Code White – Inside an emergency department in crisis


Flinders Medical Centre Emergency department is often over its patient capacity. Photo: Ben Lewis


It takes just two minutes and 205 steps to walk from the staff carpark to Flinders Medical Centre’s Emergency Department, but it’s enough to gather yourself for the storm awaiting inside. Flinders is the second largest hospital in South Australia, and its emergency department (ED) is rarely below maximum capacity.

Patient numbers are recorded on a colour-coded graph – below capacity is orange, above capacity is red, and over 125% of capacity is white – or 66 patients in a department designed for 53. It’s rare that Flinders ED has a day without entering white for several hours – data collated from SA Health’s own monitoring system reveals “code white” conditions 49 percent of the time over a typical month.


Movies and TV shows create the expectation that ED’s are hives of constant frantic action – loud alarms from equipment, staff running and shouting “stat”. In reality they’re unexpectedly calm, the striking sound is that of chatter. Communication is key in an ED.


At the changeover of every shift, the medical staff meet to handover patients, news and gossip. On her way to handover, Tamsin*, a senior doctor in the Flinders ED, passed the glass wall that looks out to the waiting room. The sight wasn’t positive. No one wants to be in a hospital waiting room, yet the view that morning was a sign of what was to come. In one of the blue armchairs a lady was seemingly asleep under a blanket, apparently having been waiting overnight. An elderly couple came prepared, sitting quietly with knitting needles. A security guard sat bored on an office chair at one end – half watching the TV on the opposite wall, half watching the cross section of humanity spread across the room, all in need of attention but not knowing when it would come. This was a typical sight, Tamsin recounts, and the feeling of guilt hit. “You know that they’re there, but there’s nothing you can do about it. There’s no space to do anything.”


As she approached handover one of the doctors from the previous night shift looked up. He looked like hell. “Sorry. It’s not good news,” he said, exhausted. Handovers regularly begin with an apology to the next shift.


The team ran through the patients in the department, the situation in the waiting room, and any news from the previous day. There’s no time for complaining, they know they just need to get on and provide the best care they can in the situation they face. Even under-resourced and over-worked, it’s some of the best medical care around.


“Wow there’s a lot of admitted patients here.” It’s the phrase said every day. Looking through the patient list Tamsin recognised several patients who had been in the ED during her shift the day before. These are patients who have been admitted to the hospital but are waiting for a bed in specialist wards. They might be people in need of cardiac care, mental health, or general medical observation. They’ve been seen, stabilised and handed over to the ward, but the hospital is in bed-block – there aren’t beds to put admitted inpatients into, so they’re just left in ED.


With those inpatients in the ED, the capacity of the entire department is reduced. It not only removes one bed from the quota, but also staff time. With less ability to move patients through the ED, waiting times increase.


Tamsin’s first job was to assess those inpatients waiting to go “upstairs”. Once a patient is stuck in ED, internal politics takes over. Even though they’ve technically been admitted to the hospital and the specialist team is meant to take over their care, because they’re in the ED it falls to the ED staff to continue looking after them – despite not necessarily having the specialist knowledge required.


That was what Tamsin was facing. An admitted patient was blocked from entering a specialist ward, and their condition was deteriorating. “Where’s the admitting team? They need to be taking care of this.”


“You know they’re not going to come down.”


“Far out. Call them. We need to make a decision here and it needs to involve them.”


“They’re not coming.”


Frustrated, Tamsin called over the consultant – the most senior doctor on the floor. “Look at this patient … we’re going to need to talk to the family and have an end-of-life discussion with them. The inpatient team aren’t coming, so we’re going to need to make the call.” This is not an easy decision to make, and requires a long talk with family discussing all the possibilities and options.


The consultant walked out to the family to have one of the hardest talks doctors face. With ultimate responsibility for the patient, the team from the ward should have been having the discussion, but instead it fell to an already overstretched ED team.


“They shouldn’t have had to do that, but did because it was the right thing for that patient. But it meant she couldn’t do what she was supposed to, which was see patients in the ED,” Tamsin says.


For the following hours the ED was one senior doctor short as they talked to the family. Meanwhile, the patients kept coming.


There’s some turnover as patients are discharged from the ED, and other patients are discharged from wards allowing ED patients to move upstairs. But others remain stuck. Records later reveal there are multiple patients in the ED waiting for a ward bed for over 12 hours, and often at least one patient waiting over 24. The average wait to be seen rises to more than 100 minutes. The ED was over-full, every bed was in use, even the resuscitation bays meant to be reserved for the most serious Category 1 patients who have an immediate threat to their life.


“Cat.1 inbound, Ambulance four minutes out,” Tamsin hears.


“Where are we going to put them? We don’t have a resuscitation room free.” Tamsin swung immediately into action – first priority is to find a space to treat the patient. The team end up moving a patient from a bay into a corridor, shuffling a patient from a resuscitation bay into the regular bay in a different section of the ED, and reset the “resus” bay before the ambulance arrives.


Moving patients around the ED wastes time that could be better spent preparing for the incoming patient. “If you’re thinking about which of your patients is safe to move, then you can’t focus completely.” Other cases weren’t so lucky. It is later revealed a lack of space meant a patient in a life-or-death situation was assessed and treatment commenced in a corridor. While fast thinking and skilled clinicians meant that patient survived, the staff were described as being in a panic to try to stabilise the patient without having access to the acute treatment area.


The next time it happens – and doctors who spoke out are sure it will – the patient might not be so lucky.


Cat.1 patients can take hours of treatment by a team of clinicians. With these staff unavailable, the rest of the department is essentially in a holding pattern – creating its own vulnerabilities. Other patients who are classified as lower risk get bumped and end up in the waiting room for up to eight hours, including Category 3 patients whose cases are serious enough that they are meant to be seen in less than 30 minutes. As higher category patients arrive they are prioritised, increasing waiting times for Cat.3 patients, despite them still being sick patients in need of semi-urgent care. “They could get worse, they often do get worse, and no one notices,” Tamsin says later.


It was now seven hours into her shift, and Tamsin realised she hadn’t even been to the toilet. A knowing nod from a nurse releases her for that comfort break, on hold for three hours.


The department was well into code white now. Tracking eventually shows the department topped out at 81 patients. Earlier that week had been multiple days over 90, including one of 94 – well over its capacity of 53. That’s not even a record. Flinders’ ED has previously hit double capacity – 106 patients.


The rest of Tamsin’s shift is a blur of activity and frustration. Patients are brought in from the waiting room, assessed, and then sent back into the waiting room. “I’m really sorry I don’t have a bed for you. I’m doing what I can,” she tells one. Another’s assessment shows they can’t be sent back to the waiting room, but there is no bed in the ED. They’re placed in a corridor.


More urgent patients arrived and were treated the best they can – but one resus bay had been filled with a mental health patient. ED’s are particularly unsuited for mental health patients as the constant light, noise and uncertainty of the area increases anxiety and agitation. Every doctor spoken to, including Tamsin, has had an incident with an aggressive mental health patient. In order to protect the patient, staff and other patients, they are sometimes placed in resuscitation bays due to their larger area.


Bed block continued – the mental health patients are stuck in ED as there isn’t care available, other patients are left in ED as wards refuse to take them.


Finally, the next shift arrived for handover. Maybe someone can finally get out to the poor 80 year old who has been waiting for six hours. “Sorry. It’s not good news,” she says to the incoming crew.


“Wow there’s a lot of admitted patients here,” they replied. “I know that one from yesterday.”




A week later Tamsin is sitting in a café. It’s been a blur of over-capacity shifts, patients and a system creaking under its own weight. Her hands grasp her mug. She is visibly shattered.


It’s easy to be impressed by the resilience of ED doctors. They seem to have never-ending reserves to get on with it and deliver world-class care. But there is a limit.


“Patients are at risk. Everyone says it, everyone knows it. Everyone keeps saying ‘someone’s going to die in the waiting room’” she says, clearly exasperated.


“The staff are disgruntled. Over it. There’s a sense of apathy from some of them.”


Peter*, a doctor in the ED at the flagship Royal Adelaide Hospital agrees. “For it to reach white, you are so are overcapacity you’re about to fall in a heap.”


“I don’t think there is one solution to all of this. But I don’t think the solution lies within the ED. Long waiting periods are not purely an ED problem. It’s that there’s no scope to get patients out,” he says.


The overcrowding problems faced by emergency departments around Adelaide is a complex puzzle of issues. However, to those on the front lines, bed block is the biggest.


The Australasian College of Emergency Medicine, responsible for training emergency physicians across Australia and New Zealand, has expressed concern about overcrowding in SA ED’s. “Patients are experiencing longer and longer waits in South Australian emergency departments. We know that the longer a patient is blocked in an emergency department, the higher the likelihood of adverse patient outcomes”, says ACEM President Dr Simon Judkins.


“We believe that no patient should spend longer than 24 hours in an emergency department.”


According to SA Health data, an average of 350 patients exceeded that time every month over the last half of 2018.


The lack of beds is not a new issue, but has never been effectively addressed. Unbelievably however, not all beds in hospitals are made available for use. These are so-called flex beds – beds which exist, but a conscious decision has been made to not put them into operation.


“There are physical beds there, but if they choose not to open them or staff them, they don’t exist. It’s amazing,” Tamsin says, shaking her head.


“When we call out and say ‘help’, they can open these flex beds. But why aren’t they open all the time?” A shrug accompanies the obvious question in a time of chronic overcrowding.


“You’re looking for a logical explanation,” says Bernadette Mulholland, Senior Industrial Officer with the South Australian Salaried Medical Officers Association (SASMOA). “There is no logic. If you’re looking for logic you expect those beds to open.”


SASMOA is the professional association representing employed medical doctors in SA. However, after hearing concerns from clinicians, Mulholland says her role changed to one advocating for patient interests.


“Flex beds aren’t funded, so you’re incurring a cost (to open them). So they don’t like to do it,” she says.


“At the end of the day they’re putting a price on the patient. What is that price? ‘We’re not going to open that bed, we’d rather have someone elderly sit out in that ramp.’ It’s cheaper to have that ambulance sitting there rather than bringing them to the back. Cheaper financially, not to patients or the community.”


Health Minister Stephen Wade has put the onus on the individual hospitals for managing bed numbers, stating in Parliament “I expect managers to manage. On a day-to-day basis, they will flex up and they will flex down.”


Yet there’s no official explanation about why beds are kept inactive when the system faces regular overcrowding, caused in part by a lack of beds for patients. Neither the Minister’s office nor SA Health responded to requests for comment.


“There is ever increasing budget pressure. They’re spending money on the wrong things … not putting an emphasis on patients,” says Mulholland. She adds that hospital administration fail to engage clinical staff on processes.


One of those processes that could vastly improve the situation is “over-census”. The idea seems simple – in busy periods, each ward in the hospital accepts an extra admitted patient above their capacity, thereby spreading the patient load across the hospital instead of concentrating it in the ED. A minimal inconvenience for each ward would make a huge difference to the ability of the ED to maintain patient flow, and improve patient care by getting them onto specialist wards sooner, say clinicians and ACEM.


Half a world away in Alberta, Canada, over-census saw the number of admitted patients blocked in ED drop by almost half. That translated to an extra half-a-million hours of ED bed availability for incoming patients across nine hospitals, during an eight-month period. Decreases in ED overcrowding were also seen during a similar trial at Canberra Hospital. However, despite this evidence, local hospitals have been resistant to implementing the option during crisis periods.


Other wards “don’t see it,” Tamsin says. “Sometimes they come down and say ‘wow this is really busy’, and we say ‘no, this is normal’.


“If each ward took one stable admitted patient from the ED, it would add a tiny inconvenience to each ward. But the ED might go from 40 admitted patients to 20 admitted patients. It would make a huge difference to the emergency department.”


Peter agrees.


“I’m not sure you can ever really appreciate what it’s like to be in ED when it’s busy unless you work there and all those pressures are your problem,” the doctor says. “I don’t think you get all of that feeling of how busy and stressed they are unless it’s your stress.”


Tamsin sighs. “Nothing is going to happen until a politician’s family member dies in the back of an ambulance, or has to sit in a waiting room for eight hours.”


As she leaves the café she turns back, a steely determination filling her eyes. “It’s ridiculous, and it can’t keep going on like this.”


She disappears into the night, knowing that in just a few days she’ll be walking back into that storm.


*names have been changed to protect medical staff and patient identities.