Sustained commitment needed to solve A&E overcrowding

The solution to the current A&E crisis lies not just in emergency departments but throughout the provision of health services, writes Dave Hughes

Yesterday, 601 admitted patients nationwide lay waiting on a trolley or sitting on a chair in an overcrowded emergency department.

The same day, news broke that nurses in the emergency department at Beaumont Hospital had unanimously voted in favour of industrial action as patients were interviewed on radio across the country detailing the indignity and suffering they had gone through and their disbelief at how nurses and doctors could be expected to work in such intolerable conditions.

Yet they believed those health workers had done their very best for each of them individually.

The INMO is balloting for industrial action across all major emergency departments and the result, according to the general secretary, Liam Doran, will inevitably be in favour of taking action.

But how, you might ask, will industrial action or strike action help the situation? Won’t it only make it worse for patients?

The unfortunate answer is that when a situation becomes intolerable, then the highest risk to patients is to continue admitting them into a full hospital, which is putting them at higher risk than they were already exposed to by their original illness.

There is no silver bullet or quick solution to overcrowding, but the INMO has not sought such a solution.

The organisation, for the past 10 years, has counted the number of admitted patients waiting on trolleys and publicised them.

It is the one consistent and solid statistic which, on a daily basis, notifies the public of the state of our health service.

Yet the stark fact is that overcrowding happens every single day; it is only when it reaches the crisis of 601 patients on trolleys that the vast majority of people become aware of the issue.

The HSE and the Government cannot credibly defend this situation but they do.

It is no surprise that demand for the health service increases in winter and the more severe the winter, the higher that demand becomes.

It happens every year and it is entirely predictable.

This year is worse because five years of cutbacks has meant that excessive overcrowding has occurred throughout the summer and hospitals this winter were already under pressure coming into the cold period.

Ironically, the situation would be much worse except for the fact that we have had a mild winter so far.

The reality is that overcrowding is the itch which no government will scratch because the solution lies not only within the emergency department, but also throughout the provision of health services which are costly and are demand driven.

When patients attend an emergency department and are deemed appropriate for admission they should, within a short period of time, find themselves in a bed suitable to the their condition.

If admitted patients are waiting long periods and in excessive numbers, it is an indication that the appropriate wards are already full and there are no available beds.

When that situation continues over a number of days and the numbers of patients waiting continue to increase, that indicates the hospital is already full.

Internationally, for a hospital to run efficiently, an 85% bed occupancy is considered ideal, with a 90% bed occupancy seen as being the most tolerable level.

In Ireland, for the past decade, hospitals are consistently running at 100% occupancy and in some of the regions now most chronically hit by overcrowding, the relief hospitals who had smaller emergency departments have been closed, leading to even more pressure on hospitals that were already operating at 100% bed occupancy.

How can the full hospital get back to a situation where is operates on the basis of 85% bed occupancy?

There is a complexity about how that can happen, but it is not complicated.

Patients can only be admitted to a hospital when deemed appropriate for admission by the relevant consultant.

They can only be discharged from hospital when signed off for discharge by the relevant consultant or member of his/her medical team.

But large acute hospitals have many consultants working for them and admission and discharge practices can vary from one to another and can have an impact on the pace at which patient’s progress through the hospital system.

Much of the efficiencies which can be extracted from improving admission and discharge policies have been achieved but there is still progress to be made in having consistent practices across all divisions and specialities applied uniformly and every day summer and winter.

Within hospitals, admission and discharge policies must be fine-tuned and operate consistently.

Sufficient beds must be supplied in the first instance to meet the demand for the particular speciality or geographic area and where smaller hospitals have been closed, additional beds are manifestly required in the larger hospital.

These issues must be dealt with proportionately to ensure that both beds and staff adequate to the demand which is predictable are put in place in every acute general hospital.

The other reason for much of the overcrowding is the inappropriate detention of patients in an acute general hospital where their condition does not require that level of medical intervention but they do require alternative residential or home care.

This is really community care and is an area which the health service has struggled to provide in circumstances where the overall funding has been less than adequate.

Change programmes of the scale required in the health service requires investment.

It has been a well-recognised practice in business that to achieve long term gains very often significant investment is required and becomes costly in the change period.

Long term savings are generated only when the investment has been put in. In Ireland unfortunately, that has not been the case.

While a significant percentage of health service funding has been shifted from hospital care to community care over the past two decades and hospital stays have diminished, investment in community services is underwhelming in terms of the demand for those services.

The solution will only come with a sustained commitment over a five year period.

This must involve:

- A determination as a community that emergency department overcrowding is unacceptable in any circumstance;

- Sustained investment in community services which allow for appropriate care without hospital admission and/or discharge to appropriate care settings;

- Adequate registered nurse to patient ratios and sufficient beds in the major acute hospital sector to deal with the demand of the speciality and geographic area demographic of the patient population;

- Immediate opening of all beds currently closed with a recruitment of staff to care for the admitted patients.

Dave Hughes is deputy general secretary of the Irish Nurse and Midwives Organisation

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