InDaily can reveal the full details of a damning probe into ramping at Adelaide hospitals, by external reviewers commissioned by the Chief Psychiatrist, which found one in three mental health patients brought to hospital by ambulance was forced to ramp – including more than 10 per cent of children.
The report details 168 cases of ramping at the Women’s and Children’s Hospital in a single year – a week after SA Health categorically denied ramping occurred at the hospital and rejected claims from the Australasian College for Emergency Medicine that it was happening.
The investigation was undertaken in response to concerns from the SA Ambulance Service about increasing problems with mental health patients experiencing ramping, which is when patients have to wait more than 30 minutes – usually in the back of an ambulance outside a full emergency department – to be handed over to the care of the hospital.
Sometimes patients are brought in to the emergency department to wait inside with paramedics, rather than in the ambulance, but it’s still considered “internal” ramping. This usually occurs at the Lyell McEwin Hospital and Women’s and Children’s Hospital.
The investigation found that patients are often demoralised, suffer “a lack of dignity”, experience delayed treatment and “may have restricted access to comfort requirements, such as toilets, food and water”.
It also revealed that clinicians and paramedics feel “helpless” about how to stop ramping, with “conflict and division” between the ambulance service and hospital emergency departments, who often blame each other for the problem.
The investigation report is dated November 2019 but has only been publicly released now, just days after InDaily reported calls for its publication and six months after the Chief Psychiatrist disclosed in his annual report that it had been finalised.
READ MORE: Some of the most troubling cases
The report revelations coincide with a rally in Adelaide this afternoon, with paramedics marching from Victoria Square to Parliament House, demanding more resources to reduce ramping.
The Ambulance Employees Association has described the findings as “a bloody disgrace”.
AEA state secretary Phil Palmer said the cases highlighted were “a denial of human rights”.
He said ramping had caused “loss of life and a lot of suffering”.
“In terms of the loss of life that could have been saved, this government has got blood on their hands,” Palmer said.
The investigators – two highly experienced psychiatrists – visited the emergency departments of the Royal Adelaide Hospital, Lyell McEwin Hospital and Flinders Medical Centre.
They interviewed doctors, nurses, paramedics and mental health staff and examined ramping data from across the system.
They found that in 2018, a total of 10,994 mental health patients were brought by ambulance to South Australian emergency departments.
More than 34 per cent of those – 3,762 patients – experienced ramping, and in one hospital the rate was as high as 60 per cent.
Those rates are well above a stated target set for ramping in the “2019-2021 Service Level Agreement” that stipulates ramping should occur in less than 10 per cent of ambulance arrivals.
The Lyell McEwin had the highest rate of ramping at nearly 60 per cent of cases, followed by the Royal Adelaide (46.2 per cent), Flinders Medical Centre (35.5 per cent) and the Queen Elizabeth Hospital (32.2 per cent).
Of these ramped patients, the majority were transferred within an hour, but one in every 16 waited for more than an hour and one in every 77 waited for more than two hours.
Twenty-three patients waited more than three hours, with the longest wait being 4 hours and 48 minutes.
That patient was a middle-aged woman with an intellectual disability and cancer, brought to the Royal Adelaide.
Another patient – an 89-year-old woman – was ramped at the Queen Elizabeth Hospital for more than three hours.
The oldest victim of ramping was a 103-year-old man, forced to wait nearly an hour at the Lyell McEwin Hospital.
“Consumers presenting with a mental health crisis experience several frustrating delays in their care journey through an ED, but to experience an extended delay right at the start of the journey is truly demoralising,” the report states.
“There is a lack of dignity and comfort for consumers cared for within the confined spaces of an ambulance for an extended period.
“Consumers experiencing acute psychosis will have definitive treatment for this illness delayed.”
The report highlights a range of causes of ramping for mental health patients, including “access block” in emergency departments, a lack of non-ED alternatives for patients and a lack of resources right across the mental health system.
“The use of ramping has led to some conflict and division between the SA Ambulance Service (SAAS) and hospital EDs, two services that should be mutually supportive of each other,” the report states.
“A degree of mistrust and blaming has emerged (which can also occur between ED staff and mental health staff), undermining the ability for these groups to work collaboratively in the best interests of consumers.
“Clinicians in both hospitals and SAAS acknowledge the adverse effects of ramping on consumers and services and want it to end, but feel somewhat helpless about what can be done.
“This has a negative impact on morale and can lead to disillusionment and ‘burnout’.”
The investigators said that of the 1252 mental health patients taken to the Women’s and Children’s Hospital by ambulance in 2018, 168 were ramped – more than 13 per cent.
The report raised concerns about that rate “given that these consumers are adolescents and children, and therefore particularly vulnerable”.
However it noted that 99 per cent of children were transferred to hospital care “within one hour”.
“There were two adolescents who were ramped for over one hour, although these were just over the one-hour threshold (66 and 63 mins),” the report said.
The investigators were also critical of high rates of ramping of elderly patients, noting that more than 30 per cent of those aged 65 and over were ramped, while more than 40 per cent of patients aged 80 and over were also left waiting.
“This is concerning given the potential vulnerability of elderly persons with a mental health presentation,” the report said.
The investigators noted that ramping was a serious problem “for all consumers, not just mental health” and is putting lives at risk.
“Ambulances waiting at hospital EDs are unavailable for new tasks, and this can cause delays in ambulance response times across the city and the state,” the report said.
“This has the strong potential to cause adverse outcomes for persons experiencing a medical or mental health emergency, and longer delays for those people requiring an ambulance carry for less urgent transport.
“There are doubtless a number of cases where this delay has had an adverse impact on someone’s health, and potentially on their life.”
The investigators were critical of the RAH’s design, saying it “did not take into account how ramping would be managed, and in fact assumed that the model of care would eliminate ramping”.
“Yet the SAAS feedback was that ramping was much worse from the very first day the new RAH opened, and has continued since,” the report says.
“The need to redesign the ambulance bay to lessen the impact of diesel fumes is an example of the lack of planning to manage what was a predictable problem of ramping.”
The report also said rising rates of methamphetamine (or “ice”) use was partly to blame for increasing numbers of mental health patients being brought to hospital, leading to more ramping and “access block” in EDs.
The report makes 24 recommendations including greater transparency over ramping incidents, increased resources for hospital mental health units, an expansion of community-based mental health treatments and placing mental health nurses at ambulance stations.
The investigators say SA Health should explore increasing the size of Adelaide’s hospital EDs to meet demand.
They’re also calling for hospital clinicians to personally speak with and assess all patients while they’re ramped.
“The process of external triage, where the consumer waits in the ambulance and is not reviewed by a triage clinician, should be the exception rather than the rule,” they state.
They also say patients must be given “appropriate access to food, water, and toilet facilities whilst being ramped”.
As part of the reforms, the reviewers are urging local health networks to “actively collaborate rather than acting in silos”, noting “a culture of non-cooperation”.
“There is a reputational risk to hospitals, SA Health and government from continuation of ramping as a practice, as it is rightly seen as emblematic of a dysfunctional health system,” the report states.
Chief Psychiatrist Dr John Brayley has published a response to the report, supporting a number of the recommendations.
He says some of them “involve solutions requiring input from different agencies, and will need consideration in relevant committees including the Trauma Informed Practice Working Group and a Steering Group which oversees a memorandum of understanding between emergency services related to mental health care”.
Opposition health spokesman Chris Picton said “hard-working clinicians are being ignored” while “hundreds of patients are suffering every week at the hands of the ramping crisis”.
He said it was “disgraceful” the report hadn’t been released sooner.
“This report has been sitting on the (Health) Minister’s desk for more than six months – and the crisis has only escalated more since that time,” he said.
“Today we will see the passion of our hard-working paramedics as they call on the Marshall Government to address the crisis which has doubled under their watch.”
In a written statement, Brayley told InDaily his office would work closely with all local health networks “to implement the recommendations and improve outcomes for mental health consumers”.
“While not all of the 24 recommendations are applicable to every ED, the recommendations have relevance to all Local Health Networks (LHNs),” he said.
“Metropolitan LHNs have been engaged in the process, and a summary of feedback and response to recommendations document has been prepared.”
Brayley said “a number of actions consistent with the recommendations of the report have already been undertaken”.
“This includes the expansion of the MH-CORE trial across all metropolitan LHNs as part of the mental health COVID-19 response, the re-establishment of hospital in the home within CALHN, the commencement of the Urgent Mental Health Care Centre, and there have also been changes to mental health bed management,” he said.
“The report is being used to inform a revision of the current Memorandum of Understanding between emergency services related to mental health – work being collaboratively undertaken by Mental Health, SAAS, SAPOL, Emergency Departments and the Flying Doctor (Service).”
Health Minister Stephen Wade said “we welcome this report and its recommendations”.
“The fact that South Australian Ambulance Service (SAAS) requested this report and the Chief Psychiatrist has delivered it shows that we are committed to improving care for patients,” he said.
Wade said the report had been provided to the local health networks and the SA Ambulance Service.
“A number of the recommendations are being implemented,” he said.
“The Chief Psychiatrist is an independent statutory officer, and decisions regarding whether and when reports are released publicly are decisions for the Chief Psychiatrist.”
Wade said “all of the cases cited in this report occurred in 2018 and reflect the legacy of ramping we were left by the former Labor government”.
“This report has laid bare Labor’s broken system that we are now fixing through unprecedented expansions of emergency departments at every suburban hospital across Adelaide,” he said.
Some of the most troubling cases
Case Study 1
- Middle-aged woman with an intellectual disability and cancer
- Brought to Royal Adelaide Hospital after her residential facility called police about her “verbal aggression”.
- Ramped for 4 hours and 48 minutes
Case Study 2
- Woman in her 20s with borderline personality disorder
- Brought to Queen Elizabeth Hospital after her mother raised concerns about her “anger, hitting her head on a wall and voicing suicidal thoughts”.
- Ramped for 4 hours 33 minutes.
Case Study 3
- Adolescent boy with autism
- Brought to Women’s and Children’s Hospital “after threatening self-harm and harm toward his younger sibling”.
- Ramped for 66 minutes
- Assessed and sent home 4 hours and 10 minutes after arriving at hospital
Case Study 4
- Woman in 80s threatening self-harm
- On wait list for inpatient mental health unit
- Ramped at Queen Elizabeth Hospital for 3 hours and 16 minutes
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