Paramedic after hours plan dangerous for Porirua

BY ROB KIEBOOM
Last updated 09:34 13/11/2012

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OPINION: Dr Rob Kieboom has worked at several emergency departments and for five years at the Kenepuru A&M centre. Below he outlines his concerns about the plan to replace the clinic's overnight service with a roving paramedic.

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People who get sick overnight in the Porirua basin will be worse off under a proposal to close the Kenepuru Hospital Accident and Medical (A&M) centre overnight.

Despite a Capital & Coast health slogan to deliver healthcare "better, sooner and in the right place", this proposal is being driven by a desire to cut costs, including the amount local health care providers, including GPs, contribute to providing an overnight service for patients.

This is not an attempt to improve overnight medical care for the largest group of low socio- economic patients in the Wellington area.

A single vehicle roving paramedic service has been proposed to replace the A&M's overnight service.

This plan is to use "excess capacity" in the Kapiti urgent overnight care model to require its single paramedic to cover all GP- level calls overnight from a population of 100,000 stretching, from Kapiti through Porirua.

Patients would no longer have direct access to a doctor via the A&M between 10pm and 8am. Instead they will phone a triage service that will try to assess the degree of illness and determine if and when they need to be seen.

The roving paramedic will then be dispatched (if available) to see the patient at their home.

People could be waiting in line for hours to be seen because the paramedic has three or four patients already on his/her list.

This is far from ideal and there are numerous medical and moral issues of concern.

Ambulance and paramedic staff are dedicated and skilled professionals but this proposal will simply be unable to deliver a safe and timely service.

Most residents between Plimmerton and Tawa can access Kenepuru Hospital A&M centre in five to 10 minutes' drive.

Two experienced A&M nurses and a doctor are available overnight for immediate care if needed.

The purpose-built centre is warm, safe, well equipped and well-staffed.

Between May and September this year an average of 18 patients have gone there between 10pm and 8am.

More than 90 per cent of these patients were treated and sent home, with only about 9 per cent having to be referred to Wellington Hospital for further treatment or admission.

Patients covered by the roving paramedic service may wait in line at home for potentially several hours to be seen. This is ludicrous, not to mention potentially dangerous.

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A significant number of patients who present acutely to the A&M centre overnight are Pacific Island infants and toddlers with fevers and respiratory distress.

Quick and experienced assessment is needed to rule out such conditions as meningitis and to treat potentially fatal respiratory conditions such as bronchiolitis and asthma.

Infants and young children can deteriorate extremely quickly and delay of treatment of a few minutes can sometimes make the difference between life and death.

Other conditions needing urgent assessment include chest pain and abdominal emergencies - such patients can currently be seen straight away at the A&M centre.

It is medically dangerous to expect these patients to wait at home for a health professional potentially hours away.

The group proposing to close the A&M claim a major benefit would be fewer hospital attendances and admissions.

However, a recent analysis of the Kapiti Urgent Care paramedic service by Otago University revealed an astonishing 40 per cent of patients were taken to Wellington Hospital for further treatment. And these are not the acutely ill patients that dial 111 for ambulance service but "second tier" illnesses assessed over the phone as being manageable in the patient's home.

Less than 10 per cent of patients seen at Kenepuru A&M overnight are sent to the Wellington Hospital emergency department, compared to 40 per cent by the Kapiti Urgent Care paramedic service. Forty per cent of Kapiti paramedic patients thus required a dual response from the paramedic and then the ambulance service. This is a huge waste of resources not to mention the expense.

Also of note is the paramedic service hardly ever sees sick young children, the most difficult patients to assess and treat. Add in the large numbers of acutely ill infants and toddlers over winter as seen overnight by the A&M centre and the paramedic referral rate to hospital over winter will probably be over 50 per cent. The ambulance will be unable to cope with this demand and emergency department and hospital admissions will skyrocket.

While the Kapiti overnight paramedic service is a great benefit for that district - which doesn't have a purpose built A&M centre on its doorstep - it is not a suitable replacement for the Kenepuru clinic

Many children take an hour or more of observation and treatment before they can be sent home - and there can be three or four arrivals in the space of an hour in the middle of the night to the A&M.

A lone paramedic simply could not cover and treat these children in a safe and timely manner. Lacking the time and resources to properly assess and treat these patients, the paramedic will have to get the child taken to Wellington Hospital ED by ambulance, tying up another valuable overworked resource.

A parent invariably goes with the child and it may take a couple of hours or more to be seen depending on the severity of the illness.

Once treated transport is needed to get home - often involving the other parent driving into Wellington with the rest of the family, adding more cost, stress and inconvenience.

A medical issue that could have been dealt with in just over an hour could now take five or six hours through the night. Caregivers who have attended hospital overnight may be too tired to work the next day, a cost to a low socio-economic group that has not been factored into this proposal.

Latest talk is the group proposing the closure may be back- tracking on the proposal for a single paramedic replacement. Hopefully they've realised four or five roving paramedics in separate vehicles would be needed to provide a reasonable alternative to Keneperu A&M overnight.

The Capital & Coast health website proclaims the importance after hours of sick children under six getting "the right care, at the right time and in the right place". It advises the Porirua public to go to A&M.

Why then, is it trying to limit after-hours care to this population?

A leading advocate of the closure proposal, Porirua GP Dr Larry Jordan is also on the website advising people to take their sick children to A&M overnight.

Looking to the future one cannot help but think that overnight closure may well be the first step to 24-hour closure of the Kenepuru A&M centre.

- Kapi-Mana News

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