A&E Waiting Time Limits
The Herald reports:
Health Minister Tony Ryall will impose maximum patient waiting times on hospital emergency departments. …
The Herald reported yesterday that a consensus is emerging – in talks among senior physicians and health officials – that the maximum time should be six hours and that no patient should be left waiting in an emergency department corridor. Recommendations are expected to be made to Mr Ryall within weeks.
This is a very brave move by Tony Ryall. Under Labour we saw billions thrown into health, but very little measurable improvements for that money. This means that Labour could talk about how much it cared, but never be measured on success.
Tony is putting in place measures that will introduce better accountability. DHBs will have to front up and specify what resources they need to ensure they can see all A&E patients within six hours. The DHBs can be held to account for that, and also the Minister and central Government an be held accountable if they fail to adequately fund the DHBs.
He cited Britain’s success in reducing emergency department waiting times through a target maximum wait, set in 2004, of no more than four hours from arrival to admission, transfer or discharge. Within several years, he said, the proportion of patients waiting in emergency departments for more than four hours fell from 23 per cent, to 3 per cent.
In New Zealand, Health Ministry data from one large emergency department and two of medium size indicated that while the majority of patients were seen within several hours, up to 20 per cent at one of the hospitals spent more than eight hours in the emergency department.
Looks to be a good plan.
November 25th, 2008 at 8:29 am
I hope it is as the patients line won’t get any shorter, it’s like a river running which you never conquer just manage.
We can whistle all we like but at the end of the day the staff in the ED’s don’t come to work and say right who we going to make wait a long time.
Yeah lets make his day shit he looks like he needs a dinner party story to share for the next 6 months.
They come to work and then get on with it, enjoying the respite often between working their arses off.
good luck to National, I’m looking for honesty in waiting lists DHB’s not knocking people off of them to look good.
The of course the waiting list to really be 6-9 months before an op even if it’s in a private hospital
November 25th, 2008 at 8:38 am
I’ve always thought the hospitals do a very poor job of assessing patients when they come into A&E
Even McDonalds will send someone out with a hand held order system to process their customers.
That’s what hospitals should have.
A doctor out the front, doing a very, very quick 2 minute evaluation of patients to sort them into:
See straight away
See within an hour
Can wait up to 3 hours
Patients should then processed for name etc with a handheld and be given a colour code with the time they arrived
Red (See straight away) Sit by the door
Orange (See within an hour)
Brown (Can wait up to 3 hours)
Then it is just a matter of sending them through into properly staffed treatment rooms
This stuff isn’t rocket science, and in fact the Health System could learn a lot from the burger
industry in terms of service.
November 25th, 2008 at 8:42 am
It’s called triage.
dead, wounded, walking wounded.
Read a good book on a Vietnam war doctor’s tour of duty in the 70′s.
It’s title was the numbers used by the US Army Medical Corps to name the categories.
But you’re right it’s not rocket science.
November 25th, 2008 at 8:43 am
As always I am utterly flabbergasted by what happens in the health system. Are you really trying to tell me that this multi-billion business with layers upon layers of “managers” and “boards” does not even have this most basic of performance standards? A disgrace, if not simply criminal…no wonder more people die of ‘accidents’ in the health system than of road accidents.
November 25th, 2008 at 8:49 am
Yep, waited 9hrs once.
November 25th, 2008 at 8:54 am
DPF: This is a very brave move by Tony Ryall.
No it isn’t. It just means that we continue the system where the DHBs get the blame, and the minister can escape: I told them that patients should be treated in time, but they’re not listening. Socialist healthcare works by rationing and queues. No apportioning of the blame will fix that.
So what’s next? Bill English telling investors that stocks only can go up? Prospective home owners that they can only buy homes at a higher price than the seller bought it for?
November 25th, 2008 at 8:58 am
I was down in Timaru recently about a hospital in Southland that had approx 30 productive staff (nurses, doctors etc) and approx 90 non-productive staff. I don’t think the survival time for a business with that sort of ratio would be very long.
November 25th, 2008 at 8:59 am
democracymum, let me tall you what is currently happening in a hospital in South Auckland. A friend of mine, an elderly man, 92 years, taxpayer all his life, broke his hip on Friday. He still hasn’t been treated. I suppose they use triage: this man will probably survive, or is old anyway, so we’ll fix preventable diabetes, people who drove to hard, drunks, drug users, and others who simply didn’t care about themselves first.
This man has been prepped for four days now: so that means no food, because they might have to operate him. He’s in great agony. His condition is rapidly deteriorating due to being starved, the pain and care he receives.
You really think a hospital should be like a war zone? It is already.
November 25th, 2008 at 9:07 am
Wrong Berend,
It is basic Management 101.
First describe the desired outcome (B), next analyse where you currently are (A), third create the plan to get from (A) to (B) and measure progress.
We have seen the laissaiz faire approach fail, “Give them more money, they are smart enough to spend it well”, because special interest groups mostly guided by Deborah Powell, saw the money coming and found aggressive ways of diverting it into higher salaries and easier conditions for Junior Doctors etc These actions were actually counter-productive in the true sense of measurable outcomes for patients. The Health beauracracy also assisted in this fund diversion by creating endless feedback loops and an army of managers and policy analysts, again there were no meaningful output gains to be had by this.
The most recent Minister (“I’m Cunliffe and I’m running the show”) pretended to be action-man by firing the HBDHB on flimsy (and certainly not unique) grounds and we will see that one in Court before it is all over but the action was all noise and no substance in terms of getting something done to improve the lot of patients which after all is what it is all about.
I for one am willing to give Ryall a chance to live up to the high expectations that have been created.
November 25th, 2008 at 9:07 am
berend
That is a disgrace. The lack of food is a real problem, I’ve had my daughter in A&E with a broken arm and faced the same problem, you end up with a child, or in this case an elderly man dehydrated and weak, all because they are not managing this important stage of the treatment process.
Earlier this year I slashed my small toe open, lying in a pool of blood I knew I should really have it stitched but
it was a Friday afternoon, no appointment available at my doctors, and I couldn’t face going to A&E to wait for hours so just glued it together myself.
November 25th, 2008 at 9:11 am
If I was Tony Ryall I would get together some Doctors, Nurses, admin people and patients (remember us)
and work through some ideas to solve this work flow problem.
They could even role play it in a test situation, to work through some of the potential variations
The I would test it in a small A&E and then a larger A&E and once refined roll it out all over the country
November 25th, 2008 at 9:13 am
Experience tells that if you are faced with a wait in A&E and have a wound, remove the bandage and bleed on the floor.
This used to work when nurses had to clean up but I suppose now that they all have degrees, there is someone else paid to do the cleaning up and it wouldn’t create the same sense of urgency. Worth a try though.
November 25th, 2008 at 9:20 am
It would also help if A&E departments started to turn away people who turn up with the flu’ and send them off to a clinic.
You don’t have to spend long at an A&E to see the numbers of people who are a) ignorant of how our health system works or b) Don’t know enough English to know the meaning of the words ACCIDENT and EMERGENCY or c) know that they won’t get charged for seeing a doctor and are prepared to take up space and wait all day if necessary for free treatment.
Of course A&E staff are in a no-win on that one as if they miss a serious illness hidden amongst the sniffles and sneezes, they will get crucified.
November 25th, 2008 at 9:25 am
The simple solution, and it is one that is used overseas to great effectiveness, is to put a doctor in the waiting room to see patients as they walk in the damn door.
Go to any emergency room in NZ and the first thing you will often see is paperwork, where non medical staff use policy to slow the process.
In California, having a doc in the waiting room reduced wait times from 6 to 2 hours. It’s not rocket science people.
November 25th, 2008 at 9:26 am
DPF, with your obvious contacts within the National Party and your wish to push the boundaries of blogging now that there are few Labour liars still in operation to attack easily, perhaps you could get a blog worthy statement from Ryall yourself that has a bit more flesh on the bones of the idea.
I am simply not interested in the Herald as a source for discussion topics. We’re here discussing what if’s and maybe’s because we just don’t know – reflected by the fact this collection of comments are driven by a fart from The Herald that claims to be a turd.
November 25th, 2008 at 9:28 am
if it’s not an accident or an emergency why not charge them a GP’s fee?
November 25th, 2008 at 10:06 am
Fuck me – a decent proposal to set targets and move service levels in the health service upwards and we get a bunch of fucktard rightwing angry folk going mental.
If YOU want to improve YOUR society get out there and GET INVOLVED at the grass roots.
Otherwise STFU.
November 25th, 2008 at 10:07 am
This sounds like change in a good direction and all power to Tony Ryall.
My understanding is that under Labour the number of health bureaucrats has increased and increased. National is changing that with more people at the front end of health care delivery. Doctors and nurses that actually treat patients.
Good work!
November 25th, 2008 at 10:07 am
The basic problem is that governments cannot run businesses and public hospitals are grossly inefficient.
Part of the problem with A&E is bed block and hospitals will respond to waiting time targets by disguising the problem, as Waikato Hospital has done:
http://kiwipolemicist.wordpress.com/2008/08/21/waikato-hospital-puts-a-band-aid-on-their-inefficiencies/
November 25th, 2008 at 10:12 am
Kiwipolemicist, I suggest you email Ryall with your analysis. Good work.
November 25th, 2008 at 10:16 am
expat: thank you. You’re an optimist if you think that Ryall will take any notice of my opinion
November 25th, 2008 at 10:19 am
I’m skeptical about saying that wait targets will improve service. In the UK, hospitals have used all kinds of dodges to meet wait targets, from keeping patients in ambulances for more than an hour before allowing patients into A&E (more than 40,000 instances in 2007) to moving them unassessed into corridors in another department when the target wait time is approaching…
November 25th, 2008 at 10:21 am
expat: I’ve emailed Ryall, let’s see what happens.
November 25th, 2008 at 10:56 am
For all of you people who want to put doctors into waiting rooms, I assume none of you have been to an emergency department. Every person arriving at the ED is seen and assessed by a triage nurse. That is why those with minor problems are the ones who wait for ever. And if you are wondering why we don’t send the minor problems away, it is because we are not allowed to. The triage nurse can only suggest that you see your GP or go to an A&M.
Democracymum: the lack of food in the waiting room is deliberate. Otherwise people who need surgery would eat and delay their operation still further (and, believe me, it does not matter if you tell them not to!)
Kaydid: I’m skeptical too. Unless Ryall actually deploys some real resources, the same thing will happen here as did in the UK.
November 25th, 2008 at 11:01 am
you sound like an angry idealistic optimist.
It isn’t a proposal, it’s vague idea of targets. There are no details as to how targets will improve flow of patients, what new method is required, how much it will cost, where the money will come from, and whether it will actually be funded. There is no mention of what will happen if the targets are not met outside of blaming the management. There is no mention of how they will track implementation of method that hasn’t even been invented yet.
Let me know how many years it takes you to first get involved at “grassroots” level before you actually make a difference. If you start now, you may, if you’re lucky, not make a difference over the rest of your professional life. Keep the cliche slogans for naieve fools and children who don’t know better and do have fun mopping those hospital floors won’t you.
November 25th, 2008 at 11:02 am
david – you are spot on regarding all the bludgers hoping for a free medical consultation who seem to have a willful disregard of what constitutes ‘accident’ or ‘emergency’. Despite millions of dollars pumped into setting up the Community Services Card and GP PHO practices, which heavily subsidise or offer free primary care, we still have a hard core of citizens who ignore all these services and choose to take no responsibility enrolling in a free or cheap health scheme to turn up instead to A&E and demand instant service. A friend of mine is and A&E nurse and came around last week after her shift, she said of the 12 patients waiting at the end of her shift eight had been assessed as GP cases. Reminders to these folk that they need to see their own GP is often met with a torrent of abuse and threats.
democracymum – yes it is tough hanging our in A&E (especially when you are a genuine case) with a starving and thirsty kid (been there and done that). But remember, depending on what sort of break in the limb is can mean a simple plaster cast or surgery. People forget in the heat of the moment that the most conservative treatment route has to be initially taken. The ill-timed consumption of food can mean the difference of being operated on quickly or being forced to wait overnight till full digestion has taken place. My husband is a hospital surgeon and hardly a week goes by when one of his elective f***wit patients, despite a face-to-face consultation, follow-up letter and a phone call from a nurse restating not to eat before booked surgery, does so. The resulting loss in operating time, when someone elese could have been seen, misuse of staff time etc is a huge burden on the system and the taxpayer. These same idiots rarely seem contrite or embarrassed at their self-induced stupidity and naturally demand they get operated on the next day.
November 25th, 2008 at 11:09 am
As one whose mother died as a direct result of the so called health system cock up I will try and not let emotion get in the way of the debate.
the health system like many things governemnt get involved with is inward focused It is process and procedure driven
the customer is viewed as the problem. the process and the procedure is all important.
if the customers gets a good outcome it is ancillary to the real job
As one who has been involved in customer service in the private sector and worked for several of the worlds best customer service organisations its is frustrating to watch the shambles play out.
You see those at the top have no idea or understanding of what constitutes good customer service.
they are blinded to the simple and obbessed with the complicated. the Sir Humphries delight in building road blocks to good customer service because they have a command and control mindset.
they set up failure systems they will never succeed and then blame the customers.
Take the roads its all the customers fault that we have traffic jams. Nothing to do with idiot planning.
Until we change the people or change the people nothing will improve.
we need to forceable remove the old CD and insert the new CD in the top 2 inches.
November 25th, 2008 at 11:12 am
Great. Will we also have tractor production targets as well?
While the health system remains a “free” service with no reform, waiting lists remain the only rationing agent. Any targets will only cause unintended consequences elsewhere. I predict tears in the future.
November 25th, 2008 at 11:31 am
sally said
“My husband is a hospital surgeon and hardly a week goes by when one of his elective f***wit patients, despite a face-to-face consultation, follow-up letter and a phone call from a nurse restating not to eat before booked surgery, does so”.
They need to learn consequences apart from being bumped from a list as to them it just means more delay.
If they are going to waste OPM why not charge them for doing so?
As for suggesting then a doctor/manager needs to send them off to their local GP with a flea in their ear if it is simple and tell them off if they haven’t registered for a pMO /GP.
Assuming there isn’t a shortage in their area.
November 25th, 2008 at 12:34 pm
It will be interesting to see, in a few weeks when Mr Ryall receives his “recommendations”, whether his estimation of what all this will cost is in the right ball park…
PS: Turpin – in most cases there probably IS a shortage in their area! Been trying to get registered with a GP for 2 years now… “Oh sorry, we can’t take any new patients just now…” “Oh sorry, you’re not in our area…” etc etc
November 25th, 2008 at 12:45 pm
My grand daughter age 16 was earlier this year sent to A&E by her doctor at 6 pm. Almost lifeless. After 3 hours waiting was sent to a general ward to await the senior doctor next day. He arrived 7am and put her immediately into ICU where she remained very ill for the next 9 days. The Senior Doc did his nana at the other staff including telling them (if they didn’t already know) that he was on call 24/7 and that he should have been called asap.( She had contracted a virus infection which made survival touch and go.) Did it make a difference? I doubt it.
Last week(Thursday) one of my male employee’s complained of a headache or in his words a very severe migraine. By evening he was vomiting and had severe pain in his head. Sent to A&E where he waited for 3 hours, vomiting etc. By the time he was seen his brain had swelled and he was in serious trouble. Blood tests revealed meningitis, so he has spent five days in the hospital.
Good action once the right people get to work but bloody woeful at entry. Contrast that with going in to the entry desk with someone suffering chest pains and the reaction is instant and service really good.
All this in a hospital that has just had an injection of 125 million for a new building. And nice too but pointless if the customers are not looked after when in urgent need.
Earlier this year some hospital A&E dept’s in Aussie set to wor to tackle just these problems with some amazing results.
Perhaps someone with some time can look back for the news items.
November 25th, 2008 at 1:05 pm
redbaiter
I realise that in some areas there is a shortage, hence my caveat.
The medical council isn’t as efficient as they make out, in fact in 10 years I’ve heard/seen some stupid stupid behaviour and non professionalism.
I know 4 overseas GP’s in different parts of NZ as well as a coupla specialists, all have had problems with the medical council at soemtime.
All very experienced, one ran an a&E that is busier than Auckland, who’s surgical experience surpasses some of our surgeons in the area they are based.
but no the gnomes pull the strings.
all are contributors.
considering the barriers to entry in medicine you’d think they’d be more efficient and on the ball.
Is it the same with the engineers and others?
November 25th, 2008 at 1:15 pm
It’s called triage
Indeed it is and it already happens in most ED’s – its not a publically visable but patients are certainly being prioritised
so just glued it together myself
So you didn’t really need to go to ED afterall did ya love?
It would also help if A&E departments started to turn away people who turn up with the flu
You’d be surprised at the ailments that people turn up to ED with – man flu is a regular!!
The brutal reality is that ED’s are seriously under staffed, are becoming increasingly unsafe to work in and have an incredibly high staff turn over – it’s a vicious cycle! Wgtn is suposed to have approx 35-40 FTE nursing staff and currently operate with around 25. People are leaving in droves due to poor management and unsafe working conditions. While its not the sole reason for extensive waiting times it is certainly one of the many contributing factors to our crappy health system.
Advice: unless your completely convinced that your dying, don’t go.
ps – no i don’t work in ED
November 25th, 2008 at 1:20 pm
25 out of 35-40
no dept can sustain that for long.
it seems management and HR don’t seem to see the staff goodwill eroding as they should, otherwise there might be more urgency to solving problems.
November 25th, 2008 at 1:27 pm
Waiting problem solved–no patients except for the Deputy Chief Administrator.
http://www.youtube.com/watch?v=Eyf97LAjjcY
November 25th, 2008 at 1:35 pm
last year I had to wait five hours in Hutt Hospital for my son to be treated for a badly dislocated thumb. The waiting in the same space as drunk, foul mouthed low-lives was the worst part. Even worse than the constant smell of urine that seemed to permeate every chair in the place. Mind you, it was a good lesson in why you should study hard at school so it wasn’t completely wasted time.
November 25th, 2008 at 1:38 pm
“no dept can sustain that for long”
exactly – and they wonder why people make mistakes. They missed my 2yr’s broken arm last year. The consultation with the Dr was all of 6mins long, (i shit you not) including x-ray (of the wrong part of his arm), on a trolley bed in the hallway. Had to take him back the next day because his elbow was the size of his head. When i made a formal complaint they brushed me off going on about how hard it is to diagnose children, which i completely agree with so why wouldn’t you take an extra 5 mins to do the job properly.
The problem is systemic – wards don’t have enough beds so ED have to hold patients for longer, patients back up in ED = extensive waiting times.
November 25th, 2008 at 1:52 pm
and they have built the NEW wellington hospital with less beds and a growing population.
duh!
November 25th, 2008 at 1:59 pm
“and they have built the NEW wellington hospital with less beds and a growing population”
Clearly we’re dealing with morons.
November 25th, 2008 at 4:15 pm
My husband is a hospital surgeon and hardly a week goes by when one of his elective f***wit patients, despite a face-to-face consultation, follow-up letter and a phone call from a nurse restating not to eat before booked surgery, does so.
I saw this in action a few months back, I was in hospital for scheduled orthopaedic surgery (after only a 7 month wait for an urgent operation, way to go ACC, but that’s another story), and this dumb ass turns up 6 hours late for his surgery cause he wanted to play in the snow & get his shopping done! And then wanted to be done straight away cause he had to travel back to where he came from before the roads shut with too much snow! If it had been up to me I would of said bugger off to him when he turned up, charged him the lost theatre time, and only agreed to do his surgery without anaesthetic (it was only removing a stabilising wire in his foot the nurses told me.) No wonder there is so much slack in our health system.
But on the A & E thing, they need to be harder on some people who turn up simply because they don’t want to pay to go to their normal doc, or the after hours medical centre. Though I know at Dunedin hospital, they analysed the patient data, and only a very low percentage of people presenting at A & E weren’t urgent, it is just lack of space & medical staff that make the waits long there.
November 25th, 2008 at 4:21 pm
tupin @11.31 – I would love to see these dolts who eat before elective surgery and others who are ‘DNA’ (did not attend) clinic appointments fined or made to pay the cost in some way. We already have the ‘carrot’ eg a free health care system but it is taken for granted and under-appreciated by many people, that I think a ‘stick’ is needed to get people to apprecaite the financial and social costs of their selfishness.
My husband worked as a surgeon for 18 months in a well known and hightly regarded American private charity hospital, which took patients on the seriousness and chronicness of their condition not on financial ability to pay. In other words very similar to NZ. But what a complete difference in attitude. Patients and families from all ethnic groups and socio-economic classes were represented and highly grateful to get free, top quality medical and surgical care pre and post operatively. They signed contracts agreeing to adhere to all the medical and surgical advice for an optimum outcome post-surgery, eg agreeing to attend all physiotherapy sessions, agreeing to dietary changes, agreeing to take medications, agreeing to all follow up surgial care ete etc. There was a mutual understanding between patients, families and the hospital that private donors had contributed to this hospital which has an endowment in the $US billions, and that everyone needed transparency and reassurance that money was being spent effectively and honestly. In other words it was someone elses time and dime, so play nice. I would love a bit of an attitude change here in NZ but not holding out for it.
November 25th, 2008 at 5:39 pm
Sally’s (and others) comments highlight the unusual (and actually quite selfish and stupid) way many people behave when something is seen as free and a god given right. It’s one of the underlying problems with any free welfare state or government supplied facility as it’s the usual other-people’s-money behaviour. An argument for attaching some cost to health care (not the true cost but sufficient to prevent treating it as a free and unlimited resource)
In the health system it’s exacerbated by an almost unwillingness on the part of elements of the clinical hierarchy to see organisational efficiency to be as important in treating the health of the person as medical knowledge and skills. These are elements of the old school of doctoring who saw the hospital as their fiefdom and patients as an unfortunate byproduct of treating sickness and disease.
Luckilly, this aversion to seeing organisation as important is reducing but we seem to be replacing it with managers and bureaucracy not relevant to actually treating the patients. For instance, the reporting requirements to government bodies change (and increase) faster than many DHBs can keep up with. Even funnier (not) is that several DHBs have problems doing the reporting and cannot fully ‘recover’ funding because they cannot provide evidence they did the appropriate treatment.
We are making it worse by paying our doctors relatively badly. My cousin, a doctor, who wished to immigrate to NZ (his education and training having all been paid for the UK government), went instead to OZ as he was offered such a poor package that he didn’t think he could live off it.
On a final note, I do remember the first round of new managers going in to health back in the 90s. I had to laugh as they were typically the ones who could not cut it in the commercial world and it showed.
November 25th, 2008 at 6:10 pm
I’m concerned at the rate of nursing students who drop out or work to a chronically undecipherable tertiary degree.
I haven’t found one nursing student who knows whats going on in their degree. these are the few who hang in to try and complete the degree. Faces I saw from two yrs ago up to several months ago are no longer here at Wintec. They were no where near completion of the degree. I only know of one who is still going hard. She has already had professional experience and is a JP so is of high standing in the community. she has no confidence of her standing in the degree.
That’s hard. I myself am going into my third year in media arts. There are aspects I know I’ll have to work doubly hard at next year but I have confidence to overcome because of my last three years in academics. But when someone of professional standing in the community has no idea, that’s not a good sign of being educated.
Hard work is hard work and we feel accomplished achieving in it. But to work hard and feel no achievement is not healthy learning.