Dunedin Hospital’s ‘Code Black’ could have been avoided if signs acted on

Dunedin Hospital’s “Code Black” episode could have been avoided if warning signs had been acted on sooner, a confidential internal report suggests.

On March 24, the hospital became so overcrowded that 18 patients were waiting in the ER area for beds to come free.

Southern District Health Board chief executive Chris Fleming declared a Code Black critical situation, and a determined effort by staff resulted in the hospital being back to normal seven hours later.

This week, Health Minister Andrew Little singled out the incident as an example of why health sector reforms were needed.

A debrief report on Code Black, a copy of which has been supplied to the Otago Daily Times, tells a story of poor communication between staff and blown chances to avert the looming crisis.

The previous morning, March 23, the hospital was forecasting 55 patients would be discharged that day, and staff knew several elective operations were scheduled for the following day.

“It was clear that the 55 forecast discharges needed to occur,” the report said.

At 8.40am senior staff discussed the idea of texting all the hospital’s senior medical officers (SMOs) about the need to achieve the discharge target, but it was not until 12.20pm that it was determined that was not possible and an email was sent instead.

A 1pm meeting recognised that elective cases would probably need to be cancelled and some schedule alterations were made, but a decision to cancel further operations was put off in the hope the situation would improve.

“There is collective recognition that the triggers to proceed with these cancellations was present at 5pm on Tuesday and the fact that these were not subsequently cancelled until the following day was a missed opportunity that created uncertainty and pressure on the perioperative team the next morning.”

At 7.30pm the hospital’s emergency department was full, and by 7am the following day 18 patients were in the emergency department waiting for a bed.

Actions taken that day included:

• 31 new nursing graduates scheduled for off-site training were brought back to the hospital to work;

• Discharge lounges, treatment rooms and the surgery admission unit were opened to patients;

• Graduates transferred patients from the emergency area to elsewhere as space became available;

• Inpatients who needed a scan were sent home and reprioritised first for imaging work;

• A “relatively high proportion” of elective surgery was cancelled.

The report said the main factors for reaching Code Black seemed to be the low number of patients discharged over the preceding long weekend and the high number of patients who arrived at hospital on Tuesday in acute need.

The number of operating theatre hours spent on acute patients on March 25, the day after Code Black, was double that of Wednesday, but operating theatre hours almost halved on the Friday.

On Thursday, SDHB chairman Pete Hodgson accepted Little’s criticism that Code Black had been because of poor planning and management, but said staff had performed exceptionally to remedy a patient flow problem which was not unique to the South.

Association of Salaried Medical Specialists executive director Sarah Dalton said she was “flabbergasted” the SDHB had no way of texting all its SMOs, and said emailing them would not have been efficient.

“Typically SMO emails are jam-packed full of stuff and because of clinical demands they don’t get to sit down and check their emails … as a fast way of contacting SMOs, email would be a terrible idea.”

Doctors worked in an on-call culture and were used to dealing with phone calls and messages instantly, she said.

SMOs’ ultimate responsibility was the care of their patient and they should not have discharged anyone who was not ready to be sent home, Dalton said.

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