Mid-west hospital chief defends revamp plan

  • Niall Hunter, Editor

The consultant heading up the hospital service reorganisation project in the mid-west has rejected claims that the plan is not being resourced properly.

Critics of the plan have expressed concerns that vital facilities are not being put in place to accommodate the changes, which include the ending of 24-hour A&E services at Ennis and Nenagh Hospitals from April.

However, the project director, consultant surgeon Mr Paul Burke, told irishhealth.com he rejected claims that adequate resources were not being put in place to deal with the transfer and reconfiguration of services in the mid-west.

He said provision had been made for beds and other hospital facilities, ambulance cover and consultant manpower to deal with the changes. Mr Burke said the remaining local minor emergency units at Ennis and Nenagh will have longer opening hours at the weekend to deal with any additional workload.

Mr Burke says there were a number of major components to the hospital changes planned for the mid-west, many of which were recommended in the Teamwork report of 2008.

"Firstly, we are reconfiguring acute surgery services which, along with critical care services were originally identified in the Teamwork report as being disparate and spread out across the region and needed to be centralised as soon as possible. That was the primary message in Teamwork"

"Also, it was felt that the emergency care service arrangements that existed in Ennis and Nenagh, with emergency care physicians running these services without direct responsibility to any overall supervisor in the region, were unsatisfactory and unsustainable."

In addition, Mr Burke says, there were risk factors identified with regard to paediatrics, obstetrics and trauma being treated locally. It has been agreed that all trauma, paediatric and obstetric emergencies from now on will not be brought to local hospitals in the region but will go directly to the Mid West Regional Hospital (MWRH) and the regional maternity unit in Limerick.

"For example, if a child is born and is in respiratory distress, the anaesthetist might not be on-site to deal with such cases. There are already excellent anaesthetists there but they have been on one in two rotas for the past 25 years and when they retire it might not be possible to provide the same level of service with replacements within the new hospital framework. Also, currrently they may be replaced by locum staff when they are on rest days at weekends, and with paediatric emergencies there may be risk issues involved."

"It was clear there had to be more rigid enforcement of bypass protocols for trauma, obstetrics and paediatrics, and once these are signed off on the issue of A&E can be dealt with."

Mr Burke says in Nenagh, between for example, between 8pm and 8am, ED attendances are low.

"You might have seven or eight cases. Two of them might be medical cases which should not go to A&E and should be sent by the GP to medical assessment unit. The rest of cases are either minor injuries or the type of case you would expect to be dealt with by the out-of-hours GP service. Some cases might be 999 calls."

"As soon as the ambulance service are at a level that they need to be at, the A&E changes will be put in place. Additional ambulance availability will be needed and this should be in place within the next two months."

Prof Burke says when these are in place, local emergency services will close their doors to walk-in referrals and minor injuries (minor injuries and accidents) after a certain hour.

"The hours of opening at the local hospitals will vary depending on the time of the week, but there are likely to be longer opening hours at the weekend. We are looking at tailoring hours to demand but it will be a minimum of 12 and a maximum of 14 hours of opening for walk in-cases and minor injuries. Outside these hours, these cases will have to go to Limerick. Many of these would already do so anyway."

Prof Burke says it should be stressed that all GP-referred medical emergencies will still be seen at Ennis and Nenagh Hospitals on a 24-hour basis and processed through medical assessment units.

He said the plan provides for separating A&Es in Ennis and Nenagh into separate medical assessment and local emergency units by early April, at which time the current 24-hour full A&E service at Ennis and Nenagh Hospitals is due to end.

"There will be no emergency surgery in Ennis, Nenagh and St John's Hospital in Limerick after July 1."

"We are trying to promote best practice by having direct GP referral to emergency team on-call. We plan to tighten up communication between GPs and senior medical staff in the local and regional hospitals."

Mr Burke has rejected some of the concerns expressed about the provision of services as a result of the changes planned.

"I do not really accept what has been claimed. I think one has to look at everything against a background of economic reality and against the background of change. People have said we are doing it in a piecemeal way. I don't accept that. In terms of financial commitments there is an absolute commitment to build a critical (intensive) care block in Limerick Regional. We expect that to be approved and it should be in place at the end end of 2010. The changes that need to be put in place are being put in place."

He claims moving services will not cause resource problems. "The only resource that is moving is emergency surgery. We will need an emergency theatre in Limerick, and this should be ready in mid-July. We should also get extra beds for emergency surgery by freeing up beds not currently in use."

"Overall, the primary motivation for the reconfiguration is safety - that remains the primary motivation for the project."

Mr Burke stresses that part of the reconfiguration of services involves bringing as much care as possible closer to the patient. "A lot of elective work will be done locally. We will be bringing in new services - day surgery will be done in Ennis, Nenagh and St John's in Limerick, and there will be outpatient services in these hospitals.

"As regards emergency consultant manpower in Limerick and new A&E, the impact of centralising emergency services in Limerick wil not have a significant impact on the ED at Limerick because we will be sending in acute surgery. These cases will go to the surgical assessment unit and not the A&E."

Mr Burke said two additional emergency medicine consultants are in the process of being appointed to Limerick, and will come on stream within the next three months, bringing the total in Limerick to five.

He accepted that there is an issue regarding the need to upgrade Limerick's A&E unit. "The new ED is an ongoing issue. There is no question that a new ED with larger space is needed, but I would emphasise again that changes being put in place at the moment will have little impact on Limerick's A&E."

"We would hope that by developing and concentrating on medical assessment units we will move many patients away from emergency departments."

Mr Burke said as part of the new model of care, to facilitate additional emergency surgery patients coming to Limerick, a new admissions/discharge process will be introduced to make sure that patients are not kept too long unnecessarily in hospital and can be discharged as quickly as possible back to their local service.

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