Emergency departments across the country are under unprecedented strain since the Covid-19 pandemic. A senior doctor at Auckland City Hospital tells investigations editor Alex Spence it is compromising the care she and her colleagues can provide to acutely sick patients.
She has taken the day off, but soon the emergency doctor’s phone vibrates with a message from Auckland City Hospital begging her to come to work.
The texts seem to come day after day now, as hospital administrators scramble to find enough clinicians to staff one of the country’s busiest trauma centres:
SOS SOS SOS.
Desperation x 9000! Dept bursting at the seams.
Cover needed for ALL shifts.
Dr Amanda Rosenberg, 50, is an emergency medicine specialist from the United States. She grew up in New York City, studied the philosophy of quantum mechanics at the prestigious Brown University, and then did pre-medical studies at Harvard. She speaks several languages and is a mother to four kids.
Rosenberg first came to New Zealand two decades ago, following a husband who was a sailor in the America’s Cup. The marriage didn’t last but Rosenberg’s affection for New Zealand did. She has lived here on and off since, working most of that time as a senior doctor in Auckland City Hospital’s accident and emergency department, helping to treat some of the city’s sickest people.
In the past few years, the job has been getting harder and harder, Rosenberg says.
Since the Covid-19 pandemic, the department has seemed to lurch into a new crisis. It feels more stretched than ever, Rosenberg says, with critical shortages of doctors and nurses to treat the growing numbers of acutely ill Aucklanders and not enough inpatient beds to admit them to. Staff are stressed, demoralised, and increasingly worried about the quality and safety of the care they’re providing.
“Everyone’s getting burnt out,” Rosenberg says. “We’re exhausted.”
For the first time in her career, Rosenberg says she has thought about quitting emergency medicine.
Rosenberg agreed to speak to the Weekend Herald on the record, without seeking permission from her bosses at Te Whatu Ora Te Toka Tumai Auckland, the local health authority, because she feels so strongly about the safety risks building up in our public hospitals. But she is not alone.
As part of an ongoing investigation into unsafe staffing in health services, we spoke to clinicians at several hospitals and analysed a trove of safety data and documents. Our reporting reveals that emergency departments across the country are severely strained - and that Rosenberg’s fears are widely held among the people who work on the front line.
Overcrowded emergency departments (EDs) are an indicator of stress in the wider health system, experts say, reflecting not just the treatment available for the acutely unwell but issues in primary care and hospital services upstream. The problems plaguing our EDs did not suddenly arrive with Covid. However, a series of disturbing developments over the past year suggests these problems have reached an unprecedented level in the wake of the pandemic.
A woman died of a brain haemorrhage soon after leaving Middlemore because the wait to be triaged was too long.
Desperate nurses in Whangārei asked their bosses to bring in Army medics to relieve them.
Auckland City’s ED became so overcrowded that patients were moved into a public atrium designated as an overflow area for mass-casualty disasters.
And in May, the Weekend Herald revealed that a trio of people with severe mental illness were made to wait between 58 and 94 hours to be transferred to a psychiatric facility - the longest anyone has ever waited for an inpatient bed at that hospital.
Around the country, staff say they’re confronted daily with overflowing EDs but don’t have the resources to cope. Waiting times are increasing. Ambulances are stuck on ramps for hours. Patients are left for long periods in unsuitable spaces without adequate medical equipment, monitoring, or privacy.
Overworked clinicians say they’re being forced to ration the care they provide. Inexperienced staff are being asked to perform tasks beyond their capabilities. And incidents of violence and aggression against staff are on the rise.
The Health and Disability Commissioner says the number of complaints it receives about EDs has risen by 43 per cent in the past few years, to 202 last year. Complaints specifically about waiting times are increasing at an even faster rate.
Te Whatu Ora - Health New Zealand, the national health authority formed last year by the merger of the 20 district health boards, says it is working on a range of short- and long-term initiatives to fill clinical vacancies. But staff say they feel like they’re not being heard. Many have quit. Others say they’re considering leaving for better pay and conditions in Australia. Those who remain say they’re going to work every day feeling stressed and anxious.
“You think you’ve hit the bottom of the barrel and then it just gets worse,” says one senior nurse.
‘Exhausting and overwhelming’
Rosenberg began her medical career in the early 2000s at a major trauma hospital in Baltimore.
In a city with high rates of gun violence and drug overdose, she quickly became accustomed to treating severely ill people in extremely stressful conditions. She has worked in other challenging environments in the US and Haiti.
And so it’s not lightly that Rosenberg says she is gravely concerned about the situation at Auckland City Hospital.
Built 20 years ago, Auckland City’s ED now receives roughly twice as many patients on a typical day as it did when it was opened. In total, it saw 105,536 people last year, according to the latest Te Whatu Ora figures, an average of nearly 290 per day. (Middlemore, the city’s busiest A&E, saw 110,980.)
On any shift, Rosenberg says the ED should have at least 11 doctors on duty but there are frequently fewer than that available. The shortages get worse at night when senior doctors tend not to work, she says. Late shifts are mostly staffed by junior doctors who “are being asked to work above their level of training because we don’t have the senior staff to staff the department at night”.
Since the Covid pandemic, the number of roster gaps caused by doctors calling in sick has increased substantially. In the past, doctors might’ve “powered through” when they had a cold or other minor illness, Rosenberg says, but that is no longer considered acceptable. And yet the department hasn’t developed a system for covering these absences.
After a serious incident involving a patient, an internal review found that “there has been no increase in staff numbers to cover the increase in the amount of sick leave being taken... The department currently relies on an ad hoc approach and staff goodwill to cover vacancies created by sick leave.” The review recommended that the ED adopt a formal on-call roster to cover sickness and surges in patient numbers within six months.
That has not happened, staff say. Instead, administrators constantly send out text messages pleading with staff to pick up extra shifts.
Nurses say their staffing shortages are even more acute.
“We have an incredibly junior workforce dealing with a high workload and high stress,” a senior nurse in the department told the Weekend Herald.
Data from the hospital’s health and safety monitoring system shows that staff have repeatedly escalated concerns about understaffing to their senior managers in the past few years.
According to figures obtained under the Official Information Act, there were 169 unsafe staffing reports filed in 2019-20; 361 in 2020-21; and 292 in the last financial year. These figures understate the reality, staff say, because they are often too busy to fill out the paperwork necessary to submit a report, or don’t bother doing so because they don’t think it will make a difference.
Emergency department work is inherently taxing. It involves shifts at unsociable hours, contact with large numbers of people who are vulnerable and distressed, and quick decision-making with limited information. The consequences of getting something wrong are extreme. It is a “perfect storm for staff burnout”, researchers say.
In early 2020, a study published in the New Zealand Medical Journal found that 60 per cent of staff surveyed across 22 EDs were experiencing burnout. Rates among nurses were particularly concerning. “Safety, financial sustainability and quality of care are likely being adversely affected,” the authors said.
Since that study was done, the pressures have got worse, the staff say.
“It’s exhausting and it’s overwhelming,” when the department is over capacity and understaffed, says one of Rosenberg’s colleagues. “Everybody’s just so tired, so stressed, that simple interactions break down.”
“You’re just trying to do the minimum to keep yourself and your patients safe,” a senior nurse adds.
The lowest point came in March when the ED was overrun by patients but there was nowhere for them to go because hospital wards were full.
Ambulances were diverted to other hospitals in the area. Staff escalated concerns to management several times, which resulted in some people being moved into a public space designated as an emergency overspill area with no privacy. It was a “horrible experience” for the patients, Rosenberg says.
Since then, hospital executives have been trying to streamline the flow of acute patients through the hospital and remove bottlenecks. They have brought in additional pharmacy and allied health resources, improved IT systems, and introduced better handover and referral processes. This has made “significant progress”, says Te Toka Tumai Auckland’s interim lead Dr Mike Shepherd.
But it hasn’t alleviated the underlying pressures, says a senior nurse. “We’re still working in terrible conditions.”
‘Perfect climate for a sentinel event’
Auckland City Hospital is not an outlier.
Over the past few years, front-line employees and their union representatives have repeatedly raised the alarm about quality and safety issues in EDs across the country. In several places, staff became so exasperated that they issued formal health and safety notices to force health authorities to take action - with limited success.
A review of these documents by the Weekend Herald reveals a host of common problems affecting staff and patients.
“Staff are working under increased pressure and stress, severely impacting their physical and mental health due to excessive demands,” said a complaint in Hawke’s Bay.
“Our department’s staffing has reached a crisis point where we are frequently in code red,” said nurses in Masterton.
“ED is faced with staffing shortfalls every shift of every day,” said a provisional improvement notice in Whangārei.
In October, a health and safety representative at North Shore Hospital warned of “dangerous working conditions” including chronic understaffing; patients waiting for extended periods in spaces with no monitoring, oxygen, call bell, suction, infection controls, or privacy; and nurses being left on their own to care for 10 or more patients in a cramped ambulance bay.
Faced with unmanageable workloads, nurses were struggling to carry out routine tasks, the representative said. The stress was impacting their personal lives. Some struggled to sleep before shifts. Others were so burnt out they had taken time off work.
Staff warn that this stress becomes a vicious cycle: burnout leads to more staff calling in sick, which leads to heavier workloads, which leads to people leaving, which leads to bigger deficits. Overworked staff don’t have the time, skills, or mental energy to provide good care. Mistakes creep in. Adverse events happen.
“This is the perfect climate for a sentinel event,” the notice said - an incident that results in serious injury or death.
‘Pride in being a public servant’
At a national level, the experts who monitor the effectiveness of our health services say they’re not yet seeing clear evidence that the staffing crisis and access barriers have led to more bad outcomes for patients than would normally occur in hospitals.
In October, a report by the Health Quality and Safety Commission said there were “early signs of deteriorating outcomes” in some key safety measures, including inpatient falls leading to broken hips and preventable blood clots after surgeries, but its analysis had not detected a dramatic reduction in the quality of hospital services.
Talk to clinical staff, though, and they insist the situation on the ground is more pressing than the high-level data indicates.
They say there’s no doubt the strained conditions are impacting the quality of hospital care and putting people at greater risk of harm.
“The reason that I speak out, the reason I’m burnt out, the reason that for the first time in my life, I’ve considered leaving emergency medicine,” Rosenberg says, “is because I can’t provide the timely, quality care that I would like to my patients.”
“If I didn’t think there were knock-on effects for my patients, I wouldn’t be talking to you today,” she says.
Clinicians say mistakes are inevitable at the best of times in a high-pressured ED, but the risk of catastrophic outcomes for patients increases when senior staff is overburdened and juniors are asked to do tasks beyond their skills and experience.
An elderly dementia patient falls because there’s nobody to keep watch. A man with sepsis deteriorates but nobody notices. An inexperienced nurse dispenses the wrong dose of medication.
All of the sources who spoke to the Weekend Herald said they were aware of preventable incidents that have resulted in serious consequences for patients, along with a much larger number of clinical errors that were picked up before it was too late.
“There’s definitely been a lot of close shaves in the last year,” says a senior ED nurse at a mid-sized hospital.
Rosenberg declined to discuss specific incidents because of patient confidentiality.
Staff say they are anxious they will be blamed for mistakes that happen as a result of circumstances that are out of their control, which could be severely detrimental professionally and personally.
These concerns got to the point that last July a senior executive at Te Toka Tumai Auckland emailed staff reassuring them the authority would back them up if they were subjected to a complaint or investigation because of the difficult working conditions.
“Like you, we cannot remember a time when the system has been under such strain,” Margaret Dotchin, the chief nursing officer, said in the email, which has not been reported until now.
“We know that those who are providing clinical care have concerns in the current circumstances that they may not be able to deliver usual safe care due to constraints on the system imposed by the impact of staffing shortages and the high prevalence of respiratory viral illnesses.”
Dotchin assured staff that Te Toka Tumai Auckland would “shoulder the burden of responding and provide maximal support to any staff involved” in a formal process.
But Rosenberg’s main concern for her colleagues is “moral injury”, a concept that describes emotional damage when a person has been put in a position that violates their ethics.
Often used to describe the psychological impact on soldiers exposed to atrocities in war, moral injury can also happen to health professionals who are unable to provide the care for patients that they’re trained to deliver.
For Rosenberg, the prospect of working in a publicly-funded service committed to a high standard of universal care was an important distinction between New Zealand and her home country, and one of the main reasons she chose to settle in Auckland.
“I take huge pride in being a public servant,” she says. “I want to work in public service. My kids go to a public school.
“I want to be part of a culture where our government provides basic human rights... and when I can’t provide the care for my patients in front of me that I know they deserve - and that I know we’re capable of providing if we only invest in that - it causes a great deal of moral injury personally. And I know that a lot of my colleagues feel the same way.”
‘We need more of everything’
In May, Health Minister Ayesha Verrall visited Auckland City Hospital. Before her arrival, an email was sent to hospital staff announcing that measures were being taken to mitigate extreme pressures on acute services.
“Te Toka Tumai has experienced extraordinarily high volumes over the last 24 hours with high acute presentations and admissions,” said Dotchin, the chief nursing officer.
In response, an additional 40 “flex” beds were being opened, private ambulances had been contracted to help transfer patients, education and training had been deferred, and temporary staff were being brought in from outside agencies.
Some employees rolled their eyes at the timing of the escalation measures - coinciding as they did with the minister’s visit - but these were not the only steps Te Toka Tumai Auckland, and Te Whatu Ora nationally, have taken in response to the crisis.
Andrew Slater, Te Whatu Ora’s new chief people officer, says that senior executives do appreciate the pressures on EDs and are trying hard to rectify them.
In an interview with the Weekend Herald this week, Slater acknowledged that patient volumes in EDs nationally are the highest they’ve ever been, staff morale is low, and violence and aggression against staff is increasing. “I accept that we absolutely do not have the number of front-line clinical resources that we need at the moment on our front line,” he says.
There are no quick fixes. New Zealand faces intense competition for medical staff at a time when there is a global shortage of skilled healthcare workers, Slater says. It is trying to combine 20 district health boards with different processes and cultures, which will take years to bed in. But Slater says he was encouraged that Te Whatu Ora recruited about 1000 new nurses around the country in the past year (not all in ED). And Te Whatu Ora is currently developing a range of short- and long-term initiatives to retain existing staff and recruit and train more workers.
Executives are “pulling every lever we can” to reduce vacancies, Slater says.
At Auckland City Hospital, Rosenberg says there are several measures that doctors have been pushing for that could make a material difference to care in the ED, if the hospital was willing to pay for them.
She rattles off a list: overhaul the rosters so that senior doctors are on duty around the clock; implement a formal system to cover sick calls; build the dedicated behavioural assessment unit for patients in acute mental distress that had been planned before Covid; buy another CT scanner; and outsource radiology scanning to overseas providers so that scans can be read at night.
“We are constantly adjusting the way we manage our resources and investigating and implementing improvements, and we are making good progress,” Shepherd, interim lead for Te Toka Tumai Auckland, says in response.
The hospital is trying to “optimise” the roster in ED to cover gaps around the clock, but can’t provide a formal system for covering sick calls because of “a national shortage of doctors”, Shepherd says. A business case for a second CT scanner has been completed and “is currently under consideration”. A planned rebuild of the ED entrance and triaging area will take into consideration patients in mental distress.
Some staff say the national restructuring of the health system, which began nearly a year ago, has compounded the crisis by diverting executives’ attention, creating confusion and uncertainty about the direction of services, and paralysing decision-making at a local level. It has widened a gulf in trust and understanding between management and clinicians at the ground level.
Despite all the reassurances, these clinicians say they don’t feel that their bosses truly understand their daily reality.
“It’s like trying to explain to someone who hasn’t got children how exhausting it is to be a parent,” says a nurse in Whangārei.
Another nurse adds: “We’ve been telling them for ages we need more staff, more space, we just need more of everything. But they’re like, ‘Oh no you don’t, let’s just make you more efficient.’ Which makes us feel like they don’t really care about our wellbeing.”
This sense of futility is central to the moral crisis that Rosenberg describes. You can escalate your concerns about working conditions only so many times before you begin to feel that it’s pointless to even bring them up.
Rosenberg says she hasn’t given up yet. “I still find a huge amount of joy in the face-to-face interactions with patients on a daily basis,” she says. “And that’s what keeps me going. Knowing that I’m doing the best I possibly can in constrained circumstances.”
“That still outweighs the moral injury,” she adds. “But it’s a challenge on some days.”
Soon, Rosenberg’s phone buzzes again. Another text message from the hospital. Another shift without enough doctors. Can she come in?
Alex Spence is a senior investigative journalist based in Auckland. Before joining the Herald, he spent 17 years in London where he worked for The Times, Politico, and BuzzFeed News.
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