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EDs - welcome to my (third) world
[ by Niall Hunter, Editor www.irishhealth.com]
Following emergency medicine consultant Mr John McInerney through the busy emergency department of Dublin's Mater Hospital, prior to interviewing him in the quieter confines of his office, you notice a number of things.
Basically, it's the human picture behind the shock horror headlines of our still broken health service: patients on trolleys, patients on chairs; patients on ambulance trolleys. And, not visible today but sometimes, Mr McInerney says, patients being treated on the floor.
A new low, if you'll pardon the macabre pun.
This is a far cry from the brave new health service promised by the current Minister and (repeatedly) by his predecessors. It's a health service capacity problem that has been with us for decades, through economic booms and busts, but it's a problem that no politician or health manager, despite oodles of bluster and spin, has appeared able to get a handle on.
But it's the current grim reality in the Mater, which is, like many other hospitals, trying its best to meet increasing treatment demands as resources dwindle, or are simply invested in the wrong places.
John McInerney says he has supported James Reilly's current initiative to reduce ED waits, with its emphasis on hospitals doing things more efficiently in return for targeted resources.
But, he says, there's a limit to how 'leaner' you can manage things. Eventually you become as lean and efficient as you can, and then what? Well, sick patients keep on turning up, and you need more resources to cope with the demand.
And, by the way, the health service is broke, as well as broken.
On this particular Wednesday afternoon, at around 2.30, there are, says John McInerney, 30 patients waiting for a bed on trolleys and chairs in the Mater's ED. Four patients remained on the ambulance trolleys they arrived on, as the ambulances that took them to the ED waited outside in the courtyard.
"The ambulances have to wait for the trolleys to be returned to them so that they can go back into service, Other trolleys are being used at present and a few of our patients are on chairs."
Says Mr McInerney: "It is obviously easier to treat patients on trolleys than on chairs and we have had situations where we have had to move patients who have been on chairs to the floor of the ED for treatment if their condition worsens and we cannot put them on a trolley."
"This is Third World medicine, it's intolerable for patients and their families and it partly explains why it is often difficult to get staff to work in EDs."
"It is simply soul-destroying when you come into work in the morning and you see the same patient on a trolley who you saw the evening before but who is still waiting for a bed and they look at you..."
John McInerney, who is secretary of the Irish Association for Emergency Medicine, says the kernel of the current ED overcrowding problem in many hospitals is lack of access for ED patients to inpatient beds and this is usually caused by the fact that many of these beds, often as many 90-100, can be taken up by delayed discharge patients.
These are usually elderly patients who are finished their acute care and who need to be discharged to alternative care, such as private or public nursing home beds, transitional beds, or home care packages. Unfortunately, he says, the funding tap for this type of care appears to have been turned off.
"I would certainly agree with the nurses union's contention that bed closures, particularly community bed closures, are having a negative effect on hospital capacity."
Mr McInerney reckons there are 90 delayed discharge patients in the Mater at present and other major hospitals would have similar numbers. It can take at least 30 days to find suitable alternative care for these patients.
"One patient admitted to an 'overnight' ward here has now been here for 50 days," he says. "So it isn't really surprising that in the Mater today we have 30 patients in ED who need admission but are still waiting."
"The early part of a week after a bank holiday is always busy. You might see 200 patients in a day and 30 to 40 of them might need beds; unfortunately they are now left waiting due to a shortage of capacity."
He says among the reasons for increased pressure recently on the Mater's ED is the closure of public elderly care beds at nearby St Mary"s Hospital in the Phoenix Park. Also, the Mater's patient population is getting older and sicker and in need of more care.
"In a way medicine has become the victim of its own success. People are living longer than before, but this means they need more care as they get older and sicker. Another factor, I would say, is that people are giving up their health insurance, having to wait for treatment and often end up in EDs."
Mr McInerney says he welcomed the establishment of Minister Reilly's SDU, tasked with cutting trolley waits.
"However, I would currently find it hard to see as attainable the Minister's target to have all patients attending EDs admitted within nine hours of registration. We are a long way off this target right now- we seem to be moving backwards.'
"Last year, the SDU pumped funding into the Mater and some other hospitals to ease pressure on their EDs. They said we will give you more money to discharge more patients into the community if you change the way you work and work more efficiently."
Mr McInerney said hospitals largely complied with this in return for funding, "but there is only so much 'lean mangement' you can achieve. Eventually it will come down to needing more resources to sustain any reductions in ED overcrowding."
He says the SDU needs to find funding to invest in community facilities to help reduce delayed discharge patients who are finished their acute care, and thereby ease pressure on EDs.
"The HSE's Acute Medicine Programme, under which GPs can refer acutely ill patients to acute medical units (AMUs), has helped divert some patients away from EDs. However, we still have the same exit problem - people in AMUs may also need to be discharged to non-acute care, which might not always be available."
Mr McInerney feels that culturally in our health service, there has been a chronic acceptance of ED overcrowding and delayed discharges, and this needs to change.
And the grimmest legacy from our long-lasting crisis is the simple fact that many people die unnecessarily in EDs, as we saw in HIQA's recent Tallaght report.
John McInerney says extrapolating international studies to Ireland, his Association estimates that up to 400 patients may die unnecessarily in our EDs each year as a result of overcrowding and its inherent risks. The grim message is many patients will increase their risk of getting sicker and dying unnecessarily the longer they remain in an ED.
He says these risks may be mitigated somewhat by the 'Full Capacity Protocol' practice of moving ED trolley patients onto wards, which is implemented in some hospitals, but not at the Mater. This, he believes is the lesser of two evils for ED patients, but is not an ideal solution.
Mr McInerney believes there are longer-term solutions to our ED crisis. He points to the largely positive example of the reorganisation of cancer services in recent years.
"Most cancers are now dealt with as quuickly as possible but in EDs we are often seeing patients with very serious conditions like arthritis because they have been waiting over a year for treatment. If they can succeed with cancer services they can do the same with emergency medicine. We need an ED "Tsar' in the same way that we have had cancer 'Tsars'."
John McInerney accepts that there are major financial restrictions on the health service, but believes the money could be spent better and moved from elsewhere in the service to improve the ED situation.
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