Last week, the Lismore App asked the question, 'What is going on at Lismore Base Hospital?' after yet another poor statistical showing in the latest Bureau of Health Information report.

Chief Executive Officer Tracey Maisey answered our call for an explanation so the Lismore community can fully understand why its emergency department is underperforming compared to neighbouring Northern NSW Local Health District (NNSWLHD) hospitals and scoring below the NSW state average.

Ms Maisey has been in the position of CEO for thirteen months. That's enough time to look under the hood and identify where the problems are; however, not enough time to create meaningful change, some of which are completely out of her hands.

It should be noted that the Lismore Base Hospital (LBH) is performing well with surgery wait times and patient experience, as has been reported previously. This story focuses on the ED (emergency department).

"I guess the first point, a lot of it is to do with the acuity (severity of illness) and the ageing population. I will just talk about the LHD (local health district) for a second and then sort of drill down on Lismore.

"So, you know that we've got an elderly population. 17% of the population is aged over 70 years and the population is going to grow 11% between 2016 and 2036. In the aged population, there will be 70% growth in the age of 70 to 84 years and 85% growth in the 85-plus years. So, we're seeing an ageing population, and as you would know, with healthcare, that comes with an increase in acuity."

Ms Maisey then compared the LBH ED numbers from April to June 2024 to the same period in 2023 and explained the different triage levels involved.

"Triage 1 is extremely unwell, so, resus (resuscitation), Triage 5 (T5) are those people that could potentially be looked after at urgent care or general practice? This is for walk-in patients now. It's not always black and white. Clinical conditions aren't black and white, but that's a general guide to triage.

"So, in the two periods that I referred to, we've had a 10% increase, Triage 1 to Triage 3 categories, another 499 patients. And we've had a 7.5% decrease in Triage 4 and 5, a reduction of 319 patients. Now, what that means is the likelihood of you needing to be admitted if you're a Triage 1 to Triage 3 case is obviously significantly higher than a Triage 4 to 5. So, just looking at the board, emergency department attendance numbers are interesting, but not probably nuanced enough. We've had a 4% increase in episodes of care. That's the admitted episodes of care.

"What's happening is we're getting an increase in acuity of patients presenting at our emergency department, which means we have an increased requirement for beds. When you've got a confined bed stock, and we've actually had all of the surge beds, that is, we open them for winter and close them for summer, we've had all the surge beds open for an extra month this year. And in fact, we've still got 14 surge beds open, and we'll probably keep those open now. I don't think we'll end up closing them.

"So, when you have an increase in acuity and, obviously, an increased bed stock, there are a few things you can do. You can improve your average length of stay, and ours has improved a Lismore, it has reduced from the previous year. And when you look at what's called the relative stay index, which is where you look at the complexity of the patients, if they were all staying at an optimal length of stay or a peer average length of stay, it would be a 1. Lismore is 0.98. So, the length of stay for the complexity of patients is pretty good.

"The challenge is that we have a far higher percentage of patients, even though we've got a good length of stay, staying longer than 20 days, and that's the elderly patients. That's because we haven't got enough aged care beds."

In terms of numbers, across the LHD from 2019 to 2023 there was an increase of 28% of patients staying longer than 28 days. For LBH, in 2019 13% of patients stayed greater than 20 days, and this increased to 22% in 2023.

"We're seeing an elderly patient cohort presenting more acutely, taking up more bed days, and we're having more increasingly challenged times in discharging them because we've got a shortage of aged care beds."

Ms Maisey provided more statistics to support these findings. Across the LHD aged care ratios are calculated at 60.1 beds per 1000 eligible population. Eligible population is defined as aged over 70 years for non-indigenous population aged over 50 years for Aboriginal and Torres Strait Islander population.

"If you calculate that for our population, we're 477 beds undersupplied. And, if you looked at where we were, I used some information for the Special Commission of Inquiry, in the first week of September, we had 61 patients across the district who were medically ready for discharge but weren't able to be discharged because they were waiting for an aged residential care place. That's remained steady over the last few months, but it's certainly gone up in the last couple of years."

With aged care places at an absolute premium, is it possible to look after some of these medically discharged patients at home?

"It absolutely is. Our preference is to, obviously, look after the patient in their home so they don't need to come into the hospital, but also to be able to discharge home at an optimal time. And in order for that, you obviously need to invest in what's called Hospital and Home and Community Nursing.

"We're just restructuring that service across the district, and we're bringing our Hospital in the Home and Community Nursing teams together to increase our capacity and capability in that service. And I think you'll start seeing some results from that, particularly in the Lismore area, in the next few months. And using modes like virtual care and remote monitoring and all of those technologies that afford us to be able to keep people well at home.

"There's only so much capacity to do that, though. We still need residential aged care places."

Residential Aged Care facilities in Australia are funded by the Federal Government and operated by approved providers.

Back to the LBH ED, if patients are staying longer because there is nowhere for them to go, you have trouble getting people in. Ms Maisey said, of course, they are not okay with this scenario.

"We're as upset about this as you would expect us to be. So, what we did in July was the director of clinical operations and I convened a whole of Lismore Base Hospital patient flow group, which includes clinical representatives from the emergency department, the wards, the patient flow unit, Allied Health, Hospital in the Home, mental health and drug, a whole range of people, to look at this issue. We looked at the data and looked at what we can do to continue to try to improve our statistics.

"There's been a range of interventions put in place, and we're starting to see some of the benefits from that. I think that's going to take a few months to do that. We've still got a high level of activity coming through, another 5.5% ambulance arrival.

"We need to improve our performance. As I said, we would have had all the surge beds closed now; I've agreed to keep open an additional 14 beds. We're looking at the ED beds, beds adjacent to the emergency department. We may look at opening those on a permanent basis to try to move the patients through. But Lismore Base Hospital only has so many beds. That's a short-term response to a medium-term issue. It is one of ageing, and it is one of demand, and it is actually one of general practice. We're very fortunate to have had the Goonellabah Urgent Care Clinic open, and, as I said, we've had a reduction in Triage 4 and 5 cases. We think that is attributable to that urgent care service opening."

When asked if having a clinic at the hospital is an option, Ms Maisey said she doesn't really want to bring primary care patients to a hospital.

"There's a range of models available. We have some co-located primary care and secondary care services; I'm not sure we need to have it at the hospital. I think what we need to do is have a comprehensive range of Primary Care Hospital and the Home Community Care Programs running so that they present to a general practice in a timely manner. And, they're able to be assessed and diagnosed in a timely manner rather than not being able to access primary care and therefore presenting to an emergency department in a more acute state. We need a strong primary care arrangement.

So, if there were a simple answer to this, we would have found it. We've got a lot of heads on this. I think having those clinicians leading that patient flow program, keeping some beds open, looking at the emergency department and investing in Hospital and Home and Community Care, we can probably turn it around. But it's not something I can just sort of wave a magic wand over and suddenly fix it. It's far more complicated than that."

Ms Maisey did offer another potential solution called 'Step-down capacity'.

"We need more subacute capacity. Ballina and Casino would be well placed to expand subacute capacity. As you know, those hospitals sort of work as a network now, and we'd have longer-stay patients at Ballina or Casino and our more acute patients at Lismore. But again, that's part of the planning conversations we need to have with our clinicians, our community and the government.

"It's a potential to look at, but we're far from putting those plans in place. We've got to have a lot more conversations with our geriatricians and clinicians and community before we do that. The reason I'm raising that is there is limited expansion space at Lismore, and as I said, there's already been quite a significant investment into Lismore. There just isn't the land, and there isn't the space, to be quite honest."

The significant investment into Lismore was the $312 million update, which concluded in 2023 when Stage 3 opened. The project was co-funded by the State and Federal Governments.

So, further expansion of LBH looks difficult, if not impossible. With an ageing population, health care for Lismore and the Northern Rivers situation will be a particular challenge for Tracey Maisey, the team at NNSWLHD, the Ministry of Health, and the Federal Government.

People visiting the ED will have longer wait times unless solutions are found and acted upon to free up bed space at LBH. An increase in Residential Aged Care Facilities and more At Home Care are needed sooner rather than later.