'Beds not the solution to ED crisis'

[ by Niall Hunter, Editor www.irishhealth.com]

The Chief Medical Officer of the Department of Health there needs to be a much greater focus on reducing outpatient waiting lists in hospitals.

And Dr Tony Holohan  believes solutions to chronic overcrowding  problems in emergency departments should not involve simply increasing bed numbers.

In an interview with irishhealth.com, he said better quality information on the exact extent of the outpatient waiting list issue is needed.

 “We need to focus on outpatients more as an issue. Inpatient waiting times have for the most part been improving because there has been an organisational focus on making that improvement.”

 “Now we need a substantial emphasis on doing the same in relation to outpatients and I am confident that we will see improvements at that level.”

 He agrees that the data on the extent of the outpatient problem is poor. The HSE produces no official figures on overall numbers waiting. The Comptroller and Auditor General last year reckoned there were around 175,000 people on outpatient waiting lists at the moment.

 “Yes the information is poor. We have a very good information system for inpatients but we need to strengthen our information on outpatients.

Asked if there could be even more than 175,000 patients on lists, he said that remained to be seen through verification of lists by the HSE. “There may, for example, be people on more than one outpatient waiting list for the same issue so all of those information issues need to be ironed out before we can say truly what we are dealing with.”

“It is up to the HSE to outline how this plan will work but I am well familiar with what is planned and I know there will be plans in place by about mid-year.”

On trolley waits, Dr Holohan says this does not necessarily indicate that there are too few beds, but that there are too many people on trolleys.

“That is not acceptable to me, or to the Minister or anybody.”

He says there are a number of different solutions to the trolley issue that do not involve increasing bed numbers.

“In the mid-west, for example they are developing a ‘boarding in’ policy where patients for whom a decision to admit has been made are moved in certain circumstances onto the wards.

Dr Holohan admits that nurses and consultants have clashed on whether this is a safe and workable policy, but he is in agreement with it.

“In terms of safety, the infection control issue would give me greater concern in the actual emergency department, where there would be large numbers of patients all together. The level of morbidity and morality has been shown to be greater in emergency departments than on wards. Overall, there are a number of ways of tackling the trolley wait problem and it isn’t just about providing extra hospital beds.”

He says another factor will be that the Fair Deal scheme will more appropriately accommodate “delayed discharge” patients and free up more beds, thereby reducing trolley wait pressures.

On the shift from less reliance on hospital care and greater reliance on primary and community care,  Dr Holohan says this was always going to be a very long-term process.

 “A lot of progress has been made in some areas but there is still quite a way to go. Primary care is an area that is being prioritised in another wise challenging (financial) environment.”

 But is reducing bed numbers before the proper primary/community care system is bedded in not a case of putting the cart before the horse?

“There is no question that our reliance on acute beds is something that has to change. There are probably significant numbers of hospitalisations taking place that are unnecessary. “

Dr Holohan says more flexibility is needed in the system to allow staff to be concentrated more in primary care-based services rather than in-hospital care. “Taking beds out of the system is in a sense a way of achieving that.”

Asked if we do not have a hospital bed shortage right now that needs to be addressed, Dr Holohan points out that the bed capacity report of 2008 found that in excess of one-third of people in hospital on a given day did not need to be there.

 “They were there, for example, because the should have been discharged earlier, they being admitted too early for surgery or did not have access to ambulatory diagnostic tests. All those type of problems can be tackled in such a way so as not to require the number of beds we have at the moment.”

“At the sharp end of this is the work Barry White, the HSE’s director of quality and critical care is doing in relation to new programmes for treating stroke, heart failure and other chronic conditions. These would be patients who are heavy utilisers of hospital services, but we are capable of reducing that reliance if services are configured differently. So, for example, you can put in place services that will reduce the risk of people getting strokes and that will allow you to take pressure off hospital services.”

Asked if it was not overly ambitions on the part of the HSE to try and implement such a radical change this year and reduce beds further on the back of it, Dr Holohan said that is the commitment that has been made.

“It is up to the HSE to outline how this plan will work but I am well familiar with what is planned and I know there will be plans in place by about mid-year.”

On MRSA and other healthcare infections, he says our health system has an issue with these infections just as every other developed health system has.

“We have been making strides here – the incidence of MRSA and other healthcare-associated infections(HCAIs) has improved and the HSE is getting on top of this problem.”

On obesity and other lifestyle risk factors as a threat to the nation’s health, Dr Holohan believes i a combination of regulation and education is the key.

“It is a little of everything. Regulation has been effective in relation, for example, to tobacco and the smoking ban but on its own regulation is not enough. Education also is not enough on its own. We need to be doing all these things in concert.”

Dr Holohan says, however, our smoking rates are still too high, and this will ensure we have a significant problem with lung cancer and heart disease well into the future.

“In addition, our alcohol consumption patterns are probably the highest in the EU and are cause for concern.”

Obesity, he says is just another example of the many risk factors endangering the future health of our nation. These factors are leading to a major emerging problem of increased chronic disease.

“This is something we are going to have to find a way of tackling.  As  a society the various risk factors are increasing the number of cancer cases each year by 5% and something similar for cardiovascular disease.”

 

badger5079  Posted: 22/07/2010 23:25

The main reason that the general public objects to being stuck in the Emergency department are the lack of privacy, the general mayhem and noise, the presence of multiple vomiting, shouting drunks, the smell of faeces and urine and vomit, the lack of room for relatives to comfort them and the perception that medical treatment doesn't begin until they are on a ward. My solution for the lack of privacy is that they should be sent to a ward once the decision to admit has been made. Ideally, the consultant should be available all day and night to review patients and send them home if necessary. The cost of admitting patients to a ward and discharging them is considerable in terms of paperwork and medical exams. Hospitals are trying to bring online a system where newly admitted patients can be assessed by a senior doctor (ideally, the consultant on-call) who can make a decision to discharge to GP or follow-up in the outpatients. Howver, the medical personnel department will not provide the extra nurses to staff these wards so the nurses won't support the idea. Also, many consultants refuse to come in to the hospital after 5 p.m. unless somebody young is in a life or death situation that absolutely requires their input. Many of them won't therefore be able to see patients at 9pm and decide to discharge them so they end up staying overnight and not getting out until the next afternoon at the earliest.

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