Emergency update
Some EDs in the public system do little to inspire confidence. Dr Chris Luke, a consultant in emergency medicine, is the first to admit that he has worked in EDs that resemble “hell holes”. Hence his enthusiasm for the relatively new €4.7 million ED at the Mercy University Hospital (MUH) in Cork city, which he believes represents the “acme of what can be achieved” in terms of layout and technology.
This new department, whose “round-the-clock” status is under review as part of an ongoing reconfiguration of hospital services in the Health Executive South (HSE), showcases some major solutions to the challenges facing emergency medicine. “It’s ergonomically designed to maximise staff efficiency and both patient and staff comfort,” Dr Luke says.
On the day I visit, the waiting room is relatively quiet but an electronic notice board advises patients of a four-hour wait. Fortunately, there are no children queuing, but, even if there were, the wait is made tolerable by the inclusion in the waiting room of a colourful glass-walled cubicle, decorated with a jungle mural and equipped with a Plasma TV and an assortment of toys. This is the sound-proof children’s waiting room, its transparent walls ideal for observation and sound-proofing, with an en suite rest room which includes baby-changing facilities.
Through the door leading from the waiting room, the reason for the four-hour wait becomes evident. Patients lie on trolleys along a central corridor and others lie on trolleys in the Major Treatment Area, designed with the care of those on trolleys in mind.
“It’s high-vis, and open plan so that the nursing staff and medics can observe all of the patients all of the time. Sicker patients are straight in front of the nurses’ station and doctors’ desk,” Dr Luke says. The desk at which staff work runs almost the length of the room and boasts a number of computer screens, one of which displays Cork’s own emergency medicine website.
“We have one of the most modern websites in these islands thanks to my colleague, Dr Íomhar O’Sullivan. This is probably the best website for emergency medicine in the country and, arguably, on these islands. Instead of staff having to find and consult books, everything is online: how to manage poisoning, heart attacks, limb injuries, strokes, or whatever, plus information for patients. You can find almost everything you need on the website,” Dr Luke says.
The site, http://handbook.muh.ie/ contains guidelines for staff and patients.
This online service is invaluable. So too is the technology that allows doctors view X-rays on one screen while alongside, on a twin monitor, is the radiologist’s report. “We have imaging on tap: CT brain scans, MRI scans of brain, torso and limbs, ultrasound and ‘plain’ X-rays, of any part of the anatomy, are easily viewed on monitors throughout the department — side by side with the report — which is often completed within 20 or 30 minutes of the scan being done.
“In fact, the level of sophistication and the quality of radiology service that we have achieved at the Mercy is absolutely superb. And it’s a huge boon in terms of quality of care, risk management and reducing diagnostic difficulty for doctors, because inexperienced doctors can be understandably anxious about interpreting X-rays or scans and the quality and the rapidity of the radiography service is superb.”
The Majors area also includes a quiet interview room, to accommodate psychiatric or social work cases, or simply private conversation. Next door is one of the few self-contained “isolation facilities” in the country, with en suite, and CCTV. “We have the ability to change the ‘climate’ in the room”, Dr Luke says, which we use for patients with infectious disease, including tuberculosis, “a resurgent problem”. A smaller isolation facility exists in the Observation Room, a glassed-off area, where patients can be monitored separately from the Majors space.
The ED provides a separate entrance for its Resuscitation Room. “So there’s no need for ambulatory or ‘walking’ patients to collide with more serious emergency cases. The ambulance can swing around outside and it takes about 10 seconds to get a case into Resus,” Dr Luke says.
A small family room adjoins the Resuscitation Room, a comfort not on offer in the former ED.
The new ED was designed with considerable input from clinicians who fought for certain basic principles to be adhered to. “In the end, it was recognised in the department’s layout that there are three basic groups of people who come to the ED: the critically ill and injured (or ‘blue light’ cases), who need to go straight to the Resuscitation Room; then there’s the moderately, often elderly, sick patients on trolleys, the people who make up the bulk of those trolley-bound patients seen in pictures of corridors in many Irish EDs, with lung, cardiovascular and neurological disease, and diabetes; and then there are the ‘ambulatory’ or walking patients. The critical idea is to recognise that these groups of people should be streamlined into different areas of the ED” Dr Luke says.
“In many older departments, they are not separated, and it leads to a confusing mish mash of the patient cohort, which makes life trickier. It’s more difficult to manage them because each of the three groups has specific needs.
“The walking patients want to get in and out as quickly as possible, they don’t want to be treated next to very sick people, and they shouldn’t have to get lost in crowded corridors: so that’s what we’ve done. Ambulatory patients come in one end, while ambulance patients come in the other end.”
About 75% of patients are treated in the ambulatory area of the ED for ailments ranging from allergies to adverse (legal and illegal) drug reactions, head injuries, skin reactions, eye complaints, asthma, collapsed lung, or indeed any kind of injury, as long as the patient is able to walk or stand.
“The ambulatory area here works extremely well,” Dr Luke says. “And in fact, if I had my way, 90% of patients would be ambulatory. In other words, in my view, too many people are put on to trolleys unnecessarily.”
There are other simple innovations that have helped improve efficiency — for example, the installation of an intercom, a basic piece of equipment, surprisingly absent from older EDs.
“Simple technology like an intercom enables staff to get assistance instantly. There are EDs where 10% of staff time seems to be spent simply trying to locate other staff,” Dr Luke says.
“Intercom enables them to be called urgently.”
Other basic improvements include a consultants’ room for Dr Luke and his colleagues, and a staff room for time out and teaching. “As you can imagine, teaching and ‘time out’ are vital for frontline staff and yet there are hospitals up and down the country where there aren’t such facilities,” Dr Luke says. And then “to cap it all”, Dr Luke has two Advanced Nurse Practitioner (ANP) colleagues, who, he says, provide “a ‘de luxe service’ for ambulatory patients. “Their typical turnaround time is less than an hour: patients are seen by highly trained, Masters-level nurses, with at least 10 years’ experience in emergency care, who can prescribe, stitch, take bloods, and plaster limbs. They treat a considerable number of our ambulatory patients autonomously (but under the auspices of the consultants), and as far as I’m concerned their introduction has been one of the greatest developments in Irish emergency departments in recent years.”
One of the other innovations which has proved highly popular with patients and GP colleagues has been a Rapid Access Trauma Service, whereby colleagues can refer ambulatory patients directly to Dr Luke and his ANP colleagues, “in office hours”, avoiding unnecessary waits at night.
It is clear the new MUH ED represents a much improved environment. So why are some patients still waiting so long?
The shortage of beds throughout the service is the primary cause, but there are other “human factors” at play too, Dr Luke says.
“We have a national shortage of doctors, which has been flagged for years, and not only are there fewer doctors but they are also treating fewer patients. That’s just the nature of the generational change. In the old days, a senior house officer (a non-consultant hospital doctor) might see 15-20 patients in a shift, but in recent times, I have worked with some young doctors who see less than a half-dozen patients in a shift. It’s a cultural thing, and younger doctors are sometimes a bit more risk-averse, and perhaps more fastidious than they used to be.” Worst of all, a dwindling number of Irish-trained doctors are prepared to work in the ED because they perceive the work as too uncomfortable or difficult.
Then there’s the problem of inappropriate referrals by GPs. “We still get a disappointing number of people sent to the EDs in this city with long-term ailments, like back pain, musculo-skeletal problems, or skin complaints, who really should be sent to specialist out-patient clinics or other facilities in the health service. The reasons for these referrals include a chronic shortage of such facilities, or specialists (like neurologists, rheumatologists or orthopaedic surgeons) nationally, but sometimes such referrals just look lazy, especially given the publicity that ED overcrowding has been getting for years now”, says Dr Luke, controversially but frankly. “Those of us working in Ireland’s emergency departments regard this as very unfair.”
And compounding this is the reluctance of nursing staff on wards to take even one extra patient on a trolley in their part of the hospital, Dr Luke says (he has been berated by colleagues for even raising the issue, he says).
“The Irish Nurses and Midwives Organisation (INMO) will talk about ‘health and safety’ as the reason for not decanting one extra patient to in-hospital wards, even though the long-standing risks to patients (and staff) within the country’s EDs could scarcely be greater,” he adds.
He is also concerned about the behaviour of patients themselves — a major reason why so many them end up in the ED.
“The population now drinks and smokes so much, they take so many calories but so little exercise, and they are increasingly prepared to resort to shocking violence.”
Too many people, says Dr Luke, use their EDs as a kind of ‘medical McDonalds’. The ‘I’d like an MRI and a biopsy, please’, or the ‘I was passing by, so I thought I’d get my in-growing toenail or mole or whatever checked out’ syndrome is another major problem, he says.
“To resolve the ED problem, there is going to have to be far more honesty and even financial accountability, right across the board, and on the part of absolutely everyone,” Dr Luke says.
Finally, and controversially, he believes Irish doctors should be obliged to work in emergency medicine for three to six months, immediately after their first “probationary” 12-month internship.
“The mass exodus of new medical graduates every summer Down Under is a cause of severe difficulty in staffing our EDs and, recently, it has brought the viability of the Mercy ED into doubt, because not enough local doctors could be found to work there (or indeed in all of the nation’s 30-odd EDs),” Dr Luke says.
“I accept that the proper solution to this staffing crisis is ‘ideal’ working conditions and training for ED work, along with the employment of only senior dedicated medical and nursing staff, as opposed to mostly medical trainees. But we are already making good progress towards that scenario and our graduates still shy away, resulting in a growing dependence on expensive and sometimes unreliable locums. So, in the short term, I can see no realistic option but to make ED work a mandatory affair.”
Dr Luke says that at the end of the day, “our expensively trained and vitally needed graduates would be working a shift system which is family-friendly and reasonably well-paid”, and the experience which they gain would make an invaluable contribution to their clinical and professional skills, which in turn can only be good for Irish patients.
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