Delirious elderly patients collapsing on the floor as overworked hospital staff try to treat everyone and ambulances backed up outside in the car park. This was the grim picture painted of the reality of our hospital emergency departments on Thursday by nurses and doctors working on the front line.
The public could be forgiven for thinking we have heard this before, but the Irish Nurses and Midwives Organisation and the Irish Emergency Medicine Association warned that this month's data shows that patient treatment has reached a new low.
Two years of delayed care, cancellations of operations, shortage of GPs and other community health staff together with rapidly spiralling Covid-19 cases are leading to an unprecedented crisis that the unions claim is being ignored by Government.
Most people give little thought to the overcrowding crisis until it is their grandmother or their child left waiting on a trolley.
Patients who have spent time on trolleys say things like “I thought you might have to wait if you were not serious, I didn’t know that everyone has to wait” or “I have health insurance, I didn’t think this affected me.” The reality is quite stark according to Karen McGowan, an emergency department nurse and president of the INMO.
She explained when patients arrive at an ED they are triaged in Categories 1, 2, 3 or 4 with one representing the most serious category, for example, people whose heart has stopped.
“What we are finding is that the 3s or 4s patients are turning into 1s and 2s in our waiting areas because they are waiting so long,” she said.
This can mean elderly people becoming delirious and people collapsing onto the floor in the waiting area, she said.
“Category 1 is immediate, they need to be seen right away and the Category 4s need to be seen but they can wait. We have huge attendances and they can be waiting up to 15 hours to be seen by a doctor,” she said. “It is happening nationally.”
An emergency nurse for 14 years, she said this winter is the worst she has seen due to the mix of high cases and the impact of cancelled operations.
Her assessment is backed up by emergency department consultants who say having patients on trolleys is not only due to staff shortages in EDs but is linked to bed or staff shortages in hospitals and problems accessing care in the community.
“The intention is to pick out those with the greatest need for treatment first. We are clearly getting to Category 1s and 2s but if you are in triage Category 3 you are going to wait an extraordinary period of time to be seen,” said Dr Fergal Hickey, spokesman for the Irish Association for Emergency Medicine.
In a joint letter to the chief medical officer Dr Tony Holohan, the two unions warned on Thursday: “You are aware that we are entering a whole new accelerated phase of this virus. As of March 27, 89,432 of the pandemic’s total 1,442,877 cases had occurred within the past two weeks, meaning 6.2% of Covid infections had occurred in approximately 1%-2% of the pandemic’s timeframe.”
In recent days, Government politicians have focused on how many hospital Covid-patients were not admitted primarily for Covid-19, pointing out how they are not as sick as in previous waves. However, Dr Hickey said it is “nonsense” to equate this with reduced pressure.
“Even if they are not particularly symptomatic they are a risk to vulnerable patients, and the hospital is full of vulnerable patients. This is a very significant risk,” he said bluntly.
As many infected people in this current wave are asymptomatic, there is in fact a greater chance of Covid-19 being passed among patients in crowded corridors and in multi-bed wards.
This is why the unions are calling for mandatory mask-wearing to be re-introduced in an effort to cut the number of infected people turning up at hospitals - not as a measure to halt the spread but to control it.
Behind this call is the growing number of cases linked to hospital outbreaks, Phil Ni Sheaghdha, INMO general secretary said.
“This extraordinarily high level of infection in such a short period is leading to increased hospital outbreaks due to overcrowding and increased outbreak-related patient deaths,” she said.
During the nine months since the end of June last year, there have been 477 hospital outbreaks. This compares with 424 in the 17 months between February 2020 and June last year.
While the focus is mainly on older patients, she also warned of increased numbers of children coming to EDs around the country. This is where the crisis in hospitals can be traced back to wider issues in the health system. Many of these children are seriously ill but a proportion of them could be treated at injury units.
These units can treat broken bones, objects stuck in a child’s nose, burns and even minor head injuries but, in general, the messaging to the public on this is not clear.
The units are not the full solution as they do not open overnight, with most closing at 8pm and there are just 11 listed on the HSE website, but they could be a bigger part of the solution to hospital overcrowding.
Some hospitals like in Ennis, Co. Clare, also offer medical assessment units that can treat conditions such as chest infections, urinary tract infections or non-acute cardiac problems.
Paramedics have told theprotocols currently do not always allow them to take such patients to these assessment units, as calling an ambulance in most parts of the country triggers a journey to an acute hospital with an emergency department.
A new system, funded under Slaintecare, called Pathfinder allows paramedics to assess elderly people on the spot and offer home treatment if suitable. A report on the first year of this programme in north Dublin found 69% were suitable for home treatment.
Older people increasingly make up a larger proportion of the number of patients on trolleys, so any programme which could offer them treatment at home is to be welcomed.
Overall, the prognosis for the hospital system is not good, with hospitals like University Hospital Kerry being forced to cancel elective procedures again due to Covid numbers.
This means that an elderly patient, waiting on a hip operation, instead remains unsteady on his feet, and is more likely to fall and break something. He will then end up in the ED, probably on a trolley. A woman waiting for stents to be put in her heart for a relatively minor condition instead faces the risk of becoming sicker, and ending up in ED.
In January alone, HSE data shows some 1,093 people aged over 75 waited at least 24 hours for admission to a hospital bed, with 173 of those patients in Cork University Hospital.
Now could be a good time to really listen to the patients and the staff who experience life in the emergency department. At the end of the day, reports and initiatives are worthless unless they make a real difference to the most vulnerable in our society.