Today’s question relates to a paramedic’s right and duty to report inappropriate practice within the aged care system. Today’s correspondent says:

I met with the Aged Care Quality and Safety Commission, as a paramedic, not as a representative of my jurisdictional service, regarding the practices of many RACF [Residential Aged Care Facilities] relying on ambulance or ED to attend to any catheter (SPC [Suprapubic Catheter] or IDC [Indwelling Urinary Catheter]) or Gastronomy tube (PEG [Percutaneous Endoscopic Gastrostomy]) issues. This practice can see significant delays in care, with the Aged Care Quality and Safety Commission saying that facilities need to provide these services on site and is part of their responsibilities.

Question

If a facility is not providing the required level of care due to a facility policy, let’s say a nursing home having a policy to not catheterise a male patient, simply because they are male, can jurisdictional ambulance service stop their clinicians from reporting these issue to the Aged Care Quality and Safety Commission or NDIS?

I think ambulance services forget the AHPRA code of conduct in such situations.

Health Practitioner Regulation National Law

I’m not sure of my correspondent’s jurisdiction so I will use NSW law as my example.  Registered health practitioners have an obligation to report ‘notifiable conduct’ by another health practitioner.  Notifiable conduct means (Health Practitioner Regulation National Law (NSW) s 140):

(a)        practising the practitioner’s profession while intoxicated by alcohol or drugs; or

(b)       engaging in sexual misconduct in connection with the practice of the practitioner’s profession; or

(c)        placing the public at risk of substantial harm in the practitioner’s practice of the profession because the practitioner has an impairment; or

(d)       placing the public at risk of harm by practising the profession in a way that constitutes a significant departure from accepted professional standards.

Where a nurse is employed in an RACF but doesn’t provide the relevant services because of their employer’s policy choices and therefore inadequate resources, then none of those provisions apply.  The RACF may be failing in its duties but the nurse is not engaging in reportable conduct.

Aged Care Quality of Care Principles (2014)

These principles are made under the Aged Care Act 1997 (Cth).  They require each provider to provide the services listed.  Part 3 of Schedule 1 sets out the care services to be provided to all residents who need them.  It says, amongst other things, that a residential aged care facility must provide nursing services (see [3.8]).  Nursing services are:

…  carried out by a nurse practitioner, registered nurse or enrolled nurse, or other professional appropriate to the service (for example, medical practitioner, stoma therapist, speech pathologist, physiotherapist or qualified practitioner from a palliative care team), acting within their scope of practice.

Services may include, but are not limited to, the following:

…

(b)       insertion, care and maintenance of tubes, including intravenous and naso‑gastric tubes;

(c)        establishing and reviewing a catheter care program, including the insertion, removal and replacement of catheters;…

On one argument, an RACF may say that calling an ambulance to have a patient taken to hospital to have their catheter changed is indeed the RACF ensuring that the service is provided. (Provided the RACF is paying for the ambulance transport etc. If it’s being paid for under arrangements to provide ambulance free of charge to pensioners, by Medicare or other arrangements then the RACF is charging the client for the service that someone else, ultimately the Commonwealth, is paying for!)

Assuming that it is a breach of the principles, what is a paramedic’s obligations?  The AHPRA code of conduct says paramedics must work respectfully with other health practitioners. It says:

5.1 Respect for colleagues and other practitioners

Good care is enhanced when there is mutual respect and clear communication between all health professionals involved in the care of the patient…

5.2 Teamwork and collaboration

Many practitioners work closely with a wide range of other practitioners, with benefits for patient care.

Effective collaboration is a fundamental aspect of good practice and teamwork. Good patient care requires coordination between all treating practitioners. Healthcare is improved when there is mutual respect and clear, culturally safe communication, as well as an understanding of the responsibilities, capacities, constraints and ethical codes of each other’s health professions. Working in a team or collaboratively does not alter your personal accountability for professional conduct and the care you provide…

Principle 6 says:

Practitioners have a responsibility to contribute to the effectiveness and efficiency of the healthcare system and use resources wisely.

Good practice under this principle includes upholding ‘the right of patients to gain access to the necessary level of healthcare, and, whenever possible, help them to do so’ [6.1(b)].   Paragraph [6.2] Health Advocacy says ‘… good practice includes that you use your expertise and influence to protect and advance the health and wellbeing of individuals, as well as communities and populations.’

It is therefore consistent with the Code to raise concerns, but it has to be done carefully.  Simply reporting an RACF to the Aged Care Quality and Safety Commission or NDIS may not be appropriate if there has not been an attempt to raise concerns with the RACF and understand if this is an issue of management choice or perhaps this day there was a particular staffing or other issue.  It may also impact upon the trust if RACF staff feel they cannot call for assistance when that is required. One can see that escalating concerns through the ambulance chain of command so that it is the ambulance service raising the matter with the RACF management and with the hospital – to bring the entire health service together – may be a better approach.

I also note that the Aged Care Quality and Safety Commission says “If you’re raising a concern or making a complaint on behalf of someone else, make sure they or their representative knows this. They have a right to know about your concerns and be involved”. That may mean if you want to report ‘we were called to transport Patient Jones to hospital for a service that should have been provided in the RACF’ you may need to speak to Patient Jones or their family first to let them know the concern; and they may be better place to raise the concern with the RACF or the Commission.

But the simple answer to the question asked is I cannot see how a jurisdictional ambulance service could ‘stop their clinicians from reporting these issue to the Aged Care Quality and Safety Commission or NDIS’.

It seems to me that the way they could come close to that is by a direction to employees not to report such systemic issues but to raise it through the ambulance service. An employee must comply with lawful and reasonable directions of their employer but to meet that threshold there would, in my view, need to be a policy and process by which the administration received the concerns and dealt with them.  A blanket ‘do not report’ would not be reasonable.  Clearly an ambulance service cannot stop its staff making mandatory notifications but as argued above, they are not likely to be relevant here.

Conclusion

An ambulance service could try to stop employees raising concerns about care provided by other institutions but that could only be reasonable if the service itself had a policy to receive those concerns from its staff and to raise them with the other service provider in order to enhance the use of health resources and appropriate patient care.

Even with that I don’t see how they could really stop a good faith report but such a report may be professionally problematic without some attempt to raise it with the RACF and other professional staff to understand the circumstances and to have the concerns addressed.

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.