Three Years on and Nothing done-Article from IMT re National ED emergency

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[HTML]http://www.imt.ie/opinion/2009/04/three_years_on_and_nothing_is.html[/HTML]

Three years on and nothing is done
Mr Fergal Hickey
The persistence of the emergency-department overcrowding problem three years after the Minister termed it a 'national emergency' and the lack of Ministerial and HSE action is a very serious cause for concern, writes Mr Fergal Hickey.

On March 28, 2006, after the number of patients on trolleys (‘inpatient boarders’) reached new records, the Minister for Health and Children, Mary Harney TD, rightly declared that the widespread problem of emergency department (ED) overcrowding was a ‘national emergency’.

At that stage, there were 314 inpatient boarders waiting in Irish EDs, a shocking indictment of the HSE’s inability to adequately manage its emergency workload. International evidence confirms that in a given population, the number of patients admitted to hospital each day as emergencies is largely predictable and therefore manageable.
As an acknowledgement of how important this issue was for the Irish health service and how unacceptable things had become, the Minister established a high-level Task Force to:

* Drive the implementation, on an individual hospital basis, of targeted solutions aimed at reducing the numbers of patients waiting for emergency admission and the length of time that patients had to wait;
* Ensure that immediate steps were taken at individual hospital level to improve individual patient comfort and privacy and the overall experience of patients;
* Identify and implement a range of short- and medium-term solutions for those patients that require continuing care following discharge from hospital;
* Work with hospitals to develop their internal management structures and processes to improve overall patient flow.

Original membership
The original membership of the Task Force included representation from HSE hospital management, a director of nursing, a specialist in public health medicine, an assistant national director from the PCCC Directorate, a voluntary hospital CEO, a consultant geriatrician and consultant respiratory physician.
The high-level Task Force, tasked to look into problems experienced in EDs, did not contain any consultant in emergency medicine. When this news got into the public domain and attracted the predictable adverse public comment, two consultants in emergency medicine, with considerable experience of working in both the UK and Ireland, were included. A general practitioner was later added.
In spite of this rather inauspicious start, the Task Force visited the hospitals identified as having particularly intractable ED overcrowding issues, and produced a comprehensive report that identified the causes of the overcrowding, offered generic solutions, and made specific recommendations for each of the 18 hospitals studied.

The Task Force submitted its completed report to the HSE on December 8, 2006.

Unfortunately, it lay on HSE senior managers’ desks for a further six months without any action, until it was finally published on June 1, 2007.

The conspiracy theorists will certainly have noted that this was the Friday of a Bank Holiday weekend and its release had waited until the completion of the 2007 General Election campaign. It was also published with a second document, the Acute Hospital Bed Review 2007, which tempted the media coverage to concentrate on the latter’s headline ‘finding’ that 13 per cent of patients were ‘unnecessarily admitted to hospital’ and that a larger number in the hospitals surveyed could have been treated in an ‘alternative setting on the day of care’ if an appropriate alternative had been available.
Ironically, the absence of suitable alternatives is yet one further HSE failing that seems to have escaped public comment. In spite of the unnecessary delay in publishing the ED Task Force Report and the methods to reduce its public impact, there can be little real debate around its findings.
International evidence
The report confirmed the international evidence that ED overcrowding is a symptom of hospital and community service failures and that there is a significant capacity problem, particularly in community facilities. In spite of the report being produced by a HSE Task Force, its findings are extremely critical of the HSE and its predecessors.
These include the stark realities that:
* Seven of the 18 EDs reviewed were ‘unfit for purpose’;
* Most EDs had inadequate physical infrastructure;
* There is a lack of consistent availability of diagnostic imaging;
* Hospitals are operating at close to 100 per cent capacity, with many acute beds being taken up by patients who have finished their acute care and who should be receiving their ongoing care in a more appropriate environment.
The report made a number of recommendations, chief among these were:
* The health system should adopt a culture of ‘zero tolerance’ for trolley waits;
* A six-hour total wait time from arrival to discharge/admission represented a realistic operational target for the HSE and hospitals;
* By February 1, 2007, the HSE should have set a date from which hospitals will meet a performance target of six hours or less wait time from the time of the decision to admit. (It is accepted in the report that this time is inaccurate and subject to manipulation);
* By February 1, 2007, the HSE should have determined a timeframe from which a total maximum wait of six hours from arrival at the ED to admission or discharge will apply.
Three years after the declaration of a ‘national emergency’, little or nothing has changed:
* In early 2008 and again in early 2009, new records for inpatient boarders were set in several EDs;
* Seven EDs are still ‘unfit for purpose’;
* Most EDs still have inadequate physical infrastructure;
* There is still a culture of acceptance of trolley waits, which extends right up to the Minister for Health and Children who stated in the Dáil that waiting on a trolley could be ‘a pleasant experience’;
* Firm dates have not been set for the introduction of a mandatory performance target of a total maximum wait of six hours from arrival at the ED to admission or discharge.
Instead, the HSE obfuscates. It attempts to blame ‘particularly virulent’ strains of the winter vomiting bug and ‘influenza’ for the overcrowding. The reality is that both of these conditions are much more likely to be spread in the conditions the HSE has allowed to become the norm.
It also continues to use inaccurate figures to publicly justify ‘improvement’, although an internal HSE report discussed at the February HSE Board Meeting concedes that the number of patients waiting on a trolley in EDs for a hospital bed had increased markedly from 4,430 in January 2008 to 5,341 in January 2009!
Embarrassing for the HSE
The HSE-published figures regularly underestimate the number of patients on trolleys by 30-60 per cent, depending on the hospital. There is also a pattern emerging that when returns from an individual hospital are particularly embarrassing for the HSE, they are not published on its website.
Over the three years since the Minister’s declaration, an increasing body of world literature has shown conclusively the links between ED overcrowding and excess mortality, morbidity and increased lengths of stay. Irish research has showed conclusively the deleterious effect of prolonged detention in EDs for older patients — using multiple different end-points.
And while this ‘national emergency’ continues unabated, what does the Minister of Health and Children do? She hides behind the HSE and says that ED overcrowding is an operational issue for the HSE. It was the Minister who declared the ‘national emergency’ and set up the Task Force.
The Task Force’s key recommendations of a culture of ‘zero tolerance’ for trolley waits and a six-hour maximum total wait time in the ED should be adopted as national healthcare policy.
It is, after all, up to the Department of Health and Children and the Minister to set and enforce national policy and the HSE’s role to implement this. If the Minister considered the abolition of ED overcrowding a key priority for the HSE, then there would be some hope of success.
Regularly criticised
Health professionals are regularly criticised for knocking the health service without offering any solutions. The Task Force report has clearly stated what needs to be done. The DoHC should adopt the recommendations of the Task Force Report as national policy and mandate the HSE to implement them forthwith.
There should be an urgent national capital plan to rebuild the seven EDs that are unfit for purpose and upgrade the many other departments that are deficient; after all, air passengers would not be expected to fly on planes that were deficient or were unfit for purpose.
Given the current economic downturn, this refurbishment could be done far more cheaply than it would be done in better economic times. The only other honourable option is for the Minister to explain to the public why the elected Government is not prepared to fund a decent, up-to-date emergency health service for all its citizens.

Mr Fergal Hickey is a Consultant in Emergency Medicine at Sligo General Hospital and President of the Irish Association for Emergency Medicine