Worsening situation at Royal Darwin Hospital

Introduction

Emergency departments (EDs) provide expert medical care for undifferentiated, unscheduled patients with illnesses or injuries 24 hours a day. As EDs are available 24/7 and are often the entrance point into the broader hospital and healthcare system, their efficiency is undermined by reductions to inpatient or community-based services. Across Australia, it is increasingly common for EDs and hospitals to operate at 100% capacity every day. Operating at this level places unbearable pressure on ED clinicians, which is reflected in increased risks of sick leave and burnout.
 
The Australasian College for Emergency Medicine (ACEM) has serious concerns about the capacity of the hospital system in Darwin to meet community needs for timely emergency care. ACEM data and data from the Australian Institute of Health and Welfare (AIHW) show a deteriorating situation with regards to people being seen on time, placing patients at risk and placing increasing and unsustainable pressure on ED staff.

1. Overall ED demand in Darwin has increased significantly, despite the addition of a new regional hospital in August 2018.

Presentations to the Royal Darwin Hospital (RDH) and Palmerston Regional Hospital (PRH) have increased by around 30% since August 2018, when the Palmerston facility opened. Prior to the opening of the PRH ED in August 2018, the RDH ED was seeing approximately 71,000 patients per year[1]. After the opening of the PRH ED, RDH ED sees approximately 61,000¹ patients per year and PRH ED sees approximately 30,000 per year - a net increase of 20,000 patients per year (a ~30% increase).

2. According to the AIHW, in the NT people present to EDs at nearly twice the rate per 1,000 head of population when compared to other states, require admission to hospital at a higher rate, and present to the ED with more potentially preventable presentations.

In the NT, ED presentations per 1,000 people is more than double that of other states (690 per 1,000 in 2018-19 compared to a national average of 329 per 1,000[2]). In the NT more people also required admission to an inpatient bed than the national average. Politicians like to blame ‘GP type patients’ who present to the ED inappropriately, however, this is not the cause of overcrowding problems or long waits in Darwin hospitals. The problem is the lack of inpatient beds.

3. Wait times are worst for ED patients waiting to be admitted, with only 30% of patients admitted within 4 hours at Royal Darwin Hospital.

At slightly over 15 hours, 90% of patients had been admitted in 2018-19¹, while the number of ED patients waiting for more than 24 hours at RDH increased by over 20% (623 patients in 2018-19 compared to 507 in 2017-18)[3].
 
The current situation results in patients ‘double bunking’ (having to put two patients in one cubicle) and being put on trolleys in corridors and other inappropriate spaces on wards. This is a frequent daily occurrence due to a lack of inpatient beds.  ED staff are stretched to look after these overflow patients and patient safety is under threat.

4. The Palmerston Regional Hospital has limited inpatient capacity so there are not enough inpatient beds to accommodate increasing presentations - this leads to deteriorating waiting times and deteriorating conditions within the ED.

PRH provides a geriatric ward, a rehab ward and a few beds for low acuity medical admissions. These are essentially new services which were deficient prior to PRH opening and so have made very little difference to Darwin hospital’s capacity for acute patient admissions. Since the opening of PRH, acute patient admissions from the ED have in fact increased by 10% at RDH – more than any other NT hospital¹. Furthermore, despite the addition of PRH, patients attending the RDH ED still face the longest average wait times in the NT; this has been the case since 2011-12¹. In 2018-19 alone, just over half of all ED patients were treated within 4-hours – the lowest of all NT hospitals and well below the national average of 70%¹. The situation is worse for people presenting with acute mental and behavioural conditions, who are 18% less likely to be seen within the appropriate time[4].

5. Long waits and overcrowded emergency departments compromise patient safety.

Nearly all inpatient admissions from both EDs come through RDH. The hospital runs at 120+% capacity most days, despite the recognised fact that for a hospital to run efficiently it should run at 80-90% capacity (to cope with the ebb and flow of demand). Hospitals running at more than 90% capacity are more likely to suffer from ED access block (patient wait times of more than 8 hours) and an increased duration of ED stay[5]^,[6], which has been shown by multiple reports and publications to be associated with an increased risk of death[7]^,[8].

6. The Darwin hospital system requires at least 100 more beds.

In order to address the problem – and potential consequences – of long and inappropriate waits in the ED and provide the health system that the Darwin community deserves, the Darwin hospital system would require approximately 100 more inpatient beds and this should be provided as a matter of urgency.