Overcrowding, delays, cross infection: Review reveals emergency department issues

Patients in nine hospitals were often treated in the wrong places, sometimes corridors, in situations where it was “unclear” who was supposed to be providing their care, a clinical review has found.

It warned of the potential for people to receive inappropriate specialist input and recommended specific wards be used to avoid so-called “safari rounds” where consultants must seek out scattered patients.

The independent review team consisted of clinical and management experts from Scotland and England who undertook a programme of visits between August and November, 2019.

“The review team witnessed widespread boarding and outliers – any bed, anytime, anywhere and including mixed gender,” the document said.

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“This does not create extra capacity, leads to safari rounds, increases length of stay, introduces harm by non-specialist care and increases staff absenteeism.”

Although acknowledging often excellent work by staff, the report was commissioned to examine non-scheduled care at nine hospitals found to be “under the greatest pressures” during the winter season of 2018/2019. These had “significant numbers” of patients waiting for long periods on trolleys.

They included Naas General Hospital; Tallaght University Hospital; the Midland Regional Hospital Tullamore; the Mater Misericordiae University Hospital; Cork University Hospital; University Hospital Limerick; University Hospital Waterford; St Vincent's University Hospital; and Galway University Hospital.

It identified consistently “high numbers of patients waiting for admission to an in-patient ward bed on trolleys either in EDs (emergency departments) or on wards in the majority of the hospitals visited”.

“Many patients waiting were being cared for in a variety of areas that were often unsuitable, such as hospital corridors, and where it was sometimes unclear who was providing care.”

ED attendances over the period in question ranged from 83,000 at the Mater Misericordiae University Hospital to 30,000 at Naas General Hospital. Facilities in Tallaght and Limerick were new while in Waterford and Galway, the departments were “old and barely fit for purpose”.

The average time patients spent in ED before leaving for admission averaged between 10 hours and 58 minutes to 17 hours and five minutes.

Although staff were found to be fully aware of various safety issues and patient experiences, and attempted to safeguard patient safety, the authors noted that “given the design of many clinical areas and the demands on the staff, this remains a cause for concern”.

“There was also a widespread and unrelenting desire among staff to improve that care. However, this has to be contrasted with some poor experiences of overcrowding, prolonged trolley waits, intrusions upon the dignity and privacy of patients who were, at times, exposed to unacceptable delays, risks and cross infection.”

The inspectors noted there was often “no clear understanding” of who was supposed to be providing care. Delays in admitting patients to wards, and processing those who were not admitted, resulted in crowded emergency departments and, in turn, further delays. A lack of capacity and a shortage of staff and funding were consistent underlying themes, it said.

Of some concern was the mix of patients in wards. The document outlines a need to minimise the number of under different consultants on a ward.

“Although the wards are described as specialist wards most of them operated as mixed economies with several specialities and as many as 10-15 consultants ‘owning’ patients per ward,” it said. “This leads to ‘safari’ ward rounds which impact on efficiency and prolong lengths of stay.”

Hospital staff often did not know who was in charge or if they were approachable or consistently visible.

Among 30 recommendations, the team said there is a need to develop a national operational management model, less top-down and more locally driven; as well as an increase in the visibility of hospital leadership; and an updated escalation policy to ensure surge capacity can be identified within the system.