RAMPING
Unsafe Ramping Conditions
Members,
Ramping is now deeply engrained in the system, having been officially given a moniker of ‘delayed transfer of care’, being programmed into EDIS triage drop-down options, having stretcher-shaped line markings painted on hospital corridor floors, placards on walls denoting which ‘ramp’, and it’s very own policy Transfer of Care SOPO-1023.
6583 RAMP HOURS SO FAR THIS MONTH
Unfortunately, we do not see any improvement in ramping levels forthcoming. UWU-backed Health Minister Amber-Jade Sanderson appears to be okay with current ramping levels, blaming winter pressures and NDIS providers, then cutting funding for Extended Care Paramedics.
Ramping has been at historic levels for several summers, and winter happens yearly, Amber-Jade. While we accept that ramping is unlikely to improve, the conditions governing ramping must be safe for our members and for our patients.
Royal Perth ED
Our members will undoubtedly be familiar with the lack of space available to ‘ramp’ at Royal Perth. When more than two patients are ramped, this space can become unsafe. This corridor houses up to four A-Bay patients, an A-Bay nurse, their treatment trolley, and monitoring equipment. It also houses the clean linen store, patient belonging lockers, hospital bed mattresses, oxygen cylinders, linen trolleys, and, often, several WAPOL officers.
The frequent passage of store movements, porters, the HLM computer desk and chair, and red ‘St John torture stools’ further deplete the limited space. Even though the metal stools provided are far from ergonomic or comfortable, the overcrowding in ramp areas means officers cannot sit on the chairs and must stand instead. When crowded, the area becomes unhygienic, with our members forced to stand and work in uncomfortable proximity to patients who may be displaying ILI symptoms or who may be intoxicated, violent or aggressive. The area frequently becomes the temporary home of disturbed and agitated, drug-affected patients. The area is noisy and oppressive during peak congestion levels, contributing to workplace stress as well as exposing our members to the risk of infection or assault. The area must be terrifying for our elderly patients.
It is also not uncommon to witness officers needing to lift their Stryker with patient on board to make room for people moving within the area, as there is insufficient room to activate ‘crazy wheels’ mode. Patients are even ramped outside the ED doors during extreme periods of ramping, exposed to the elements and the public passing by. There is a complete lack of privacy, with hospital staff examining and discussing private and confidential medical history within sight and earshot of other patients, degrading and insulting patient dignity.
Sir Charles Gairdner
Similar to RPH, the area is unfit for purpose. The airlock at SCGH is only suitable for a maximum of two ramped patients before becoming overcrowded. Ramping in the airlock blocks access to clean linen, forcing members to lean over patients and stretch to reach supplies. Again, the space is unsuitable for patients with ILI symptoms or complex behaviours. After the airlock is full, SCGH directs excess ramped crews to the public waiting area.
Being wheeled into the waiting area can be degrading and humiliating for many patients and again exposes our patients and our members to crowded conditions with a higher risk of exposure to airborne pathogens. We have also had reports from several members regarding incidents of verbal abuse and aggression from members of the public while ramped in the waiting room. Ramping in the waiting room is unacceptable for our members and exposes them to unacceptable safety risks.
Ramping in Ambulances
St John’s policy states, “Patients are not to be ramped in the back of an ambulance for any length of time.” Historically, ramping in an ambulance has been the least desirable option. Today’s reality, however, may mean that this option is preferential when the hospital ramp area is particularly overcrowded or unsafe. You can access all your monitoring and patient care equipment in the ambulance. If needed, you have air conditioning and an extractor fan, and some still have Glen 20. Your Corpuls remains on charge; you have a radio, telephones, and duress alarms. You can even charge your iPad. You have all your medication, oxygen and a complete airway kit. You can even play soft, soothing music on the radio. It’s almost as though it was designed for patient care. The only issue is the patchy ambulance Wi-Fi, which is determined to connect to an ambulance 5km away rather than the one you are sitting in.
We will write to St John to request that they implement measures to improve the space and conditions of ramping areas in association with their ‘Health Partners’. If the suitability and safety of ramping areas cannot be improved, our view is that, for certain patients, it may be safer for the patient and crew to opt to remain ramped in their ambulance. Of course, this would be at the crew’s discretion after performing their ‘dynamic risk assessment’ (we learned how to do DRA when we were recently taught how to drive online) of the state of the hospital ramping area. In such circumstances, the HLM could advise the crew when a bed is ready for your patient.
We will provide further information once we have discussed concerns with St John.
Other ramping matters
Interventions on the ramp
The AEAWA have long held concerns that hospital staff and management use paramedics to bolster their internal staffing numbers and provide hospital-level care for ramped patients.
This is evidenced by the fact that ramped patients increasingly receive all of their care and treatment while ramped, with staff intending to discharge the patient directly from the ramp.
Staff increasingly ask paramedics to obtain blood for cultures, assist with bladder scans, facilitate catheterisation (then back to the ramp), move patients for X-rays and CT scans, and move patients from the ramp to a ward. Hospital staff have begun telling paramedics what analgesia to provide and initiating sedation for agitated patients, purely to facilitate longer stays on the ramp.
Paramedics have been accused of causing or exacerbating patient injuries by moving patients between different sections of the hospital. When such allegations arose, St John attempted to place all blame on the crew. We do not support our members’ performing additional, unnecessary manual handling, such as sliding patients to and from ambulance stretchers onto X-ray or CT tables and back again, then performing further slides when the patient is finally accepted into the ED. Slide transfer is one of the ‘Big 6’ causes of injury within St John, so we should minimise these unnecessary tasks performed for the benefit of the ED.
While ramped in the hospital, our ‘role’ must stop somewhere. This is hospital care and should be provided by hospital staff. While we are sympathetic to our understaffed and overworked colleagues in the ED, it is clear that St John does not intend to delineate precisely where our ‘role’ stops. The ambulance service also needs more staff (not more managers) and is also overworked.
Ambulance officers are not porters and should not be expected to ferry patients to and from X-ray departments or wards. Our role is to manage patients in the pre-hospital arena, deliver them to the ED, and provide a handover.
The Transfer of Care policy states, “Clinical care is limited to ambulance treatment areas such as the Ambulance Ramps/Triage/ABAY areas.” While it is suggested elsewhere in the document that we should ‘facilitate’ X-ray and CT scans, we believe this can be done by hospital staff alone. Hospital staff manage to get patients who arrive via the waiting room to a scanner just fine. Ambulance staff can ‘facilitate’ scans by providing a clinical handover and assisting with a single, one-way patient transfer onto a hospital bed. If the scan is not urgent, it can wait until the patient is accepted into the department.
St John uses an emotive tone to advocate for expanding the paramedics’ duties in the ED, arguing that it expedites patient care.
Our view is that it does nothing to address the care of community members who do not receive a timely ambulance because half the fleet is ramped. Further, paramedics performing these tasks mask the need for additional hospital beds and staff. WA Health is using paramedics to work inside the ED as nurses, and using our stretchers as additional hospital beds.
Hot Swaps
The recent cross-party Parliamentary Inquiry was very critical of St John’s use of emergency ambulances to perform non-emergency patient movements, such as take-homes, discharges, or transfers, noting, “Non–emergency patient transfers are contracted separately from emergency ambulance services. Despite this, emergency ambulance resources are used to conduct inter–hospital patient transfer services”
Under questioning, then CEO Michelle Fyfe was on record as stating “The one thing that I can say is that emergency ambulance services are dedicated towards the community in an emergency ambulance scenario and we would never take emergency ambulances away from responding to the community for something that was not an emergency.” How swaps deprive the community of an emergency vehicle, mask the true need for increased patient transport vehicles, and use emergency contract funding for non-emergency transport contracts; funding which is allocated for 000. As such, measures were put in place.
In Metropolitan areas, ‘hot swaps’ can only be requested by the Department of Health Site Delegate via SOC.
A Site Delegate is a Department of Health Employee who is site-specific to each hospital location.
FYI, the Site Delegate is an employee of WA Health, and NOT the HLM, nor the ANC.
The Site Delegate is responsible for patient flow and determining if/when it is in the patient’s interest for an emergency ambulance to perform a non-emergency booked interhospital patient transport. If approached to perform a ‘hot swap’, officers should redirect the request back to the hospital Site Delegate. The HLM must be able to identify the Site Delegate and confirm that they have approved the ‘use of an emergency ambulance for a non-emergency transfer‘.
The Site Delegates are:
St John of God Midland: On-Call Site Executive
Armadale Hospital: On-Call Site Executive
Royal Perth Hospital: On-Call Site Executive
Peel Health Campus: Nurse Director Clinical Services
Rockingham General Hospital: Nursing Medical Co-Director
Fiona Stanley: Nurse Director
Sir Charles Gairdner Hospital: ED Patient Flow Coordinator
Joondalup Health Campus: JHC Deputy Director of Critical Care
Please also report any inappropriate tasking of emergency ambulances to non-emergency ‘hot swap’ transfers at https://www.aeawa.com.au/report-issue, recording as many details as possible, including whether authorised by the Site Director.