SECOND OPINION:The INMO's threat of industrial action if extra patients are placed in wards is jeopardising patients' care. But why can't the rest of the hospital share the load, asks PEADAR GILLIGAN
HOSPITAL BED closures have compounded the lack of capacity that plagues the Irish acute hospital system. It is because of bed closures that the need to address Ireland’s acute hospital lack of capacity becomes all the more real. Some acute hospitals behave as though emergency departments have rubber walls and can house all patients awaiting emergency admission for prolonged periods until the wards will accept them.
The Irish Nurses and Midwives Organisation (INMO) continues to document the numbers on trolleys each day. Patients on trolleys in our emergency departments are not just numbers to me or my medical and nursing colleagues.
What the INMO has not acknowledged is that the problem of emergency department overcrowding began when the INO (as it was then) refused to allow any additional patients on hospital wards. The result of this is that patients requiring emergency admission to hospital have to wait in emergency departments. Hospital-wide overcrowding became entirely manifested in emergency departments. This means these departments became massively over crowded. The INMO has threatened hospitals seeking to place additional patients on wards at times of severe emergency department overcrowding with industrial action. The same organisation that has done so much to highlight the problem now stands in the way of an initiative that has been shown to help the situation.
We now know from the international literature and our own experience in Ireland that overcrowding of emergency departments is associated with delays in assessment and receiving treatment, increased patient morbidity and mortality, increased violence, decreased patient satisfaction and delaying of ambulances.
The ideal is that every patient requiring emergency admission should be able to be transferred to a ward bed in a timely manner. The reality with Irish hospitals running at in excess of 95 per cent capacity is that ward beds are not available when they are needed.
The other reality is that one additional patient on each ward creates far less risk than 15 to 40 additional patients in the emergency department. It is far easier to provide care to one additional patient in a ward with a relatively fixed population than to attempt to provide care to 20 and 30 additional patients in an emergency department which has to also provide care to all new arrivals each day in a timely manner when all the available clinical space is occupied.
As an emergency medicine consultant I am trained to provide initial assessment and management to the undifferentiated unwell. My daily reality is that patients have strokes, heart attacks, serious infections and life and limb-threatening injuries and I am expected to assess them when all the space in the department I work in is occupied by patients me and my staff saw hours and indeed days before. I have had to assess patients with heart attacks sitting in chairs, I have had to resuscitate patients beside cubicles as there was no available cubicle, I frequently assess patients while they are still on the ambulance trolley they came in on because there is no available emergency department trolley.
Patients I have seen and arranged admission for are often sitting on chairs for hours and sometimes days because every available trolley is in use. This is truly unacceptable to me, my medical and nursing colleagues and our patients.
The reality in the hospital in which I work is that if each ward took an additional patient at times of surge requirement, the emergency department could continue to function more safely. One additional patient on each ward would mean the hospital functioning at 102 per cent capacity as opposed to the emergency department functioning with 250 per cent of available clinical space being occupied with patients sick enough to require admission.
The placement of one to two additional patients on each ward at times of severe emergency department overcrowding has been referred to as the “full capacity protocol” and it now happens in over 600 hospitals in America.
The full capacity protocol is employed when the emergency department’s functioning is about to be compromised and in reality it means all of the hospital responding to the needs of patients requiring emergency admission. At a certain point senior clinicians, nursing staff and management agree the need for patients to be sent to the additional ward beds. These patients are selected to ensure that they are appropriate for a bed on the corridor of the ward. The experience in the US is that patients prefer being the extra patient on a ward as compared to being one of 20 additional patients in the emergency department. Frequently the wards are able to expedite a discharge such that the extra bed is not required. When the extra bed is required there is evidence to show that patients have a shorter wait to getting an actual ward bed.
To allow an emergency department with 16 clinical spaces to house all patients requiring emergency admission pending the availability of a ward bed and not to expect the rest of the hospital with in excess of 650 beds to share the load is quite frankly daft and dangerous.
The Irish healthcare system must accept that one additional patient on each ward is far safer than dangerous overcrowding of Irish emergency departments. The threat of industrial action must not be used to continue massive emergency department overcrowding and compromised patient care.
Dr Peadar Gilligan is a consultant in emergency medicine