Introduction by Croakey: The intense political and media focus on the number of COVID patients in hospital intensive care units (ICUs) is obscuring some wider system concerns that are causing critical blockages in hospitals affecting patient care.
Professor Steven Faux, Conjoint Professor of Rehabilitation Medicine at UNSW, says federal and state governments and private providers need to work together more effectively to enable the safe discharge of hospital patients requiring rehabilitation services.
Meanwhile, NSW Premier Dominic Perrottet told a media conference today that NSW health services have a difficult few weeks ahead but he is confident they are in a strong position to manage the pandemic based on these modelling projections.
NSW Health today reported 29 deaths from COVID, and said there are currently 2,525 people with COVID-19 admitted to hospital (accounting for 32 percent of 7,907 occupied public hospital beds). This includes 184 people in intensive care, 59 of whom require ventilation.
NSW Health announced expanded exemptions for critical workers who are close contacts to enable them to return to work, so long as they are asymptomatic and negative on rapid antigen tests – in line with yesterday’s National Cabinet agreement.
Steven Faux writes:
This time the stair gave way and a man we shall call Eduardo Mendez almost busted his neck. Mr Mendez is 79, he has a hot and cold relationship with his neighbours – in the hospital we know him well; he falls, he neglects himself to the point of collapse and apart from an unwavering belief that his neighbour has him under surveillance, he is usually sharp as a tack.
Our community nurse can always treat him at home. Until Omicron.
Next to him in the rehabilitation ward is Colin, who has been a paraplegic for over 15 years. He keeps getting urinary tract infections and occasionally ends up in our ICU.
He was managing. Until Omicron.
But it’s Sandy in the next room who is in really big trouble because of Omicron. She lost her leg from a fall that led to a critical loss in blood supply to her foot, and is just learning to walk with an artificial leg, which she needs to do to see her methadone prescriber weekly.
In fact, none of these patients have Omicron themselves. It’s the other tens of thousands of people in NSW who have it who are their problem.
These three people simply can’t get out of hospital for reasons explained below, which means the 400 who turn up each day to the Emergency Department (ED), with COVID-19 or other problems, can’t get in.
We need the beds now occupied by Mr Martinez, Colin and Sandy right now! But our State-run hospital’s rehabilitation departments relies on community and aged care services to discharge people safely back home – and they are all run by the Federal Government, not the State.
The State Health Department has been meeting weekly with clinicians, planning state services, trouble shooting, developing protocols, and ploughing money into acute services to make sure everyone has access to emergency departments, ICU and an acute bed.
Complex systems
The Federal Department of Health, on the other hand, has devolved the responsibility of managing the aged care sector to private providers and subcontracted vaccination services.
The NDIA is yet to set in place plans to expedite access for new patients or those with changed circumstances due to Omicron. The Transitional Aged Care Program (TACP), a federally funded program to supply care into people’s homes, had been devolved to state-run local health districts that are struggling with staff shortages and currently private health insurers are extremely limited in funding medically led rehabilitation in the home services.
Other states of Australia will face similar problems, including in Victoria where bed block in rehabilitation was an issue in the previous waves, but their lockdown meant numbers were more predictable.
So getting out of hospital might be easy for those recovering fast, having financial means, functional families or those with adequate housing. However, for everyone else, it is challenging.
As rehabilitation physicians and subacute clinicians, we hold the keys to the exit doors of the system.
Our job is to ensure that those who can manage in the community after an illness or injury can receive care at home while they continue to rehabilitate and recover. We play a critical role in moving recovering patients through the hospital system so they continue their care at home and release their beds for others waiting in the emergency department.
Mr Martinez, Colin and Sandy all understood why we needed to move them, they were reassured they would be cared for, and they were willing to cooperate: “anything to help, doctor”. It was humbling.
Roadblocks
The nursing home that would take Mr Mendez is run by a private consortium that have decided that he must have a negative PCR swab to even be considered for transfer and that might take some time. Other nursing homes are closed as they battle infections in their own staff and residents. So he stays.
As for Colin, he has the NDIS but by the time it takes to get the NDIS to increase his level of care at home, at least two to four weeks will pass (they have to decide whether our recommendations are appropriate and hire staff). So he stays.
Sandy has private health insurance so we can transfer her to a private hospital to complete her rehabilitation, but one has closed due to staff issues, another has active cases and can’t take her, and a third has staffing problems and won’t have a bed for three weeks, by when she will be walking. So she stays.
Meanwhile, our ED director is begging us to free up beds for those still in ambulances waiting to make it through the hospital’s front door.
Our rehabilitation services are not in crisis yet – but we are definitely not in a “strong position”.
Cooperative leadership needed
What we need is some state and federal cooperation and leadership that recognises the fact that if you cannot safely get patients out of hospital, you will never get new ones in.
We need to drop the rhetoric of “personal responsibility”, the “let it rip” attitude and we have to work more closely together again.
Our federally funded community programs like the NDIS, TACP, and private insurers need to explore what they can do to help the state hospitals and the thousands in them. We need to find more subacute beds now so we can keep accepting and admitting patients.
Rehabilitation planning is part of the solution, not simply a “mayday call” for when the beds are blocked.
The Council of Australian Governments (COAG) initiative of 2009-2014 showed that investment in enhanced rehabilitation services saved money ($4.8 for every $1 spent) and created capacity in our hospitals (16 virtual beds in a 300 bed hospital), but there was no federal follow up. (See, for example, these reports from 2011 and 2012.)
Now, COVID will have to be lived with, Long COVID will fill the rehabilitation and respiratory clinics for the next several years, and the need to safely discharge patients to alleviate pressure on ED is unyielding.
Subacute care for COVID needs to be on the agenda as does planning for integrated subacute care services so that our hospitals can manage increase pressure points and the dramatic increase expected in long COVID cases.
Yet we have never had a national rehabilitation strategy, nor an integration plan for federal and state subacute health services – not even a debate.
Mr Martinez, Colin and Sandy would do anything to help, let’s hope that sharing their stories will inspire those in power to take the necessary actions.
• Steven Faux is Conjoint Professor of Rehabilitation Medicine at UNSW. The names of the patients in this article have been changed to protect their privacy.
See Croakey’s archive of articles on hospitals.
