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An ED Consultant on the trolley crisis: 'There are solutions and they are multifactorial'

So far 2017 has been another year of chaos, morbidity and mortality with a continuation of the trolley crisis, writes ED Consultant Dr Jim Gray.

Dr Jim Gray

I THINK IT was George Bernard Shaw who wrote, “If history repeats itself, and the unexpected always happens, how incapable must Man be of learning from experience.”

This week, yet again, we have witnessed the depravity of record numbers of patients on hospital trolleys, Emergency Department (ED) overcrowding, multiple ambulances queuing up unable to decant the undifferentiated case-mix of health presentations. Scenes of chaos that were likened to the scenes of a major incident or a war zone.

This surge was predicable

On Tuesday this week, January 3 2017, there were 612 admitted boarders nationally on trolleys, a record high since records began 12 years ago. The following day there were 602 unfortunate admitted boarders warehoused on trolleys, the third highest ever recorded.

Taking the last 3 years, the first Tuesday of 2015 there were 601 on trolleys, the previous record. On the first Tuesday of 2016 there were 558 patients warehoused on trolleys. Again, the first Tuesday of 2017 there were 612 patients on trolleys.

My point is that this latest surge was very predictable. It happens year in, year out. Yet, Minister Harris seemed to be surprised this week and claims that it was linked to a surge in Influenza cases.

Frontline clinicians beg to differ from the Minister

The Influenza Like Illness (ILI) rates have indeed surged recently. However, most patients with ILI find it to be self-limiting and does not often require a doctor or hospitalisation.

In fact, the most recent data from the Health Protection Surveillance Centre (HPSC) estimates 173 hospitalisations from ILI. This equates to 12 patients per day nationwide and hardly translates as a significant factor in the current trolley crisis.

It is important to note that trolley patients are patients who no longer require ED care and need admission to a hospital bed. It is lack of acute beds in the system that is a key factor. When patients are warehoused, languishing in EDs, they are in effect admitted boarders aka trolley patients.

Worryingly, a record 93,621 admitted boarders languished on trolleys nationally in 2016 according to INMO data. An estimated 1.1 million patients present to A&Es annually and around 300,000 of these are admitted. Therefore a third of all A&E hospital admissions are trolley patients.

The Irish Association of Emergency Medicine (IAEM) have calculated that 300 to 350 patients die every year on trolleys across Ireland, a frightening and damning statistic of a so called first world health system.

EDs are unsafe environments when there is overcrowding

A&E targets Ambulances outside Beaumont hospital in Dublin, as the overcrowding crisis in Irish hospitals has reached new record proportions with more than 600 patients on trolleys. Source: Niall Carson

Trolley patients, particularly those warehoused in non-designated areas like conduits and corridors, have no dignity, no privacy and no confidentiality. They are subjected to constant light and noise from monitors for hours and days on end. This is tantamount to sensory torture, resulting in sleep deprivation. They constitute a fire evacuation hazard by blocking up egress and flow.

They also constitute an infection control risk, warehoused along conduits or side by side in sub-wait areas. Patients requiring isolation are often isolated in no more than cubicles with curtains. This is not isolation and constitutes a breach in the duty of care for all patients, relatives and staff.

Entry block to ED

Entry block into the ED due to the admitted patients blocking cubicles results in patients waiting in waiting rooms and on ambulance trolleys with undifferentiated chest pain, abdominal pain, headaches, collapse, generally unwellness, weakness and so on.

These are umbrella terms and there is no way of knowing what or how significant the problem is until seen by a doctor. Entry block is what ED physicians fear the most.

Trolley patients are potentially all of us who may need the emergency services at any time. Irrespective of your means, health insurance status or otherwise, if you get acutely unwell or suffer a trauma and you need urgent attention or need an ambulance, you will be taken to the nearest catchment hospital. This goes for all walks of life.

Health was one of the biggest issues in the last election

A number of our elected representatives in health have found that out and paid for it. Names like James Reilly, Alex White and Kathleen Lynch come to mind. Therefore the health crisis should matter politically.

The staff are working in very testing and challenging conditions in what is now a year round crisis and not just a winter crisis like it used to be.

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Ongoing breaches of HSE 6-hour metrics and targets and HIQA recommendations

The 2012 HIQA Tallaght Hospital Statutory Inquiry should have been a milestone. This Inquiry came about as a result of a trolley-related death at Tallaght Hospital in 2011.

Mr Thomas Walsh’s untimely death left a devastated family behind. They were subjected to a damning Coroner’s inquest where an ‘Open Verdict’ was issued and the Coroner commented that Tallaght Hospital sounded like a “very dangerous place”. HIQA announced their inquiry within 24 hours of this inquest.

I wrongly felt this was a seminal moment in relation to hospital crowding.

The 2016 winter initiative has been an abject failure overall

Despite some improvements in delayed discharges nationally, there is a worsening trolley problem evidenced by the data. The cap of 236 trolley patients daily is not being achieved most of the time.

The good news is there are solutions and like most problems they are multifactorial. The key one is lack of bed capacity.

Some solutions

  1. More beds/ capacity. ROI has 2.8 beds per 1,000 population compared to 4.8 beds per 1,000 population – the average for the OECD. We do not need a ‘bed review’. This is just a delay tactic. 1,600 beds have been taken out of the system over the last decade. Recent attempts to increase bed capacity has been thwarted by inability to recruit staff to open many of those beds.
  2. Staffing of beds. The retention and recruitment crisis is ongoing. Conditions must improve for that to happen. There are vacancies across the service at consultant, non-consultant, nursing and ancillary staff level.
  3. Improved access to diagnostics would be welcome. 247 acute hospitals must have 24/7 access to essential diagnostics. Some key diagnostics are of varying degrees of availability at night and weekends.
  4. Waiting lists need to be brought down – they’re currently at over 530,000 patients across a scheduled care spectrum – to avoid unnecessary ED attendances and admissions.
  5. Long term care (LTC) and step down beds need to be increased further to allow for more improvements in delayed discharges from acute hospital beds.
  6. Primary care. GPs need improved access to diagnostics, timely clinics and secondary care to avoid unnecessary ED referrals.
  7. Accountability. There is no corporate accountability. HIQA has no power of sanction to enforce recommendations on hospitals. It is impotent and this needs to change. There is clinical accountability via the Medical Council and an Bórd Altranais for doctors and nurses. As outlined already there is also political accountability at the ballot box.

Finally, is 2017 going to be any different from 2016? Judging from the opening days of the New Year it is hard to see anything other than another year of chaos, morbidity and mortality with a continuation of the trolley crisis. I love to be proven wrong.

Dr Jim Gray is an Emergency Medicine Consultant at Tallaght University Hospital as well as a Lecturer in Emergency Medicine at Trinity College Dublin. Follow him on Twitter @drjimgray. #Trolleysnomore

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Dr Jim Gray

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