Emergency departments under strain - a sorry saga of blood, sweat, tears and daily abuse 

7 July 2021

Article from April 2021 edition of INPractice

And to quote one very exasperated Adelaide nurse in 2021:  "It's just like a vicious cycle. You shouldn't have to be going to work to be called a #[email protected]! every five seconds!"

Ramping, overcapacity, overworked staff stressed to the point of sick leave, shortages of staff, attacks on staff, mentally ill and drug-afflicted patients a clear and present danger, fatigue, burnout, morale at rock bottom. Welcome to the daily, chaotic grind of life in South Australia’s hospitals and emergency departments.

“We are simply not coping with the workload currently,” wrote one RAH nurse to the ANMF (SA Branch).

“We cannot continue to do what we are currently doing. It’s negatively impacting on our health and morale and most sadly on the care of our patients.

“I seriously fear one of us is going to  make a dreadful mistake and have to live with it for the rest of our lives. It’s REALLY that serious right now and heaven help us if we have a COVID-19 outbreak ...  we will NOT cope!”

At Mt Gambier Hospital, the ED is constantly running over capacity with  nurse ratios often blowing out to 1 nurse to 11 patients or more.

“We’re junior heavy,” says one source.

“We’ve lost quite a few of our senior staff and we’re having trouble replacing them.

"We have only four Level 2 nurses for 21 shifts a week.

"Word's out it's unsafe. From 2016 to 2020 the number of presentations went up 150% but staffing levels have not changed. It's (staff shortages) definitely a life-threatening situation, every single  shift, it's scary."

At the Women's and Children's Hospital, exhausted, understaffed nurses have called for the suspension of elective surgery over concerns about safety and fatigue. They fear errors could occur, putting young patients at risk.

The large number of mental health patients in the ED is of huge concern to medical staff at The Queen Elizabeth Hospital.

"It's getting worse and worse", said one TQEH source, adding that mental health patients can take up a third of the ED capacity.

"The ED is not the right place for a patient experiencing an acute mental health crisis. Sometimes they wait more than two to three days before they are transferred out of the Emergency Department. In the meantime, they don't even have access to  a window or adequate hygiene facilities.

"If they are under an inpatient treatment order and at risk of absconding, they can be denied fresh air. They are stuck in a blank three-walled cubicle where there is no TV or radio and have nothing to do.

Simply put, they receive the bare  minimum. Criminals have better conditions.

“In the waiting room, they are subjected to a high-stimulus environment and sleep deprivation caused by bright lights and  the noises made by other patients, visitors, and staff.

“No wonder they get agitated, aggressive and end up assaulting nurses. Who else can they take their frustrations out on? When mental health patients are withdrawing from illicit substances, experiencing a drug-induced psychosis, or an exacerbation of their mental illness, they can become physically and verbally aggressive.”

The Advertiser reported there were more than 25,700 mental health presentations  to EDs in Adelaide last year but about  half of these did not need to be admitted to hospital.

In late February the ANMF (SA Branch) CEO/Secretary Adj Associate Professor Elizabeth Dabars AM wrote to State Health Minister Stephen Wade, asking him to immediately outline strategies that will address the needs of patients and staff within the hospital system.

“For the last three years the ANMF (SA Branch) has been raising with you the dire patient flow issue which is occurring constantly... putting both patients and nurses at risk. Despite our continuous advocacy there has been no substantial improvement in the flow of mental health clients through the system, with these clients having the longest Emergency Department wait times of any patient cohort. The results for patient care and for nursing staff in the emergency departments have been horrendous,’’ Ms Dabars wrote.

“We fear that failing to appropriately address this problem will result in disastrous consequences for the future of health care in this state.’’

In her letter to Minister Wade, Ms Dabars says the new Urgent Mental Health Care Centre in the CBD, which will have a maximum capacity of 18 patients by May, will have “minimal impact” in alleviating the stress on EDs.

To quote the TQEH source: “Their (mental health patients) screams and rage petrify the other patients in the department, who are often elderly and infirmed. Not only does their verbal and physical aggression cause distress to other patients, it can  also trigger agitation in other mental health patients simultaneously”.

Significantly, another source from TQEH stated that the situation had gotten worse with COVID, with drug-taking, domestic violence and alcoholism on the rise in the wider community, graphically observing:
“The nurses have had a gutful and are fed up; they feel that nobody listens, and no adequate solutions have been put in place to help these people. The mental health system is in crisis and band-aid fixes are not going to cut it.

“Sometimes I think we are doing more damage than good by dumping mentally ill patients into the ED. We know they have complex health care needs and the negative effect extended stays and boredom will have on them while they  are holed up in ED.

“We also do not have a dedicated Code Black team in ED. If there is a Code Black on another ward, we are left stranded and fending for ourselves. By the time security returns to ED, it’s often too late. This has been an ongoing issue and still nothing is implemented no matter how drastic the circumstances and events that occur in the department are.  

At Flinders Medical Centre the biggest issue is “backend,” says a source. “Bed blockages, moving patients through the whole hospital to create beds is an issue.

“We need more beds, it’s that simple.

“We have Code Yellow (dangerous overcrowding) at least one or two a week. We had two in one day the other day. It’s really bad.”

The source said the reported 20 per cent decrease in ambulance ramping in 2020 was only due to the COVID-19 effect when the pandemic resulted in a dramatic drop in hospital demand in April and May. “We are constantly having external ramping, there’s no let up with that.”

In fact, in 2020 South Australia recorded  its worst-ever August figures for the number of hours patients left waiting outside hospitals, with ambulances  ramped for 1,700 hours - a 45% increase in one month.

Ramping in Adelaide showed little sign  of abating in 2021 with patients waiting in the back of 24 ambulances parked outside a packed RAH emergency department  over a three-hour period in January 5.
All metropolitan hospitals went Code White on February 22, with 88 patients waiting for a bed and 15 ambulances ramped at the RAH at about 8pm. Code White is SA Health’s highest rating for the level of pressure on a hospital, with services and patient safety at risk of being compromised.

The ANMF (SA Branch) has long agitated for Government to address the dangerous issues of overcapacity, ramping and staff burnout, as well as the follies of Voluntary Separation Packages at a time when nurses are struggling to cope with demand.

“Hospitals continuing to run at overcapacity, staff shortages, staff fatigue and lack of available ambulances creates a very real life-threatening risk to members of the community,” Ms Dabars said.

“The average number of people waiting for an inpatient bed in Adelaide emergency departments in 2020 jumped from 60 a morning to around 80 over the course of 12 months. We are also again deeply concerned at the number of mental health patients being housed ad hoc in emergency departments for long periods of time.

“With the constant commotion 24/7, emergency departments are hopelessly inappropriate environments in which to house mental health patients. They are simply dumped there for lack of alternative, better-suited accommodation. It is unfair for all concerned - for the mental health patients, for emergency health care staff and for other patients affected by bed blockage and violent outbursts.

“The Government must invest in facilities tailored to meet the specific, complex needs of mental health patients.” And yet the problem persists – with no end in sight.

“There’s a lot of mental health triaging. Like the other day when half our emergency department was full of mental health,” one RAH source said.

Back in September an elderly woman waited almost five days for mental health treatment after presenting to the RAH Emergency Department.

“I don’t blame them for banging their head or throwing things at us, they’re just like trapped in a cage.” One RAH source said.

 “There’s no fresh air, they don’t even see a window. I don’t blame them at all for the way they end up acting when they’ve been there so long.”

Security is a huge issue also for regional sites, which often have to wait for police to intervene.

“Looking at SA Health generally … we get treated completely differently and shafted,” one regional hospital nurse said.

“The big thing for us out in the community is just to feel safe in employment. We need security, we need actual trained security staff, not just the cleaners and orderlies, they’ve got so much on their plate already.

“Security not necessarily just to make us feel safe but also to reassure the community that the hospital is OK.”

“We don’t have any onsite security,” a Port Pirie source said. There is no outsourced security either.

“We had nurses and a doctor get assaulted last year.

“If we have a Code Black we have to  wait for the police to arrive. Often they are quite good at coming in a timely manner but sometimes if they are busy attending other jobs then there can be a delay.

“We certainly have a lot of mental health, drug and alcohol problems. You don’t realise just how time consuming a mental health or drug and alcohol-induced person can be to look after.”

Small wonder the medical profession faces a severe shortage of nurses. According to the Nursing and Midwifery Workforce Climate Survey 2019 – Full Report, half of all survey respondents – SA nurses and midwives - were planning to leave their position within the next five years.

The aged, home care and disability sectors desperately need workers as more than 200,000 staff are due to retire in the next 15 years.

Back in September the Sunday Mail cited a leaked memo which revealed the RAH Emergency Department was struggling to meet the needs of patients due to a lack of senior nurses.

The memo showed that on some days and nights, fewer than half of senior staff required for shifts were available to be rostered. A senior nurse who spoke to the Sunday Mail on the condition of anonymity said “patient safety is at risk”. “Junior  staff are being put in positions that experienced nurses would be baulking at,” the nurse said.

“Even this week we’ve got five extremely senior nurses finishing up, which is ridiculous,” an RAH source told the ANMF (SA Branch) in late January. “People are leaving because they’re not feeling appreciated. They’re overworked, they’re burnt out. There’s no upwards mobility within their job, leading to poor job satisfaction. The burnout is huge.”

The source said the exodus of senior staff “definitely” left junior staff feeling overwhelmed.

At Port Lincoln, two GP clinics have withdrawn their services from the city hospital. Port Lincoln Hospital has relied on locums to fill the gap, but it’s understood some are refusing to return, citing unsafe staffing levels which just add to the pressure on the nurses there.

The ANMF (SA Branch) has long expressed its fears over poor staffing and skills mix at Port Lincoln, with sources even raising concerns about the future of the hospital.

Due to the chronic understaffing in aged care, nursing home residents are having to stay in acute beds for longer periods, which also contributes to bed blockage.  “Often we have patients here we can’t move out, we just can’t get them out. A lot of nursing home patients,” a Modbury Hospital source said of their bed block issues.

The high number of patients is the big issue at Lyell McEwin, resulting in slow flow-through in ED and long waits for patients in the waiting room.

The population boom in the north, a low socio-economic area, with increased morbidities and people finding it difficult to visit their GPs on short notice contribute to the high number of presentations, with staff often asked to do extra shifts or extra hours on busy days and nights.

The establishment of two Priority Care Centres in the north had taken some of the pressure off the Lyell and Modbury EDs, a source said.

“There are often occurrences of assault, that seems to be a constant variable, almost a cultural thing at the Lyell,” the source said. “The security presence is fairly good.”Of course, the problems are not exclusive to the EDs.

"At the moment (under) staffing is really dangerous. I don't understand what is going on," a city hospital ward nurse writes. "This situation is not just due to COVID-19. It's a REAL issue... so many don't feel comfortable speaking up.

"We simply cannot continue to do extra shifts and double shifts. My feet are sore and I'm exhausted, and I'm not the only one.

“Management are well aware, yet no one seems to be doing anything. We are all very tired and frustrated. Sick leave is at an all-time high. We are having to work with agency staff, who are good, but don’t have the necessary skills to manage the complexities of our patients.

“We have had three staff hospitalised in the past month, all from different things and all are various ages, but could potentially be attributed to the conditions we are working under.

“We are not working to workplace policies. We are cutting corners and putting ourselves and our patients at risk.”

Following concerns raised by the ANMF (SA Branch) about very high demand  and stress levels at the RAH, CALHN in January responded by declaring its intention to implement the SA Health Fatigue Management Framework as a  “key focus in 2021”.

“It beggars belief that CALHN would consider the reduction of some 70 FTE of nursing staff when it cannot meet current patient demand,” Ms Dabars said of Voluntary Separation Packages.

As for the continuing vexed issue of violence? Nurses and health care staff were punched, kicked, spat at, bitten, strangled, even threatened with bowel movements in 2020. In one incident last year a Modbury nurse was almost killed. Knocked unconscious, she had to be revived with CPR, after being found with no pulse, not breathing and turning purple.

Despite a commitment last May from the State Government to implement anti-violence and fatigue policies as part of our Enterprise Bargaining Agreement, violence involving hospital patients continued to rise in 2020, with an average of 36 Code Black incidents a day.

Fast forward to 2021 and the problem remains as bad as ever.

In early February it emerged violence against nurses at Whyalla Hospital had reached staggering proportions - 22 assaults reported to management  since January 2.

Staff at the hospital have been repeatedly punched, bitten, strangled by patients and even belted in the face with a TV remote control, resulting in numerous injuries.

“Whyalla Hospital must immediately implement measures to counter the surge in violence before a staff member or someone in their care is seriously hurt or worse,” Ms Dabars said in a media release which received national exposure.

“Nobody deserves to be exposed to violence and aggression at their place of work. The safety of other patients is also of utmost concern.

“We encourage all our members to notify their ANMF officer if you experience episodes of violence and aggression that you feel are not being resolved in your workplace.”

The ANMF (SA Branch) yet again is calling on all LHNs to produce plans and implement measures that ensure all people presenting to emergency departments are treated and either discharged or transferred to other more appropriate places of care within target times.

“The State Government also must take seriously the issue of violence and daily aggression against nurses, midwives and personal care workers, and commit to real action,” Ms Dabars said.

“The issue is not only a threat to people’s lives but also to the health of the health system itself.

“The medical profession faces an uncertain future given the predicted shortages in nursing numbers,” Ms Dabars said.

“We want to attract people to the most fundamentally important profession in society, not have them frightened off.”

Click here to read the April 2021 edition of INPractice.