University Hospital Limerick Niall Carson

Explainer: What is going on with overcrowding at University Hospital Limerick?

A major internal incident was declared at the hospital yesterday as it became overwhelmed by patient numbers.

LAST UPDATE | Jan 4th 2023, 11:30 AM

“INHUMANE”, “INAPPROPRIATE” AND, most strikingly, “national basket-case” were some of the terms used to describe conditions at University Hospital Limerick (UHL) yesterday, as trolleys mounted and overcrowding continued.

Difficult winter conditions at hospitals may have become commonplace across the country but doctors, campaigners and health oversight bodies have been highlighting “specific” concerns at the midwest hospital for some time, particularly over the past 12 months. 

A “major internal incident” was announced yesterday as UHL became overwhelmed with patient numbers.

The University Limerick Hospitals Group (ULHG) “activated HSE operational contingency plans with the National Ambulance Service (NAS) to divert some patients from UHL to other acute hospitals to support extreme levels of demand at UHL”.

Off-duty staff also received texts asking them to come in to try and plug the gaps.

The six hospitals in the ULHG are University Hospital Limerick; University Maternity Hospital Limerick; Nenagh Hospital; Ennis Hospital; Croom Orthopaedic Hospital and the city-based St John’s Hospital.

Meanwhile, the death of a teenage girl in December from meningitis, who allegedly spent a significant amount of time on a trolley at UHL in the hours leading up to her death, made headlines in the lead-up to Christmas.

The Taoiseach has been among those calling for Aoife Johnston’s death to be investigated. It’s understood the investigation is to begin shortly.

UHL management has said repeatedly that the hospital requires several hundred additional beds to try to meet the needs of an aging and increasing population, while campaigners have called for the return of 24-hour emergency departments to the local district hospitals. These closed in 2009.

Of the country’s hospital groups, the midwest is the only one not to have a Model 3 hospital within the wider regional hospital group, something which HIQA said was “of note” in a damning report it published on overcrowding at the hospital last year.

Model 3 hospitals can provide 24/7 acute surgery, acute medicine, and critical care, in support of the lead medical setting in each region.

The watchdog said it was “of note” that there is no Model 3 hospital in the University Limerick Hospitals Group, which “contrasts with the structure of other hospital groups in Ireland”.

In its report, it stated that it had significant concerns following an unannounced inspection at UHL, where it found the dignity and privacy of patients in the overcrowded emergency department was compromised.

The HIQA inspectors also found that the hospital was understaffed, which posed a significant risk to patient safety.

‘A very significant mistake’

One senior doctor, tracing how the hospital reached this point, claimed the origins of the crisis lies in “a very significant mistake” made when it was decided to close the emergency departments at three local hospitals in Limerick, Tipperary and Clare in 2009.

This made UHL’s emergency department the only remaining point for admissions.

Professor Declan Lyons, who was one of 14 consultant doctors who wrote to hospital management in Limerick in July over concerns for welfare and safety of patients and the reputation of the hospital, told RTÉ Radio One this morning that some problems affecting healthcare in Limerick are separate to winter surges.

“Unfortunately, we’re in the unenviable position where we’re almost characterised as a national basket case at this stage,” he said.

He outlined that the issues date back to around 2009 when the medical reconfiguration of hospitals saw a “very significant mistake made at that time when direct access to Ennis, Nenagh and St John’s Hospital for emergency care was withdrawn”, which took place following a review which found those hospitals could not provide critical care safely.

“And so from that point on, huge numbers of patients which normally would have gone to those hospitals were directed to UHL,” he said.

Only about 5% of all medical and surgical patients occupy critical care beds, according to Prof Lyons, meaning the challenge is then to “direct those patients that you think might need a critical care bed to UHL, but at the same time directing all other appropriate patients to their local hospitals”.

He said the “chronic and persistent overcrowding in the emergency department” had created conditions that were in many instances “inhumane”, and not appropriate for the evaluation of patients, with trolleys often “crammed” beside each other, as staff compete for space around each.

He described it as a “very serious situation in terms of patient comfort, but also in terms of patient safety”, as it “simply isn’t possible to carry out an optimal clinical evaluation on patients given the extent to the overcrowding” in the ED.

His words were “validation” for Marie McMahon, a Clare woman who founded the Mid West Hospital Campaign group following the death of her husband Tommy in 2018, who she said spent some time on a trolley before dying.

It was very refreshing to hear him saying this because we were constantly being told that the hospital management and consultants knew what was best for us when spoke up. The services have got worse and worse.

Management at the hospital have called for at least another 200 beds to meet present demand.

According to HIQA, the hospital has an inpatient bed complement of 530 beds, 98 of which were added in late 2020 and early 2021, and 149 day case beds.

No longer meeting demand 

Speaking on local radio in Limerick, Chief Clinical Director of UL Hospitals Group Professor Brian Lenehan said the ED was no longer meeting demand in the region.

“When the new emergency department was opened in 2017 the planned capacity at that stage was for 190 patient attendances per day. We have seen up to 290 attendances a day, and we have seen sustained attendances at over 250 a day,” Prof Lenehan said.

“And that does not include the volume of patients that are seen in our local injury units and our medical assessment units in Ennis, Nenagh and St John’s.”

He said that almost 80,000 patients attended UHL’s ED in 2022, which was “the highest number of any emergency department, anywhere in the country”.

Figures published by the Irish Nurses and Midwves Organisation showed that almost 100 patients (97) were waiting on trolleys at UHL yesterday.

Problems have been flagged for some time, whether by HIQA, campaigners or by the INMO in July 2021 when it called for intervention at the hospital following major overcrowding.

Upgrading local hospitals

Conflict exists around the best long-term route out of the crisis. Campaigners stress that the solution is to reopen the EDs at each of the three smaller hospitals dotted across the region, thereby easing the flow of patients into UHL.

However, the UHL Hospitals Group has maintained that the best course of action is providing more beds around the main Model 4 site in the city.

The University of Pittsburgh Medical Centre, best known as UPMC, is planning a private medical centre in Coonagh on the Clare-Limerick border, which it is hoped could alleviate some pressure. 

However, McMahon cautioned that some campaigners would prefer to see a “public option”.

A 60-single bed block, and a 24-bed ward for haematology and oncology patients, came on stream at UHL during the Covid-19 pandemic.

According to campaigners, there had previously been plans as part of the 2009 reconfiguration for another hospital co-located beside the University of Limerick, which would provide bed capacity required.

Noeleen Moran, a coordinator of Mid West Hospital Campaign, said this fell away as investors withdrew because of the economic crash.

“So the investors pulled out, the beds never arrived and the people lost three hospitals. The problem has just kind of grown from from that,” she told this publication.

Hospital response

In its response to last summer’s HIQA findings, the hospital said it would implement a number of short, medium and longer term measures to ease overcrowding.

Among the latter measures was “to explore the provision of a Model 3 hospital” to
support the model 4 UHL.

Mid West Hospital Campaign members such as Moran told The Journal they believe this suggested was “rowed back on” when the hospital group’s management team came before an Oireachtas committee last September.

Colette Cowan, the chief executive, told politicians that upgrading the likes of Nenagh or Ennis was a “difficult question” because they would require “specific resourcing” to ensure they could deliver more specialised treatments.

The chief clinical director, Lenehan, was more blunt. He “does not believe” that the existing model 2 hospitals are “in a position to be upgraded to model 3 hospitals”.

This was due to significant infrastructure and staffing requirements and significant capital and resourcing costs, he added.

Cowan said the elective hospital at Coonagh would assist UHL, but reopening emergency departments at other sites would see “safety issues concerning care” for patients.

She said: “For example, if as a member of the public I went to Nenagh hospital clasping my chest with a heart attack, I would like to know I was going to a cardiologist who stents every day of the week. That would not be the case in Nenagh hospital.

“We have to regionalise some very specialist disciplines, such as cardiology, in UHL.”

Teenager’s death

Meanwhile, a serious incident management team has been established to conduct an investigation into the care provided to Aoife Johnston, (16), from Cronan Lawn, Shannon, Co Clare, who died on Monday 19 December from menigitis in University Hospital Limerick. 

Aoife Johnston, from Cronan Lawn, Shannon, Co Clare, was struck by the illness and it has been reported that she spent a significant amount of time on a hospital trolley.

Speaking to RTÉ’s News at One yesterday, Professor Lenehan said the incident will be investigated in line with national HSE policy. 

The family of Aoife Johnston and those involved in her care will be involved in the review, he said. 

Also yesterday, the INMO said that over 931 patients are without beds in Irish hospitals.

This is the highest number of patients that have been without a hospital bed since the trade union began counting trolleys in 2006.

Phil Ní Sheaghdha, General Secretary of the INMO, said: “Today’s numbers require immediate and serious intervention from the government.”

The HSE also appealed to members of the public to “consider all care options before going to a hospital Emergency Department (ED) during what is going to be “one of the busiest ever periods experienced by the health service”.

It comes as Covid-19 and influenza cases continue to increase rapidly, while notifications of RSV – which had been declining for several weeks – are also increasing.

With reporting by David Ralaigh, Órla Ryan, Niall O’Connor and Hayley Halpin

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