Emergency overload: how Covid exposed Australia’s straining hospital system
Samantha Hodgson met all the criteria for a possible heart attack: “A tight, crushing pain that started in my shoulders and spread through my chest and ribcage. I was dizzy, and the pain had escalated over 24 hours so that it hurt to breathe.”
Hodgson was also on day nine of being infected with Covid-19, and until the chest pain hit, she had been feeling better. According to health guidelines, she needed an ambulance for a suspected heart attack.
But when Hodgson, who lives in Potts Point in Sydney, rang triple zero, the operator told her, “You could be waiting a while, we don’t know how long it might be”. In too much pain to walk far, she put on two masks and called an Uber to take her to the nearest public hospital.
When arrived she was told to wait outside in the rain because she had Covid.
“I sat under a little tarp outside of emergency, next to a carpark,” Hodgson said. “I stayed out there for at least two hours. I don’t remember exactly as I was so out of it.
“A doctor came and saw me after about one and a half hours, and she said they really needed to get me inside but they had no beds. I begged her to put me in a wheelchair and stick me in a cupboard to treat me, because I wanted pain relief and to know what was going on with my chest. But she just said: ‘There is nowhere to put you’.”
Hodgson’s discharge letter said there was no concerning cause of her pain and her symptoms were Covid-related. One month later, Hodgson is still trying to get access to her discharge notes, including the results of the ECG.
“I feel like Covid pain has become so normalised in emergency rooms that my chest pain wasn’t taken seriously,” she said.
Hodgson’s story goes to many of the health system issues that have led to “access block”: the term used when emergency patients are delayed being put in an inpatient bed. The relationship between access block and poor patient outcomes, including death, is well established.
Patients are struggling to even make it out of the ambulance, let alone be admitted. A report by the Australian Medical Association published on Thursday revealed no jurisdiction is meeting their targets for getting patients out of ambulances and into the care of emergency department staff in a safe and acceptable timeframe.
The AMA national president, Dr Omar Khorshid, said this ambulance ramping means patients are not receiving timely care, and that paramedics can’t respond to new emergencies.
“This is what we see when our public hospitals are in logjam,” he said.
Sydney physician and the president of the Australasian College for Emergency Medicine, Dr Clare Skinner, said rising Covid cases and a consistently high death rate had highlighted the pressures hospitals face. But the pandemic and the easing of restrictions is not the cause of access block and the hospital crisis, she said.
Access block has many other longstanding and unaddressed causes, such as the struggles for resourcing and funding being faced by other sectors including general practice, allied health, disability support and aged care. Patients cannot be discharged from hospitals to free up beds if there is nowhere for them to go because of National Disability Insurance Scheme and home care funding shortages, or if they are homeless. Patients also end up in hospital who could be treated in aged care – if only that sector had the nurses and other health workers available.
When there are wait lists and high costs for mental health care in the community, those patients also end up in hospital. “We are seeing a large increase in people presenting to emergency with mental health problems, psychological distress and drug and alcohol issues,” Skinner said.
Funding new hospital beds for these patients is little help if the staff needed to treat them are leaving in droves. Skinner says senior clinicians in particular are leaving, retiring early, or cutting back their shifts because of burnout, stress and “moral injury”. Nurses, too, have had enough. The many years of specialised training they have cannot be quickly or easily replaced.
“Healthcare workers from around Australia are saying the current conditions in emergency departments are the worst they have ever seen in their careers, and that right now access block is worse than during the major Covid outbreaks,” Skinner said.
Woeful investment by successive federal governments in preventative health, rising out-of-pocket health costs, lack of GPs and specialists in rural and regional areas, and difficulty in finding bulk-billed medical appointments mean patients are not being treated early and end up in hospital with more complex problems.
It’s why just focusing on hospitals – whether funding beds or hiring and training new staff – will never be enough to rectify the crisis in the hospital system, Skinner says. Any measures need to coincide with major reform in other areas of health and community support.
“With all of these systems such as social support and welfare, aged care, community health … as the load grows on those, the backup plan for all of them is the emergency department,” Skinner said.
During the major Covid-19 outbreaks, both federal and state governments diverted resources to the health system to meet acute needs. Elective surgery was also postponed to free up health workers to focus on the acute cases.
“But in business-as-usual times, we don’t have that and I think we need the federal government to step up and maintain the extra funding of the hospital system that was made available during Covid times,” Skinner said.
“We couldn’t postpone surgery indefinitely, so now we are trying to do everything, catching up on surgeries and care delayed during the pandemic, while also treating urgent patients and still treating acute Covid cases.”
As a result the number of patients, the complexity of their cases and the costs of treating them continues to grow.
States are responsible for managing hospitals but the federal government shares responsibility for paying for them. The federal government pays 45% of the growth in delivering hospital services each year, capped at 6.5%, but state and territory governments are united in their call for the commonwealth’s share to be permanently raised to 50% and the cap scrapped.
“There are people who fall between the cracks of the state and federal systems, and we tend to see blame and cost-shifting between those systems,” Skinner said.
Guardian Australia contacted numerous major hospitals to ask about the key issues they are currently facing and what is needed to address them. None responded to requests for comment.
An “exhausted” senior surgeon working across two Melbourne hospitals, who cannot be named as he has not been given permission from his workplace to speak to media, told Guardian Australia that “this hospital crisis has not been caused by the pandemic”.
“I think people are so sick and tired of Covid being used as an excuse for what’s happening, or as the reason to address it. Covid merely exposed and worsened the situation. Bringing back restrictions won’t bring back the nurses, it won’t inject money into all of the areas of the community and the health system where it is needed.”
He fears that because health workers have been speaking about the system in crisis for so long, politicians are “losing the importance” of their message; and all the while patients are suffering, staff are overwhelmed and system-wide reform and funding is still lacking.
“I am worried about what happens if it takes five or 10 years for anything meaningful to happen to fix this, because reform takes time,” he said.
“Because at the moment, I don’t even know how we will get through the next six months. How will we cope through winter? We’re going to see more surgeries being cancelled because of staff shortages and because of Covid or flu infections, and more pressure on emergency departments.
“And all the while, in the area of health, we are lacking true political cooperation and leadership.”