News stories about the Irish hospital system

Report highlights flaws in ED system

A new report has highlighted major flaws in the way hospital emergency departments (EDs) are operated and resourced that militate against the optimal provision of care.

It calls for increased hospital capacity to deal with ED pressure.

The report, from the Comptroller and Auditor General, found:

* Delays in access to senior doctor decision-making in 23 of the 33 departments around the country.

* Unsatisfactory access by the ED to consultation from specialties within the wider hospital in many cases.

* Unsatisfactory access to diagnostic testing in four EDs and delays in access to testing in most departments.

* Unsatisfactorily long waits for patients to be admitted following decisions to admit.

The report found a considerable differences in ED capacity and cost per attendance across the 33 A&Es around the country.

The number of patients handled by medical staff across emergency departments in the country ranged from 8.15 to 30.57 per day, while there was a major gap in the cost-range per attendance, from €85 to €281 per attendance.

The report notes that the new hospital consultant contract should extend the time senior doctors are available to make decisions on treatment and reduce patient waiting times.

However, it it says the HSE will have to monitor whether the service gain envisaged is achieved under the new arrangements.

The C&AG said a factor that needs to be addressed is restricted working arrangements in the diagnostic disciplines, that is health professionals involved in testing, such as x-rays. Current arrangements, the report notes, limit A&E access to these services at night and at weekends.

The report noted that in late 2007, the HSE set a maximum waiting time target for ED patients of 12 hours and in early 2009 it introduced a total waiting time target of six hours from registration to admission or discharge from the ED.

The study found that a comparison of the average waiting time for admission from EDs in January to May 2008 compared to the same period in 2009 showed there had been an increase of 5% in the numbers waiting 12 hours or more - 46% of patients were waiting 12 hours or more in early 2009.

The C&AG says having a comprehensive set of performance measures applicable to all A&Es would help drive performance and allow performance to be compared between departments.

The report says streaming of emergency cases and routing them through special clinics has the potential to improve ED efficiency. It says more rapid access initiatives would improve access to tests and treatment.

The report also calls for better organisation of hospitals through :

* Improved discharge planning.

* Increased hospital capacity through more day care same day admission and where necessary, increased bed numbers.

* More "step-down" beds in the community.

The report notes that some hospitals have begun initiatives improve patient flows and establish patient pathways through the hospital, but these good practices need to be replicated throughout the hospital system.

The C&AG says the provision of alternatives to acute hospital care through strengthening of primary and community care could reduce reliance on acute hospital EDs and beds.

The report also stresses that bringing plans to completion to reorient the management of long-term illnesses towards GPs and primary care will require a "robust change management programme" and implementation arrangements at local level.

The report says current out-of-hours GP services should be evaluated to assess their cost-effectiveness and whether they have the potential to reduce demand in A&Es.

It also points out that much more needs to be done in the current process of centralising emergency and complex acute care into larger hospital centres.

The HSE, in response to the report, the C&AG’s conclusions supported its strategy of modernising practices in hospitals and EDs.