Tallinn Emergency Medical Service (TEMS) reported on Tuesday that from 2 p.m. onward, ambulance operations in Tallinn were severely disrupted, which they attributed to PERH's reduced capacity to accept patients from ambulances. An estimated one-third of ambulance crews serving the city of Tallinn ended up waiting in line, and were unable to respond to their next calls.

PERH ER chief physician and director Vassili Novak told ERR that difficult situations cannot always be predicted nor additional resources preemptively planned. Regarding Tuesday's events, he stated that PERH's capacity was certainly not reduced.

"Our capacity was as usual, and we were operating at full throttle," he explained. "The entire on-call team at the hospital has always worked practically from morning until late at night to care for all the patients that have come in on their own or arrived by ambulance." Priority, he added, was given to patients requiring urgent care.

He emphasized that the issue was definitely not due to more doctors being on sick leave or an unusual work schedule.

"The on-call team was fully staffed, and everyone scheduled was at work and staffing their respective posts," the ER chief said.

"What limits us to some extent is the number of beds. The reason an ambulance may have to wait in the ambulance bay, meaning our garage, at all before handing over a patient is because that patient needs a bed," he continued. "And if all of our beds are occupied for one reason or another, then the new patient arriving by ambulance inevitably has to wait until a bed becomes available, and then we can take over."

According to Novak, they see around 20 days a year like Tuesday. Regulations stipulate that ambulances must provide assistance to patients with urgent problems within 15 minutes, and regular patients must be accepted within 30 minutes.

Although lines can end up forming in exceptional circumstances, Novak insists that no one was left without care. He confirmed that everyone who required urgent care received it, and that no patients were at risk.

He did, however, acknowledge that eight severe traumas is indeed extraordinary, and that August is also vacation season.

"I must indeed admit right now that we [workers] didn't have many opportunities to call in additional staff from vacation, but since we managed to ensure that all patients with urgent issues quickly received care and the rest who could wait were attended to as soon as possible, and the situation had fully resolved by evening, then I don't see that there was a huge need to do so," the ER chief said.

If it had been apparent that the situation was deteriorating further, with the line continuing to grow and existing resources not being sufficient to help patients in need of urgent care, Novak confirmed that he would have of course activated their crisis plan.

This plan involves calling in the entire hospital staff in a mass casualty situation, but certain conditions need to be met to trigger it. The decision is made by a dedicated crisis management team.

Nevertheless, Novak admitted that changes are needed in the future. He also noted that if there is interest in scaling up on-call teams, that begs the question of where the resources to do so should come from.

"There aren't even very many medical professionals seeking work on our job market," he pointed out. "We already have to work hard to fill our open positions."

He added that increasing the size of the team also requires greater financing from the Estonian Health Insurance Fund (EHIF), and whether this can be done that quickly is dubious. The same bottlenecks involving beds remain as well: PERH's emergency department was built in 2009, and there currently aren't enough beds there.

"Is it possible to quickly create a PERH ER-2? Probably not," the ER chief said. "But we're thinking about plans, making offers and it seems we'll have to discuss things further and make some kind of decisions regarding how to reduce such situations in the future."

Health Board: Additional crews weren't necessary

According to Health Board director general Birgit Lao, the Health Board has an on-duty crisis staff, and communication with this staff was really good on Tuesday.

By 3:30 p.m. that day, TEMS' field manager had already contacted the board, informed them of the situation and personally went to PERH to assess the situation and relate information.

Even so, Lao also emphasized that what happened Tuesday was not a continuity-of-care disruption – patients of all different categories received care.

"The Emergency Response Center was also involved and directed ambulance crews," she noted. "If the ambulance service gets the feeling and has concrete information that there aren't enough ambulance crews to handle the necessary extent of calls, there is a system in place to notify the Health Board, and we can confirm the need to deploy additional crews."

At that point, she added, additional ambulance crews can be deployed within the hour.

On Tuesday, TEMS did not consider this necessary, and so no additional crews were mobilized.

According to Lao, however, the hospital can always deploy additional beds, which it did, and the hospital can assess whether it's possible to transfer lower-category patients to other hospitals, which it did as well.

Asked whether TEMS could have taken patients to some other hospital's ER where there were no lines, the Health Board chief replied that when the Emergency Response Center receives a call and the caller states that they need assistance, the urgency of the call is then assessed based on the information provided by the caller. PERH handles critical patients, burns as well as severe multiple traumas.

She noted that if it indeed happens as it did Tuesday that eight patients with similar symptoms all have to be taken to PERH, then lower-category calls are automatically redirected to East-Tallinn Central Hospital or West-Tallinn Central Hospital and, if necessary, even to county hospitals. The last of these requires special authorization to do, but she said that on Tuesday it wasn't necessary.

Lao described Tuesday's incident as a logistical task between the ambulance service, hospital and the Emergency Response Center, which could always stand to be improved.

"Information must always flow through the correct channels, and in fact it's always possible to request additional help if there's a feeling that a patient's needs cannot be met," she stressed.

Asked whether this recent situation was more of a communication crisis and whether the healthcare sector doesn't plan on making any changes, the Health Board director general replied that change is always welcome.

"But in terms of communication, the info we received from TEMS and in great cooperation with their field manager, we managed to resolve the issue," she added.

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