IMPERSONAL PUBLIC HOSPITALS CAN KILL

And a substandard solution is being tried in Australia

On Christmas day a few years back, Mary Webber was the doctor on duty in a short-staffed Sydney emergency department. The elderly man in the bed before her was clearly unwell: high fever, racing pulse, heavy breathing, confused and complaining of persistent pain all over his body. Webber and her colleagues checked for the usual causes, but ruled them all out. No one could figure out why the man was so ill. He'd been in a minor car accident a week earlier, but X-rays following the incident had shown no signs of fractures.

Webber tried to transfer him to a bigger tertiary hospital better equipped to handle his case, but three declined before a district hospital finally admitted him. Doctors then had to play "catch up'' trying to access various test results and information being held by at least three different hospitals. One registrar noted in the man's file that it wasn't clear who was even in charge of his case. The delays added up, probably to about four days, Webber says. Eventually the man was diagnosed with a rare infection concealed in his spine - but by then it was too late. He died shortly afterwards.

Whether or not that outcome could have been avoided is impossible to say, but Webber says if things had been handled differently he certainly would have stood a better chance. "The doctors were following the normal processes, but if there had been a doctor whose job it was to check up on the tricky patients, someone who was senior enough to crash through some of the barriers and push some of the walls down, then this might not have happened,'' she says. "Or at least it might have been picked up earlier. Everyone was working very hard, but the system itself had inherent flaws when it came to patients like him - the system works very well for `in-the-box' patients who come down established pathways, but not so well for the out-of-the-box patients.''

Now a new brand of doctor designed to help manage and co-ordinate the care of those "out of the box'' patients is being piloted by NSW Health at five public hospitals, in an effort to improve safety and quality of care, and reduce errors and adverse events in a hospital system plagued by doctor shortages. Webber, along with two of her colleagues at Ryde Hospital, doctors Michael Boyd and Ross White, have been among the first to take on this new role of "hospitalist'' - a doctor who will work in hospitals in a generalist role that crosses the divisions between medical departments and specialties. NSW Health has allocated $1.4 million over two years for the Hospitalist Pilot Project, and plans to recruit about 20 more doctors to the position in July.

Exactly what such doctors will do has some degree of flexibility. They will liaise between specialists and junior doctors, as well as with GPs in the wider community. Some will create mentoring programs for junior doctors that review difficult cases and discuss what could be improved; some will develop new systems to deal with longstanding problems, such as a database to improve the lines of communication with GPs. The goal is to provide better continuity of care in a system that has become increasingly fragmented - ideally improving quality of care for patients who are chronically ill or have complex needs, such as the elderly or people with multiple health problems that don't fit neatly into one area.

But not everyone is enthused with the idea. In January the Internal Medicine Society of Australia and New Zealand released a position statement calling the plan a "short-sighted and inappropriate response to the workforce crisis'', that may ultimately result in substandard care as lesser-trained doctors are given the responsibility traditionally charged to general physicians who have to pass the same boards and standards as sub-specialists. "We're very much in favour of someone taking a holistic view, but we think the ideal hospitalist already exists in the form of general physicians,'' says society vice-president Alasdair MacDonald, who wrote the group's position statement. "Rather than creating a whole new class of doctors who don't have the same qualifications, we should be putting our money into recruiting and training general physicians, and improving remuneration for them to restore the balance of generalists compared to sub-specialists.''

Hospitalists first emerged in the US in the 1990s, and there are now more than 10,000 there. The NSW project marks the first time the role has been formally trialled in metropolitan areas in Australia. Victoria, Queensland and WA have all informally expressed interest in the program, says Professor Katherine McGrath, the deputy director-general of health system performance, who sponsored the program at NSW Health. In rural and regional areas - where doctor shortages are more acute - hospitalist-type roles are more common, though they often happen by default. In Queensland, however, the "rural generalist program'' has taken the idea to next level, developing a specific training module for rural doctors working in hospitals, and last year had that qualification recognised.

Such formalisation is not on the cards in NSW. NSW based the new position partly on the American model, which has had some promising results. A review of hospitalist programs published in the Journal of the American Medical Association found that patients' average length of hospital stay was decreased by almost 17 per cent, hospital costs dropped by more than 13 per cent and most patients were satisfied with the care they received (2002;287:487-494).

But there are inherent differences in the way the US and Australian models are set up. Under the US model, hospitalists have considerably more power than those being piloted in NSW. For example, in the US hospitalists can admit their own patients, while here the specialist is ultimately in charge of the patient and just delegates responsibility to the hospitalist. There are also differences in training and qualifications. In the US hospitalists are internal medicine specialists; about half are general physicians and the rest tend to be specialists in intensive care. Several academic centres have now developed hospitalist-focused postgraduate training.

By contrast, NSW Health is targeting doctors who have experience working in hospitals but have chosen not to undergo further specialty training - such as a senior career medical officer, or a GP who would like to work part-time in hospital. There is no separate qualification required to become a hospitalist, and it's being seen as a pathway for career medical officers to progress in their careers rather than a specialty in its own right. Training will be in short bursts in the form of one-day workshops, much like the way continuing professional development works, as opposed to any formal course, McGrath says.

The hospitalists will be working on contracts that range from two to five years - eons compared to most junior medical officers, who rotate as frequently as every 10 weeks and registrars who rotate every six months to a year. "They know how the hospital system works and they can build a long-term relationship with the specialists," McGrath says. "The whole point is to ensure there is no slippage in standards of care - the patient remains under the care of the specialist, and the hospitalist works under the delegation of the specialist - that's where we differ from America. We've made it deliberately different to protect against any risks."

But MacDonald says that itself may be part of the problem. He claims that if anything, hospitalists should be under the supervision of general physicians because hospitalists recruited here are unlikely to have the expertise and training to take responsibility for complex patients. If that's the case specialists may not trust them to hand over responsibility to begin with. Instead they'll seek assistance from another specialist, increasing cross-referrals and further complicating matters. "The optimum hospitalists already exists and what effectively we're doing is saying, well we can't train enough of them, so let's create somebody that's not trained to the same extent, hasn't had to stand up to the same scrutiny and hasn't had to do the same exams - and employ them to do that work," he says. "And let's supervise them by people who don't necessarily have the breadth of specialist's knowledge across lots of disciplines, and by administrators who are often not from a clinical background."

Even among proponents of hospitalists, there is some concern that the goals of the NSW pilot project may not reflect the achievements hospitalists have made overseas. Bill Lancashire is a senior lecturer at the University of NSW Rural Clinical School and a critical care doctor at Port Macquarie Base Hospital. He is actively pushing to have hospitalists introduced there, and says they can help reduce demands on overburdened specialists by taking over management of some of the less complicated patients, as has occurred in the Canadian system. But as to whether it can actually diminish hospital errors, he is not so sure. "I think we need to think more about why we're doing it and what we hope to achieve. Across Australia there is a real concern about adverse events in hospitals, but this shouldn't just be a reflex response to that," Lancashire says. "We need the evidence to show that adverse events will be reduced, because overseas that hasn't been the impetus; it's been specialists being overwhelmed by patient numbers."

The review published in JAMA in 2002 found that while several studies showed hospitalists improved measures such as inpatient mortality and readmission rates, the results were inconsistent. Whether they will make a difference to safety and efficiency in Australia remains to be seen. The NSW pilot project ends in December next year.

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Granny suffers 82 hours of agony in an Australian public hospital



AN 81-year-old great-grandmother endured 82 hours of agony in a Perth hospital. She lay immobilised on trolleys and in "holding pens'' before finally getting urgently-needed hip surgery in Royal Perth Hospital yesterday. Rita Robins' son Peter wants WA's besieged Health Minister Jim McGinty to explain why his fragile, elderly mum experienced days of fasting and constant surgery cancellations before she could get the operation for her seriously fractured left hip. "These are the people that public hospitals should be helping,'' an angry Mr Robins told The Sunday Times, while his mum was getting the surgery. "What do these old people do? "There are more than her going through this at the moment -- this would be just a drop in the ocean. "(Mr McGinty) says there's no health crisis, but what about this?''

Mr Robins' wife Dianne said it broke her heart to see the suffering of her kind-hearted mother-in-law -- who is a great-grandmother of five, grandmother of nine and a mother of four. "I don't think you would do this to an animal,'' Mrs Robins said. She said the elderly woman fell about 7pm on Tuesday at her Northam home and had been taken to Royal Perth Hospital by 11.45pm. Her mother-in-law then spent the next 39 hours on her back -- to stop her moving her hip -- on a trolley, being wheeled to ``empty spots'', while promises of surgery on Wednesday morning fell through.

"About 1.30pm on Wednesday, they took her to what they called a `holding pen','' Mrs Robins said. "This was just stretchers again with curtains between them in just one big open room. "And because she's on her back, they had to put a catheter in for her because she can't get up to go to the toilet or anything. "I requested that if the operation wasn't going to happen, could they feed her because she had been fasting from the night before, and could they give her some of the medication she usually takes. "But the nurse just straight out said to me, `I can't find anybody to come and do what we need to do'.''

Her mother-in-law, already suffering dementia, started to stress. "She was really tired, she didn't sleep all night, she was scared and with all this stress, it made her mind wander because she also hadn't eaten,'' Mrs Robins said. But she was left in the "holding pen'' until 2.30pm on Thursday, before getting a bed. She was made to fast again for hours on Thursday and Friday only to have the surgery again cancelled. Finally, at 9.30am yesterday, she was wheeled into surgery at RPH.

"She's not got private cover because she's a pensioner. She lives in a housing commission home,'' Mrs Robins said. "She's been a widow for seven years and she's had a real tough life. So what do these people do when they need health care?''

Mrs Robins said up to a 24-hour wait might have been acceptable. "But from the time she got to the hospital, until the operation, that's about 82 hours of her lying on her back, not being able to move,'' Mrs Robins said. "So when Mr McGinty says `There's no health crisis', I'd love to phone him up and say `Come visit now', but he's too far away from what the people are doing. "She's a wonderful lady, she's done so much for so many people _ even though she never had much. "And because she's had such a tough life she's always got out of things with a smile. So when I see her like this it just breaks my heart.''

Opposition health spokesman Kim Hames said: "If Jim McGinty cannot ensure timely medical help for people like Mrs Robins and the hundreds of others who are subjected to the same lack of treatment because of his mismanagement, perhaps it is time he does the decent thing and stands down as health minister.'' Mr McGinty refused to comment. An RPH spokeswoman said the Mrs Robins had had surgery postponed on Thursday because of pre-existing conditions, which the family denied.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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