Emergency avoidance

BY JANINE RANKIN

It's 10am on an ordinary week day in Palmerston North Hospital's emergency department, and there are already 25 patients in the unit designed to take 22.

In the waiting room, the signs remind people to wear masks if they have flu, to consider going to a GP instead, and apologising for delays getting X-rays while staff work to rule.

The chairs  fill  up more quickly than the walking wounded hobble out. A young man with the pallor of mashed potato sits nursing a bandaged hand. Another waits patiently with a bandaged foot.

The morning rush hasn't even started yet, says emergency department service manager Carrie Naylor-Williams.
There will be a bit of a lull around lunchtime, then the afternoon will build up to a frenzy. Later, when  no other medical service is open, four ambulances will  pull  up every hour.

The patients will get caught in a phenomenon they call ''queue swirl''. Instead of progressing through the unit in an orderly flow, the newcomers will increase the pressure on staff to look after several patients at once.

They will be running in circles, balancing needs and priorities, and it will take longer to process each patient.
By the end of the day, about 110 people will have checked in. That adds up to 38,000 presentations a year. It's 2000 more than last year, and 2000 more than the year before.

Compounding the challenge of dealing with the growing numbers, by the end of the year the hospital is supposed to find ways to meet Minister of Health Tony Ryall's directive that 95 per cent of people should be either discharged home or admitted to hospital within six hours of arrival.

It has come up with all sorts of clever ways to move patients on more quickly. There is the observation area, where people can rest and be assessed and monitored before a decision is made.

There is the medical assessment and planning unit (Mapu), eager to take patients in and care for them intensely before they are stable enough to leave, or it's decided their symptoms are worrying enough to require admission to the wards.

And there is the Pedal team (Post Emergency Department Assessment and Liaison), organising care arrangements and equipment so people can go home safely, well supported, as soon as possible, and not have to come back.

But despite best efforts to get people out of the department, the queue of new arrivals keeps getting bigger.
It is driven by an ageing population, by an increase in the prevalence of chronic illnesses, and acute episodes of illness among older, sicker people.

And many people are there because there is simply nowhere else to go. It's the only place open after City Doctors closes at 10pm each night, and even during the day, people can't get appointments when they need them at overloaded general practices.

But there's a new plan  to reduce emergency-department presentations by 30 per cent within a couple of years.
It's the Better, Sooner, More Convenient business plan, a blueprint for transforming health services, bridging the false divide between primary and secondary-level care.

The motivation is to make it better for patients. The department is, after all, a scary place. No-one wants to be there if there's a more comfortable alternative, and most people would rather be at home than in hospital, if they were safe.

It's also better for the taxpayer. There's potential to avoid enough admissions to hospital to save 8460 bed days. At $1000 a day, that's a saving of $8.45 million.

The goals are ''aspirational'', but there is a unity of purpose about making it happen.
That new teamwork is demonstrated in a small way when Compass Health chief executive Cathy O'Malley, who provides management services for the Central Primary Health Organisation, teams up with Feilding GP Bruce Stewart and MidCentral Health clinical board chairman Ken Clark to explain the plan.

More than 150 other doctors, nurses, managers, social service organisations, iwi providers, MidCentral Health and the Central Primary Health Organisation are working together to make it happen.

They have all been involved in the plan. They talk about the importance of attending to people's health needs earlier, at home or close to it, preventing avoidable crises in chronic illness.

There are some beacons of hope, but many of the services to make the vision a reality aren't there yet, and traditional general practices are struggling with their workloads.

Ms O'Malley is familiar with the knock-on effect, when people can't get a GP's appointment when they need one.

''It's the inability to access the appropriate care during the day that's the reason people have issues in the night.''

Often, the reason  they couldn't get an appointment during the day was because their GP was too busy, and their GP was too busy because there were already so many people needing help because their chronic illness wasn't well managed, or because they were doing tasks that a nurse could have done more efficiently.

Five integrated family health centres planned for the district that will be the ''health home'' for more than half of the MidCentral Health district's population are the cornerstones of the new approach.

Those centres will strengthen what is already in place in Otaki and Tararua. The Horowhenua Health Centre's role will grow, and there are high hopes a Feilding centre, based at the former Clevely Hospital, will become a reality on the third attempt to centralise the town's health services.

Finally, Radius Medical at The Palms is planned to become Palmerston North's centre.
They hope to attract a range of social and government agencies, such as WINZ and ACC, understanding the range of issues that impact on people's health and ability to take care of themselves.

The transformation will build on some resources that are already in place, such as the team of some 70 primary-care nurses, dietitians, quit coaches and allied health professionals who have increased their role in helping people manage their diabetes and other chronic health problems in the past six to eight years.

There will be more intensive case management of high-risk patients, greater use of nurse-led clinics, and increasing use of a growing workforce of nurse practitioners.

And there will be more ''intermediary care''  specialist and intensive help for people who would once have had no alternative to hospital.

St John will play a role, investing in advanced training for paramedics so they can assess, monitor and treat people at home, avoiding the need to transport them to hospital, and so will district nurses.

Doctors will be encouraged to make more use of the GPAL team  the General Practitioner Assessment and Liaison programme, which for nearly two years has made district nurses available to help GPs manage ''at risk'' patients to avoid a hospital stay.

It provides a rapid-response, home-based package of care for patients whose only other alternative would be a trip to the emergency department.

Dr Stewart pointed to the example of an elderly patient he saw on a Friday afternoon. He was able to arrange to keep her at home at the weekend,  knowing  she would receive several visits to check her condition and attend to her needs, and  the nurses would take action if she deteriorated further.

The family of another elderly person had this to say:
''Dad had been getting less and less mobile, and not getting out of bed.
''We were having trouble managing. We needed something, so we rang the doctor and he arranged for the district nurses to come.

''We felt the whole thing was amazing, marvellous. Dad looked forward to their visits every day. They motivated him to get up and out of bed and get back on his feet. It took the pressure off us and gave us piece of mind.''

Starting next week in Levin, and building momentum through next year, the district is poised to see rollout of a range of the new ways of doing things.

''The district was ready for this,'' said Dr Clark. ''This is important.
''It's not about switching resources from secondary to primary care  that's not the driver. It's about what the patient needs, and delivering the service where it is most appropriate for the patient.
''That might be in a hospital bed, but it might not be.''

Turned away by busy GPs
Palmerston North's overstretched general practices are struggling to see everyone who needs an appointment.
Turned away, patients are turning to City Doctors, or to Palmerston North Hospital's emergency department or suffering until they become acutely ill.
''It's a nightmare,'' said young dad Tom Rolton.

A recent arrival to the district, he was initially relieved when the family was enrolled with a general practice.
They expected they would be OK now, able to get appointments when they needed them. But twice in a fortnight, once with a three-year-old with suspected tonsilitis and then with a very sick four-month-old, they were turned away, told to go to the emergency department.

''The practice is obviously over-subscribed, but they keep on taking on new patients,'' said Mr Rolton.
The family ended up with the rest of the city's ''overflow'' at City Doctors.
Cathy Mancer is the sort of patient who hesitates to bother the doctor with minor ailments.

She soldiered on for weeks with an aching hip and leg and constant sinus problems, waiting to see if they would get too bad for her and for a doctor to ignore.

''And then I get this lump, so I confidently phone my new doctors' surgery, which is highly efficient, professional and assured me I would always be able to get in on the day.

But she was told: ''Sorry we can't fit you in until next week''.
She said she just wanted to have someone tell her it was not a malignant tumour.

Compass Health chief executive Cathy O'Malley, in charge of management support to the Central Primary Health Organisation, is familiar with the knock-on effect when people cannot get a GP appointment when they need one.

''It's the inability to access the appropriate care during the day that is the reason people have issues in the night.''
But solutions are in the wings, she says.

- © Fairfax NZ News