In a letter to the board of the Central Adelaide Local Health Network (CALHN), obtained by InDaily, the doctors say beds have been cut, frontline staff made scapegoats and medicos gagged from speaking out.
“For at least a decade, patients presenting to the RAH emergency department who require inpatient psychiatric care, have suffered unacceptable delays in transfer to appropriate beds,” the letter states.
“Stays of up to five days are still commonplace in an environment designed to accommodate patients for up to four hours only.
“Resultant harms are obvious and beyond dispute.
“The patients who wait longest typically require psychiatric intensive care beds, ‘closed’ beds, or forensic beds. These are the most vulnerable mental health patients – those most likely to be harmed by long waits in the ED.”
The Chief Psychiatrist, Dr John Brayley, has publicly raised concerns about the use of restraints, such as shackling, and the doctors say they agree that many of these practices are avoidable.
“We have been forced into unethical, inappropriate practice by a health service that cannot provide timely access to inpatient care,” their letter says.
These incidents of restraint are a symptom of an underlying problem that is not being adequately addressed.
Copies of the letter, dated September 9, have been sent to the Premier, Health Minister and Independent Commissioner Against Corruption.
The doctors say it is “usual business” for the ED to have 10-20 beds occupied by mental health patients – approximately 25-50 per cent of the beds available for the “likely-to-be-admitted” stream of patients “and means that the emergency department is also effectively running an acute psychiatric ward while seeing some 250 patients a day”.
“Daily, ED nurses and doctors are forced to provide care that they know is suboptimal and at times unethical,” the letter states.
“In addition, they work with a continual risk of violence or assault that increases with the time patients spend in the continual light and noise of the ED.
“Recent public criticism – explicit and implied – and scapegoating of ED staff for outcomes that relate to CALHN’s inability to provide adequate mental health services has had a catastrophic effect on morale.
“SA Health’s insistence that clinicians are also not allowed to speak publicly about these issues compounds the distress many staff are suffering.”
The doctors say that as of this week they will allow only six admitted mental health patients awaiting beds to remain in the ED at any one time. Any additional mental health patients will be moved out of the ED into other parts of the hospital, despite bed shortages.
“It is understood that this may worsen access to surgical or medical beds, but this is the option resulting in least overall harm to all our patients,” their letter states.
The doctors say that after 10 years of advocating for this group of acutely unwell patients “we have seen no significant progress”.
“After moving to the new Royal Adelaide Hospital we waited almost two years for psychiatric intensive care beds to open at the new site; when this finally occurred more beds were closed elsewhere, resulting in a net loss of beds and further worsening of access-block,” their letter states.
“Building a high-quality mental health service is now unlikely to be achieved through incremental reform; a stepwise, discrete break with the past is required.
It is our opinion that this may require a Royal Commission, as has occurred in Victoria.
The medicos’ letter comes amid a raft of failures highlighted in the doctors’ union’s latest site inspection report of the RAH, triggered after a weekend of ambulance ramping and complaints of 26 patients waiting for beds, including 16 mental health patients.
The SA Salaried Medical Officers Association (SASMOA) inspected the RAH ED on Monday September 14, after the union was contacted by distressed and anxious doctors, and found an elderly mental health patient had been stuck there for nearly five days, waiting for a bed for 109 hours.
The report, seen by InDaily, states that “angry and frustrated” doctors told inspectors that medical and nursing staff in the emergency department are stretched and that junior doctor training is being affected.
“One doctor stated, ‘Every week I think about leaving, I can’t continue like this. We are not doing what we have been employed to do’,” the report states.
“Other doctors confirmed that the hospital is operating at ‘normal dysfunction’…”
Doctors reported the environment was ‘congested’, ‘overcrowded’ and the escalation process ‘doesn’t work’.
They stated that when starting their shift over the weekend they were “struggling from the start”.
They said most of the beds were allocated, ramping was prevalent and some patients had been left in ambulances for up to three hours.
“The doctors stated that one patient deteriorated on the ramp because of the long wait to enter the hospital, but if the patient had been able to be seen earlier, the deterioration would have been prevented,” the report states.
“It was a near miss.”
The doctors advised that when they attended the hospital on Sunday (September 13), a “semi-disaster response had been started”, the hospital had become “completely non-functional” and there were no beds available for example if a patient had presented with stroke.
One doctor said morale was at an all-time low and the hospital administrators were “simply paying lip service”.
“The Royal Adelaide Hospital has become a holding bay and not an emergency department and we are expected to pull a rabbit out of the hat to fix it when it is not fixable by us,” a doctor said.
The report has been sent to SafeWork SA.
SASMOA president Dr David Pope told InDaily the doctors’ letter and the RAH inspection report “highlights the danger of the situation to patients and the difficulties of medical staff being able to do their job effectively and safely”.
“It doesn’t get any more serious than this,” he said.
“It’s just extraordinary that action is not taken on it. The overcrowding has to end.
“There have to be enough spaces for patients to receive the care that they need to receive in the volumes that we are currently having to deal with.
“The boards have to find the resources to properly meet the needs of the community.”
InDaily provided the letter to Opposition health spokesman Chris Picton, who said: “This letter is an explosive account from our emergency doctors who have lost confidence in the government’s management and it should shock every South Australian.
“Over the past two years the delays for care of mental health patients have increased and it is not uncommon for dramatically long stays that everyone agrees are human rights abuses.
“It’s completely unacceptable that the Marshall Government ignores the shocking stories from our doctors on the frontline and prioritise budget savings over South Australians who need help.”
Doctors have also raised concerns about overcrowding at the Lyell McEwin Hospital emergency department.
SASMOA conducted an inspection of that hospital on the same day (Monday September 14) after being contacted by staff “advising that there were safety risks… because of significant patient numbers presenting… making the emergency department immediately unsafe for patients and those working in (it)”.
“This had occurred over several days,” the inspection report states.
One doctor told inspectors: “We are at gridlock and patients are leaving the ED without being seen – we are distressed because we are not meeting patient needs.”
Another said: “I have never worked in a hospital as bad as this.”
Yet another stated: “Care is compromised, impacting on us – we are demoralised.”
In a statement, Health Minister Stephen Wade said: “The impact of COVID has caused an increase in mental health presentations to the RAH ED.”
He said while September is traditionally the busiest month of the year, from January to August this year there had been a 26 per cent decrease in hours lost to ramping compared to the same time last year.
“I thank our paramedics and health staff for their exceptional work during these challenging times,” he said.
“We also welcome the imminent launch of the State Liberal Government’s Urgent Mental Health Care Centre which will provide more appropriate care while also easing pressure on the RAH’s emergency department.”
In a statement CALHN CEO Lesley Dwyer said: “Our staff have worked on a number of comprehensive solutions to deliver better mental health services and I am proud of the way our clinicians have worked together to improve outcomes for mental health consumers.”
She said since receiving the letter she and a member of the board had met with clinicians to discuss “our shared concerns”.
“We had an open and productive conversation, and we will continue to engage with our clinicians so we can make meaningful change to our mental health services together,” Dwyer said.
“We have established and scaled up a number of hospital avoidance programs and alternative care initiatives that will help ensure mental health patients can access right care, in the right place, within their community.
“We now have four dedicated short-stay mental health beds, away from the emergency department, to help ensure people can be cared for in a more appropriate environment for their needs.
“We are clear on the need for continued reform of our mental health services and we will work to embed the solutions we have developed while continuing to identify, implement and monitor new ways we can improve the system for our consumers and staff.”
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