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Opinion Older people being cared for on trolleys rather than beds is an all-year-round issue

RCSI’s Dr Seamus Cowman looks at the issues around the healthcare of older people in this country.

AS THE ACCIDENT and Emergency trolley crises fade from front page news, how quickly we forget the healthcare crises of the winter, with an impending fear that nothing will be done, and expectation that the same will happen next winter.

Elderly people always appear to be the citizens most affected by a health crisis. The Covid-19 pandemic had a profound impact on elderly people, with almost 30% of all deaths occurring in nursing homes. Analysis from an age perspective shows that 42% of all Covid-19 deaths were of persons over 85 and over, 75% in persons aged 75 and over, and 91% in persons aged 65 and over.

In some residential homes, almost 50% of the residents died. In recent years there have been revelations and investigations into poor standards in some of our elderly care facilities. Each year the winter bed crises have worsened, and this year, the annual winter bed crises are the worst ever, with daily harrowing reports of sick elderly lying on trolleys, and in need of hospital admission, including some elderly people on trolleys for more than 50 hours.

Our record

Earlier this year, we witnessed allegations of a containment strategy by successive governments to manage legal redress from people seeking claims for private nursing home care, which they paid for, due to a lack of a public bed, which the elderly person was entitled to.

In any civilised society, the management and care of our most vulnerable elderly people is a significant benchmark of group identity and culture.

In Ireland, people over 60 or older represent 1 in 4 of the population of adults and the population of aged 65 and over is projected to double to 1.6 million by 2051. It is estimated that in Ireland by 2031, more than a quarter of a million people will be over 80 years old.

In recent years, the challenges in providing adequate health services to elderly people provides sufficient evidence, that the system is not working satisfactorily, and justifies the need to develop a new strategy with restructuring and planning for elderly care in Ireland. The immediate formation of a national committee/task force by the Minister for Health can be the first step in determining a new direction in the delivery of elderly health and social care services.

The restructuring of health and social care to elderly people will make an important contribution to solving the annual bed and trolley crises.

We do not seem to learn the lessons of the past. In today’s health services, elderly patients being cared for on trolleys rather than beds is an all-year-round problem, which becomes much worse during the winter months. It is a predictable event each year, and unfortunately, it places politicians, policymakers and health administrators in a position of conflict with the health professions. With a health budget allocation of more than 23 billion, the annual winter bed crisis is an unacceptable outcome of poor planning and inappropriate use of resources.

Challenges of care

Caring for a sick elderly person in a hospital bed is challenging at the best of times, particularly in trying to prevent the multiple complications of bed rest. Such complications can include pressure ulcers on bony prominences such as heels, sacrum and elbows; loss of muscle tone; contractures, degeneration of joints and chest infection.

Maintaining fluid balance in an elderly person, is essential, in order to prevent urinary tract infections. In wards, caring for elderly people, there are many special appliances used and nursing actions taken to prevent complications of bed rest such as a special mattress, an exercise regime, fluid balance and more.

It is extremely difficult, or even impossible to provide such a standard of care to an elderly person on a trolley. Besides inadequate prevention of complications, there are additional risks related to safety, infection control and prevention.

The psychological effects on the family, and in particular the elderly person of lying on a trolley in a busy Accident and Emergency Department of uncertainty, noise, and a lack of dignity, is stressful and demoralising. A view frequently expressed by families of elderly people, is that they are ‘bottom of the pile’. In redirecting and reforming elderly care services, there are a number of critical areas which if planned and implemented could have positive outcomes for care of the elderly.

In the first instance a national committee/task force must be formed, by the minister for Health, which should include the health professions, the HSE, Department of Health, nursing homes and other sectoral interests. Planning for care of the elderly must incorporate short term and long term objectives.

The first task is to review the existing services and identify the deficits in particular the lack of seamless services between hospitals, nursing homes and community care. There is a consensus that an essential outcome is the identification of care pathways between hospitals and all community care facilities, nursing homes, including home care.

Capacity building, human and financial resources are fundamental issues in forward planning.

The Covid pandemic created the case for a review of structures and a recalibration of governance, resource allocation, the mix of public and for profit care arrangements, quality assurance, manpower and skill mix, and these must be central themes for discussion and planning.

A review and profiling of all elderly care institutions, including infrastructure, facilities and their use is an important step. A major problem in the care of the elderly institutions is the lack of equipment and expertise to manage even minor individual patient health issues as they arise, with a resultant transfer of the elderly patient to an acute hospital, where they end up on a trolley. From the range of available care of the elderly facilities, there should be an assessment with the objective of identifying institutions whose infrastructure can be upgraded to provide extended services to sick elderly patients who previously would be sent to the acute hospital.

The availability of medical equipment such as oxygen and suction and ventilation support and administration of intravenous fluids is essential. Agreement on treatment protocols for individual patients in discussion with next of kin. HIQA should be given a particular brief to overview the newly extended facilities.

A review of staffing and skill mix is essential in care of the elderly healthcare facilities. Care staff form the majority of staff in institutional elderly care facilities, and a plan to increase the number of nurses and medical staff must be part of future plans. Care of the elderly has been an unpopular work speciality among the health professions. Changing such a perception will require a look at health culture.

This is a challenge and new initiatives should be taken through medical and nursing regulatory bodies and the HSE to promote and incentivise staff to work in elderly care. This will be important in the configuration planning to develop acute specialist services within the confines of the elderly care institutions.

An enhanced staff development, specialist and continuing education, in elderly care will help retain staff in the speciality of care of the elderly. Many of the elderly people who end up in the Accident and Emergency department suffer from chronic illness, such as COPD/bronchitis/pneumonia, heart failure and diabetes exacerbations. This could be prevented and reformed through commitment and funding to establishing a cadre of Advanced Nurse Practitioners in chronic disease management and elderly health.

This can be a central pillar in establishing appropriate treatment and retaining the sick elderly person in a care of the elderly institution, rather than sending them to the hospital Accident and Emergency to lie on a trolley. A restructuring of elderly care services can contribute directly to solving our annual winter bed crises, however failure to act in the best interests of vulnerable elderly people will leave an indelible mark for future historians, as they reflect on this period of life in Ireland.

Dr Seamus Cowman is Professor Emeritus, RCSI University of Medicine and Health Sciences.


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