The Four Corners program “Out of Time” aired on Monday evening last, illustrates disturbing and chronic problems within the St Johns Ambulance service, the main provider of ambulance services in Western Australia. The program detailed how repeated adverse events arising from inappropriate prioritizing of ambulance dispatch had not lead to any corporate wisdom, or any change of procedure to improve the quality of service and minimize harm to patients.
While the story has a statewide relevance, there is a particular significance for residents of the Bunbury region and the South West of Western Australia, since the Medical Direct of St Johns Ambulance service Dr Garry Wilkes is also the Medical Director of the Emergency Department at Bunbury Regional Hospital.
Reporter Matthew Carney focused on the failure of the organization to learn from the deaths which had occurred in association with slow response times, and addressed pointed questions to the management of St Johns, suggesting that they had a responsibility under Western Australian legislation to report “sentinel events”. Sentinel events are defined in the Health Department’s Sentinel Event Policy as including “adverse events resulting in serious patient harm or death.”
The Four Corners program detailed six cases where dispatch errors had lead to substantial delays in the arrival of a suitable ambulance and crew to persons exhibiting symptoms of life threatening conditions. All resulted in fatal outcomes and clearly fell within the Policy definition as sentinel events.
Copies of internal audits provided to Four Corners allowed comparison of ambulance dispatch priority which during the course of the recovery are upgraded to emergency priority before arriving at Hospital. The documents showed that up to 65 cases in a particular month may have had an inappropriate dispatch priority initially assigned.
A paramedic was quoted as saying that “The clinical team leaders are showing management clinical reports where up to 65 people a month are getting misdirected, or prioritized inappropriately and when the ambulance gets there it has to make a life threatening rush to hospital.”
When first confronted by the implications of the audit data, Dr Garry Wilkes, Medical Director of St Johns Ambulance expressed pride in practicing evidence based medicine, and acknowledged mistakes.
“The real question is not do you make mistakes, but do you investigate them, openly and honestly learn from them and are you prepared to change your practice, and we absolutely do that and we will do that forever.” Dr Wilkes is quoted as saying.
But when challenged by reporter Matthew Carney that the data appeared to be getting worse, not better, Dr Wilkes changed his position. “I say back to you then they are not mistakes, they are areas that are highlighted for review. No system is perfect.”
Dr Wilkes’s professed pride in evidence based medicine must be viewed within the realities of his day to day work environment, and the pressures of being a highly qualified and capable practitioner in a critical area of health delivery. In an article published in the Journal of Emergency Primary Health Care, Dr Wilkes offers frank comment on how pressure of work and information can frustrate the evidence based approach:
“As I read Professor Cordner’s interview, another autopsy report finds its way in to an eclectic pile of information labeled “In Tray”. There it sits amongst the research and journal articles, glossy brochures designed to sell new toys, minutes of meetings and the rest of the information that must be sifted through for us to adequately analyze, change and fine tune our practice. Somewhere in there is that elusive “evidence” for the much revered ‘evidence based practice’. In my other job as medical director in a busy emergency department, is a very similar pile. Different meetings, different glossy brochures, same unsorted pile of potential ‘evidence’.”
The insightful remark to be noted in Dr Wilkes comment is that evidence which is not examined will always remain only “potential evidence”, and never become a useful basis for the evidence based medical model to which he and his colleagues may profess to aspire. It is a telling admission in the light of the Four Corners program, and raises the question of whether doctors are being overextended by the shortage of expert personnel at the front line of primary medical care.
The sentinel event reporting process was apparently introduced in Western Australia in 1993, and its object is to encourage and promote the establishment of committees to review, assess and monitor health services with a view to improving the standard of health care. In other words, it is intended as a device to allow doctors time in their busy schedule to examine the reports of adverse events in their in tray, and transform data into evidence, which can then be applied to improve corporate performance and patient outcomes.
Reporter Matthew Carney raised the issue with Dr Wilkes by suggesting that the Ambulance service had a duty under Western Australian legislation to report sentinel events. Dr Wilkes did not share this view, nor did the media unit of the Health Department’s Office of Safety and Quality.
The Western Australian Health Department’s sentinel events policy explicitly states that “health services” are required to report sentinel events, and the Health Services (Quality Improvement) Act 1994 states clearly that the definition of a “health service” includes “ambulance service”, but the legislation has not yet been interpreted by any judicial process, so it remains a moot question.
Since the Four Corners program went to air, Health Minister Kim Hames has said he will ask his department’s chief medical officer to conduct a review of the cases highlighted, as well as to ensure that St Johns Ambulance is employing best practice in its operations.