulance diversion on patient mortality: how access block can save your life. Med J Aust.2005; 183: 672-673.

[2] Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med JAust. 2006 Mar 6;184(5):213-6

[3] Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006; 184:208-212.

[4] The State of our Public Hospitals reports, Commonwealth Dept of Health and Ageing, http://www.health.gov.au/internet/main/publishing.nsf/Content/state-of-public-hospitals-report.htm.