Sir, – While timely, your assessment of the trolley problem is a curate's egg ("Overcrowding: Seven reasons for record trolley numbers", Analysis, January 7th). It contains incontrovertible facts: the shortage of beds;the excessive number of delayed discharges; the severe and worsening lack of consultants; the fact that there are too many emergency departments around the country, and so on); and references the perennial problem of political timidity, all of which are easily proven.
However, you repeat the line that many patients attending emergency departments do not need to be there. No doubt, the figure is substantially smaller than you might believe but, more importantly, these patients have little to do with the trolley problem.
The crowding that emergency departments face is overwhelmingly due to the detention of admitted hospital in-patients in the emergency department after they have been referred for admission because there is no bed to go to. Study after study shows that diversionary strategies (ie encouraging patients to use alternative services to emergency departments) simply do not work. The number of emergency department attendances continues to rise while these alternative services generate new work, defeating the stated purpose of the exercise.
Second, the notion that injuries units will in some way reduce the trolley numbers is equally wishful thinking. A landmark study from Ontario disproves that naive notion and shows that the contribution patients with minor illness or injury make to impairing flow in an emergency department is small and the impact they have on waiting times for those requiring admission is also, perhaps surprisingly, negligible. While injuries units are, of themselves, a good thing and provide an excellent service to a cohort of patients, seeing them as having some bearing on the trolley problem is fanciful.
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Suggesting that the acute medical assessment unit model offered in St Luke’s Hospital, Kilkenny is a solution misses the obvious point that if bed capacity is inadequate it doesn’t matter how many additional routes you create into the hospital; this will not generate any additional capacity. Clinical justice demands that there should be no preferential access to a hospital bed – it shouldn’t matter what route a patient requiring admission enters the hospital by, their priority for a hospital bed should be based on clinical need alone.
Perhaps another obvious reason that the Kilkenny model hasn’t been taken up with the enthusiasm that you clearly have for it is that many independent commentators would see it as a bespoke solution in a small general hospital and that, notwithstanding its advocates, St Luke’s Hospital, Kilkenny, continues to have a sizeable trolley problem hospital-wide in spite of this model.
Certainly no-one can disagree with the assertion that the size of the problem and the enormous clinical risk it poses to both patients and staff isn’t being taken as seriously as it should be.
It’s nearly 14 years since then-minister for health Mary Harney declared it a national emergency. At this stage I believe the HSE understands the issue, what is causing it and what the solutions are.
Whether the current Minister for Health can bring himself to actually focus on trying to solve it, or the ultimate decision-makers in the background in the Department of Public Expenditure and Reform are prepared to do something, and soon, remains to be seen. – Yours, etc,
FERGAL HICKEY, FRCS,
Consultant
in Emergency Medicine,
Sligo University Hospital.
Sir, – When I was a young man, I played junior hurling. If I was playing badly, in an effort to deflect attention from my own shortcomings, I used to criticise other people on the field, and if I was playing really badly, I criticised everyone else on the field. Of course, I was fooling nobody but myself. Do you think Simon Harris ever played hurling? – Yours, etc,
JJ POWER,
Naas,
Co Kildare.