Quality of emergency care in smaller hospitals is largely unknown and poorly studied. System failures, staff shortages, inadequately trained staff, and lack of supervision of junior staff can lead to dangerous levels of care, aggressive investigative journalism, and potential litigation [4, 8, 11-13]. Some recent examples were highlighted in Chapter 1. It makes little sense to take a
seriously ill or injured patient to a facility that lacks adequate resources or appropriately trained staff. Logically, higher level services should be located in bigger centres thereby achieving the necessary critical mass to maintain a high level of expertise and resources. Unfortunately, political expediency often determines where hospitals are located – the end result sometimes being the duplication of unsustainable services in geographically close institutions resulting in an overall poorer level of service[71].
Teaching hospitals and ‘evidence based medicine’ generally determine practice standards but these are not necessarily universally applicable. The ‘gold standards’ of care may ignore geographical realities. Most serious trauma in Australia does not present first to a major trauma centre, and most myocardial infarctions do not present first to a facility with on-site invasive cardiology.
The ‘tyranny of distance’ in rural Australia means bypass of the nearest hospital is rarely an option and Somers argues that the GP based emergency care that exists in rural areas is essential to limit morbidity and mortality of serious cases prior to transfer to tertiary centres [72]. However Wong and Levy looked at the high mortality in 22 emergency patients transferred from rural and peripheral hospitals to a regional tertiary hospital [48]. They identified significant system issues including transfer delays and inadequate transport processes as well as patient issues of advanced age, co-morbidities and poor prognosis – suggesting much more could be done to expedite necessary transfers as well as minimise use of scarce resources on patients
with predictably poor outcomes. Stapleton took this a step further when looking at the advantages of telemedicine links between isolated and referral hospitals [57]. Mungall in the UK puts forward a similar argument claiming increasing centralisation of services has led to a ‘distance decay’ (even in a highly urbanised country) whereby utilisation of services is in inverse
proportion to the distance of the patient from hospital [47]. He concluded that there must be a balance between cost-effectiveness and the provision of accessible and equitable services.
Closure or ‘rationalisation’ of hospital services in rural areas is an emotive issue. The Rural Doctors Association of Australia is passionate in its support for small rural hospitals, arguing that there is no evidence to suggest that they are inherently unsafe and, in fact, outcomes in some areas such as obstetrics are better than large city institutions [73]. The vastly different casemix and complexity of care makes these comparisons very difficult. Hays et al looked at procedural rural general practitioners and subjected a range of obstetric, anaesthetic and surgical cases to review by rural doctor peers, regional specialists, a medical administrator and a consumer representative [74]. However, only 91 cases from 24 proceduralists comprising mostly relatively simple elective procedures were audited. The recruitment of cases and the participating doctors may have introduced significant bias into the study. Not unexpectedly, there were no adverse outcomes and quality of care was generally ranked higher by the rural doctor peers and the rural consumer representative. In an extension of this first study, Hays and his colleagues interviewed rural doctors, nurses, patients, and patients’ families on their
perceptions of what constituted quality care [75]. The consumers of health care were generally more concerned about communication, issues of
accessible health care, cost and convenience. Providers of the health services were more concerned about professional and technical issues. The recurring theme here is usually one of strong support by a community for its health services and the associated staff and infrastructure, along with a scepticism that consolidation of services in larger centres always equates with a higher standard of care. Hays and his co-authors acknowledged that all participants in their study may have felt a need to defend what they regarded as a valuable service.
The optimum size of a hospital and its emergency department is debatable but more work needs to be done to see whether patient outcomes are compromised in small departments [2, 76]. Indeed, the emergency department may well be the most error prone part of the hospital [77] and there is increasing evidence in the US literature that there are many more adverse events that go unreported [78].
Croskerry et al maintain that quality of education in emergency medicine and education about quality, are distinct but overlapping entities [79]. The authors assert these need to be considered together and, despite the apparent
importance, there has been relatively little research. It can be difficult to measure quality and whether or not quality improvement projects can positively affect the care of patients presenting to emergency departments,
particularly when it involves vulnerable populations of older people, the uninsured and ethnic minorities [60].
Evidence suggests that smaller institutions have a higher incidence of critical events in their emergency departments and indeed the wider hospital [80] and significant factors include the limited supervision and direction of junior staff [9]. Of concern are the observations in the recent editorial in the MJA
reflecting on the apparent lack of progress in the safety of healthcare in
Australia 10 years after the 1995 Quality in Australian Health Care Study [81]. This study cited an estimated 18,000 deaths per year in Australian hospitals from adverse events. At the time of writing, the Federal Government has announced the formation of a new body, the Safety and Quality Commission, to implement recommendations from the 1995 study.
Examination of quality in hospital care in other countries has also been difficult. In a UK report by Dyas et al on outcomes in major trauma, training
and specialist-led services were identified as important infrastructure changes to be achieved [82]. The report acknowledged though, that improving
outcomes is likely to involve a whole series of changes in the entire system. A paper by Esposito et al from the US State of Illinois looked at preventable deaths in rural areas and found that they were most commonly due to inappropriate management of airway problems and chest injury [83]. The authors suggested education was the most cost-effective method of reducing these preventable deaths. In New Zealand, an extensive review of adverse events across 13 generalist hospitals identified ‘systems issues’, ‘lack of
consultation’ and ‘education’ as the major areas to be addressed in reducing these events [84, 85]. The Canadian Adverse Events Study [86] showed a trend towards a higher number of adverse events in teaching hospitals than in large and small community hospitals but the authors acknowledge that their model did not fully take into account differences in the acuity of the patients at the different hospitals. They also noted that teaching hospitals receive patients at different points of care (for example, transfers of complex patients from smaller hospitals) and the difficulties involved with a number of different providers of care in teaching hospitals. Like the New Zealand study, the Canadian report focused on admitted hospital patients and has not specifically identified adverse events in the emergency department.
Some work has been done looking at critical incidents in Australian
emergency departments. Vinen and his colleagues first began to collect data in 1993 and 1994 and presented this information at the ACEM national meeting in November 1994 [87]. The bulk of these incidents involved ‘junior’ or ‘very junior’ staff and most were overwhelmingly judged to be preventable. There were very few demonstrable adverse outcomes but more than half were judged to be potentially ‘very serious’. The emergency department model proposed by Vinen of incident monitoring, identifying causative factors and
implementation of corrective strategies, borrows largely from experience in anaesthesia that has demonstrated re-engineering systems can substantially reduce errors [77]. Most recently, Hendrie and his colleagues examined adverse events in a large tertiary hospital utilising the Quality in Australian Health Care Study methodology [88, 89]. They found that just over half the
adverse events occurred prior to ED attendance and were mostly errors of commission. ED events were more likely to be errors of omission and highly preventable. In at least one small regional Victorian hospital, concerted efforts to address these system issues, has led to a substantial reduction in adverse events [90, 91].
The extent to which workforce issues impact on quality of care is difficult to identify. The 2004 AMWAC report on the public hospital workforce provided a variety of findings from its consultations with the key stakeholders [64]. The move towards ‘safe working hours’ was more difficult in rural areas due largely to staffing shortages. Ironically, in metropolitan areas, there is a real temptation for junior medical staff to ‘moonlight’ in highly paid locum jobs at other hospitals because they now have shorter rostered shifts at their place of principle employment. The high reliance of the public hospital system on OTDs with varying levels of knowledge and skills, as well as the requirements for appropriate supervision, is an ongoing challenge and is a favourite topic for the media when problems have arisen in the hospital system [13, 14]. Workforce issues are further examined in Section 2.12.