Australia, better healthcare than America- absolutely!

stethoscope-840125_1280

 

I came across this article and had to write about it. Marie Shieh, a doctor trained in America and now practices in Australia, has written a piece for the The Telegraph. In it she states emphatically that Australia’s health care is better than Americas. Full stop, no qualifiers. And as a former consumer and provider of America’s healthcare system I can agree.

Confession: my road to becoming a registered nurse started because of poor quality healthcare that my father received before his death. We were poor, not living on the streets poor, but we did not have a lot of money. My parents owned a printing business, and we did not have health insurance. When I was young my father was diagnosed with diabetes, then cancer and finally a heart condition. Because we did not have health insurance all of these medical conditions were treated very conservatively and without extensive examination. I believe, as a consequence of that, he suffered a major heart attack and died prematurely.

Now I know that he contributed to his condition with smoking and being overweight. But a lack of medical care significantly contributed to his death. From that moment on I was destined to be in healthcare, despite my attempts to move away from it. I have worked in palliative (hospice in America) care in the U.S. and now work in the Australian hospital system.

We have an amazing healthcare system. Yes, it is over-budget. Yes, there is over-crowding and never enough beds in our hospitals. Yes, people do (at times) come into emergency departments for things that could just as well be handled at their own doctors. But our system allows for every Australian the chance to have optimal health and to be free of medical issues, or at least have them treated to the best that our medical and nursing care can offer without fear of being unable to pay for such treatment.

I have always said that the Australian healthcare system would not work in America. The current push to repeal ‘Obamacare’ as it is called exemplifies this. Americans feel that they should be self-sufficient. And that is not necessarily a bad thing. Health insurance plans are out there to assist with costs. However, the American attitude of “if you can’t afford it we won’t pay for it” still leads to a class-based healthcare system. If you have money then you have health. As a nurse and believer in healthcare that is not right. Health is part of Maslow’s basic needs, and I feel it should be offered as a right just as security in the form of police and safety with firefighters.

maslow-pyramid

Maslow’s heirachy of needs- image source

Alas I do not feel that America will change their ways. The core beliefs of self-sufficiency go all the way back to revolutionary times. I am proud to say I am an Australian registered nurse. I am proud to say that the healthcare I and the thousands of other dedicated workers allows everyday Australians peace of mind and can allow us to continue to prosper.

 

The Telegraph: Trump is right about Australian health care, an American doctor in Australia says

Premature deaths in aged care facilities, what is really the root cause?

 

A recent article in The Conversation by Joseph Ibrahim discussed recent findings that a large number of residents in residential aged care facilities (most commonly known as nursing homes) died as a result of ‘unnatural causes’. The three most prolific causes identified by a recent report from the coroner’s court was falls (81.5%), choking (4.4%) and suicide (1.9%). The study also stated that while in over 90% of the cases the cause of death was initiated in the nursing home over 67% of the actual deaths occurred in an acute facility, such as a hospital. This is reflected in the patients I see in my emergency department. The report goes on to say that these incidents result in a ‘premature’ death and are in many ways ‘preventable’. I would like to bring up some important factors which may confound such a simple statement.

While I do agree that there are most likely things that can be done within Residential Aged Care Facilities (RACFs) to minimize deaths related to the above items, I do think some moderation of the situation is in order. With the ageing-in-place legislation and current climate allowing elderly people to remain in their own homes longer RACFs are seeing residents coming to them older, and more importantly, more unwell with their disease process advanced. While not an excuse I wonder how much longer RACF residents would be able to functionally thrive in their own home rather than in a facility? From my experience of working in RACFs I can say that most likely a resident is placed in a facility due to either an acute turn in their condition (i.e. fracture or some major medical setback) or commonly due to a decline in mobility and functionality due to dementia which would preclude them from staying at home. Along with the decline in mobility and functionality is an increasing possibility for falls.

A second issue is exactly what is the role of a RACF in the health care continuum? According to the MyAgedCare website in a RACF ” Staff at aged care homes can help you with day-to-day tasks (such as cleaning, cooking, laundry); personal care (such as dressing, grooming, going to the toilet); or 24-hour nursing care (such as wound care, catheter care).” Additionally, the Aged Care Quality Agency standards for RACF homes is very general with standard 2.4 simply stating ” Care recipients receive appropriate clinical care” and standard 2.14 on mobility stating ” Optimum levels of mobility and dexterity are achieved for all care recipients.” These are very broad clinical statements with no specific measurable outcomes. They are also included with other standards such as 4.8 which state ” Hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment” and 3.7 ” Care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them.” Therefore, my question again is where does the RACF fit clinically within the healthcare continuum? Is it meant to be a sub-acute residential centre with clinical nursing care as a role on-par with items such as hospitality services and leisure activities?

This case can further be made if Mr. Ibrahim speaks to RACF clinical staff. In most RACF homes the registered nurse is the clinical decision maker for initial diagnosis and guides treatment of patients. However, they have limited assessment and diagnostic tools at their disposal. They have no access to blood tests, CT scanners or even x-rays within a reasonable time frame nor I have found a RACF with a 12 lead ECG machine which is seen as a critical piece of equipment in any hospital emergency department. Additionally, medical services are exclusively provided by general practitioners who can give limited medical support within their clinic hours and an after-hours GP service which does not know the patients and can only provide cursory and event-specific advice. This leaves the registered nurse having to care for a much larger number of patients than any hospital-based nurse would dream of doing with much less equipment and no medical support on-hand.

My worry is with Mr. Ibrahim’s study, as with many previous examinations of care given in RACF homes, will place the burden of responsibility for ‘premature deaths’ at the feet of the registered nurse. I think this is largely unfounded as the RACF system is flawed and needs a truly complete analysis and re-think moving forward. If the RACF is to prevent these events from happening then let us give the registered nurses on the floor appropriate staffing numbers, the right tools and education in assessment using them along with adequate medical support no matter the time of day or night and I think you will see the number of premature deaths decrease rapidly.

References

MyAgedCare: Aged care homes (nursing homes)

The Conversation: Many older people in care die prematurely, and not from natural causes

Aged Care Quality Agency: Accreditation Standards

Coroner asks NSW health privacy rules be relaxed to fight terrorism

A report by SKY news has indicated that the Coroner Michael Burns in investigating the Lindt Cafe siege has found the Personal Information Protection Act and the Health Records Information act were too stringent and did not allow ASIO investigators to have information needed. Coroner Burns has asked the NSW government to review the privacy legislation through his findings. The Sydney Morning Herald, reporting on the findings stated that “Mr Barnes says the government should consider whether NSW Health should more readily share information so that “fixated lone actors”  can be identified and monitored earlier.

However, reviewing the coroner’s report the findings aren’t so clear. Monis did visit several General Practitioners (GPs) who referred him to psychiatrists. Monis did, on one occasion, see a psychiatrist (through a private practice) who diagnosed him with mild depression. He was also seen by the Cantebury mental health team over a period of 16 months. However, according to the coroner’s report Monis was felt to have a personality condtion and not a psychiatric disorder. Additionally, Monis was felt to have manipulated the system to present him as a person with mental instability for some reason.

While the report is obviously a summary of the information gained at the inquest I wonder what good the health information would be in assisting ASIO or any other agency in identifying and removing Monis from the streets prior to the Lindt cafe siege? He appeared to be using the system for his own gains. Monis saw at least 10 GPs within the community, all who I would presume to be in private practice; and therefore not within the confines of the NSW Health system regarding privacy and information sharing. I am wondering how ASIO would be able to know that Monis had seen so many private practitioners and that he failed to follow-up on psychiatric referrals?

I, like many of my countrymen and women, do not want to see terrorist attacks in Australia as occurred in the Lindt cafe siege and in other horrific attacks around the world. And I would be prepared to assist authorities if it was needed. But unless there could be a reasonable explanation as to what benefit would be gained from relaxing the two privacy legislative bills in regards to apprehending potential ‘lone actors’ and preventing terrorist attacks then I fail to see how this would provide benefit over cost to the general public?

NSW Health takes privacy very seriously, and that is a welcome position in my book as a healthcare practitioner and patient. While I am not completely opposed to relaxing privacy legislation I do think we owe it to the general public to have an open discussion regarding what we as that public would be prepared to give up in terms of our privacy for the safety of others. By relaxing privacy legislation, particularly in mental health situations, you risk potential patients staying away from treatment in order to protect their privacy.

Yes, it is a slippery slope. But I am willing to take that slide if there would be real benefit and recognized limits on who the information is shared with and how it will be used. The public has a right to be involved in any discussion.

Your thoughts?

References

Coroner’s report into the Lindt Cafe siege

Sky news report on the findings

Sydney Morning Herald: Lindt inquest: Mistakes cannot be papered over, coroner Michael Barnes finds

 

 

Is it still NEAT? The four hour rule, does it have a place in ED?

The National Emergency Access Target (NEAT) was implemented in 2011 to assist with combating the perceived increase in Emergency Department (ED) presentations along with increased wait times within those EDs. The NEAT was based on a similar measure in the UK which implemented a strict four hour rule which stipulated that patients within four hours from the time of triage were to either be admitted to a ward or discharge after completion of their treatment. The NEAT provided financial incentives for meeting the goals of presentations admitted or discharged within four hours, with the eventual goal to be a 90% success rate by 2015.

The Council of Australian Governments (COAGs) recognized that the inability of EDs to move patients within a reasonable time was a whole-hospital process. Bed block (the lack of available in-patient beds within the hospital) and delays in assessment and treatment contribute heavily to the increased time spent in ED. The hope was financial ‘carrots’ would encourage the hospital executives to drive efficiency within the entire hospital and lead to better outcomes for all patients wherever they were in the treatment continuum.

Funding for the NEAT program was ended in the 2014-2015 budget by the Abbot government. The goal of 90% of patients being treated and moved out of ED within four hours was not achieved. However, despite the criticism of the intervention there have been some benefits of its implementation. In 2016 Adrian Rollins from the Australian Medical Association indicated that statistics like mortality of patients were improving with the NEAT in place, and that the added funding was allowing for improvements in the hospital system. With NEAT removed that funding had stalled. The Medical Journal of Australia also published a study which stated that patient mortality decreased when NEAT was applied to a certain percentage, however there was a plateau to that relationship. A systematic review undertaken by Queensland Health over the NEAT targets also showed some mixed positive results with initiation of treatment benefited by the four hour rule.

The landscape of EDs has seen a positive change as a result of NEAT. ED short-stay wards have been developed to allow for patients who are not admitted to the ward stay overnight for continuing assessment and treatment while freeing up acute beds. Nurse initiated treatments have become more relevant post- NEAT. Hospital administrators and ward managers along with specialist medical teams have become used to the need for assessment within a set time-frame, leading to overall faster admissions.

Yes, the NEAT target was a very blunt instrument which used a very narrow gauge to serve as an incentive for a change in the way acute healthcare was delivered in Australia. However, as those reporting its history have noted it was a measure which was universal across all acute services and would allow for some rough gauge of efficiency across the hospital system. Is it by any means the best measure, no. But it gave EDs something to strive for, and on the back end it allowed for improvements in the hospital and emergency system which have benefited patients. As the Medical Journal of Australia has commented since the NEAT funding has ceased expenditure within the hospital system has somewhat stalled.

What do you think about NEAT?

References used

Medical Journal of Australia: The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target

Australian Medical Association: Nothing NEAT about putting lives at risk

Deeble Institute Issues Brief: The National Emergency Access Target: aiming for the target but what about the goal?

College of Emergency Nursing Australia: Position Statement, National Emergency Access Target

Privacy concern or valuable tool: all Aussies can have an e-health record, would you?


The ABC network has written that with a new surge in federal funding the My Health Record project looks to provide all Australians with the ability to have an electronic health summary. This is a follow-on from other E-health projects trying to establish similar results. While I can understand the apprehension noted by some with regards to privacy and sharing of health information from a healthcare worker’s perspective it is a great leap forward.



In my history as a registered nurse I remember the days before electronic health records. The nature of our health system in Australia means that an individual can present at numerous public and private health institutions without any ability of those institutions knowing prior medical treatment. This is a safety concern for the patient at worst and could potentially prolong the time for effective treatment in the least.


With the implementation of the local electronic health record if I am looking after a patient who has visited another health facility within the same area, state, or even nationally connected the doctor and I can see previous treatments and tests, allowing for more accurate diagnosis and treatment. Expanding this nationally would allow those visiting or recently moved to the area to have better quality care by allowing information sharing.


It is also better for the GP. Now general practitioners must rely on discharge summaries for information about hospital treatment. However, with the electronic record the GP could access more complete information from hospital visits, aiding in their continuation of care at home. A GP could also review and place information for patients on the record in case they travel or are too sick to speak for themselves, vital information which could save their life.


There is always a potential for abuse of the system. However, I would trust that the powers-at-be would design safeguards to prevent unauthorized information sharing of electronic health records. I, for one, will be happy to welcome this advancement in Australian healthcare. According to the ABC report individuals would be allowed to ‘opt out’ of the program.

ABC news: Everyone to have a digital health record

The tragedy of Manchester brings out the true colours of emergency services

As a relatively short-lived member of an emergency department I can say I have never been through a horrific event like that which occurred in Manchester, UK. But the spirit behind all of the nurses in the six hospitals lives within all of us.

By default emergency nurses and doctors are trained to take a patient with little background and through systematic assessment treat the priorities to bring about the best possible outcome.

Nurses learn to act selflessly and tirelessly to get the job done. I am proud to consider myself a member of an elite fraternity called emergency room nurses. Absolute praise and respect to all those who helped in the aftermath.

Should the government regulate family size?

A report in the Medical Journal of Australia has toyed with the idea of poor families being encouraged to limit the size of their families through discouraging more than a set number of kids.

Professor Jones cited the increase of children within the system over the last two decades. Professor Jones stated “We need to ask politically charged questions, such as should we be developing policies that encourage disadvantaged families to have fewer children”.

I have spoken before about professional healthcare bodies weighing in on political matters. However, a case (however thin) could be made that this is a health issue. There is a a far more concerning component to this topic.

History has shown that regulating reproduction has caused anger and disdain from society. A prime example is abortion, either by surgery or via the ‘morning after’ pill. Any attempt to limit a woman’s ability to choose how many children she has would most likely cause similar back-lash. What would be the penalty for violating the birth maximum, withdrawal of funding? Then the burden of care will still rest on the government via social services, hospitals or other agencies.

And what is called ‘low income’? Centrelink funding? Inability to buy a house? Lack of steady income? There are many Australians teetering on low income. Where would society be willing to draw the line? And what would happen if a family who had over the set maximum of children found themselves in that low-income category?

I think you understand my position on this. While it may be true that the number of children burdening the government’s budget has grown Australians have steadfastly held the belief of a ‘fair go’ and to remain non-judgemental.

Your thoughts?

Reference

Sydney Morning Herald: Should poor people have fewer children? Medical Journal of Australia