Madam, – Anne Chambers (March 18th), rightly highlights the inhumane conditions that many sick and elderly patients have to endure while they are detained on trolleys in our emergency departments awaiting in-patient beds. Regrettably in Ms Chambers’ mother’s case it was the last hours of her life and all of us can genuinely sympathise with her on her mother’s unacceptable experience. The Irish Association for Emergency Medicine (IAEM) has spent years highlighting this problem to those charged with running our health service, but to little avail.
Ms Chambers is right when she says talk is cheaper than action. We have had numerous reports on the health service, very few of which have been implemented. One could be cynical and suggest that the only reports to be implemented are ones thought likely (often incorrectly) to reduce costs.
Emergency department overcrowding is largely due to systematic failures throughout the health service. However, it is not a given that modern emergency medicine must be practised in overcrowded emergency departments as there are proven solutions to the problem. The NHS in England removed emergency department overcrowding within a year of introducing the four-hour target. This sets a standard whereby 98 per cent of patients who attend an emergency department are seen, treated and discharged or admitted to a hospital bed within four hours of arrival. The introduction of this performance standard drove change throughout the whole health system. However, achieving this standard required investment in facilities and staff, but more importantly political will and management leadership.
The Emergency Department Task Force Report, published in June 2006, gave a clear roadmap for solving emergency department overcrowding in Ireland. This was an excellent report written by clinicians and managers working at the coalface in the Irish health service. It was not an expensive report written by outside management consultants. The recommendations were:
1. The health system should adopt a culture of zero tolerance for trolley waits.
2. A six-hour total wait time from arrival to discharge/ admission represented a realistic operational target for the HSE and hospitals.
3. By February 1st, 2007, the HSE should have set a date by which hospitals would meet a performance target whereby no patient would wait more than six hours from the admittance decision to getting into a hospital bed.
4. By February 1st, 2007, the HSE should have set a timeframe for the introduction of a standard by which no patient would wait more than six hours from arrival at the emergency department to admission or discharge.
Where are we now? Sadly, none of this has been implemented. Emergency department overcrowding is now worse than ever and significantly worse than it was when the Minister for Health declared it a “national emergency” in March 2005, prior to appointing the task force. In his article “AE price hike sees visits fall” (March 17th), Martin Wall reports that the HSE claims emergency department attendances fell in January 2009. More significantly, in the same report, the HSE noted the number of patients waiting on a trolley in emergency departments for a hospital bed had increased markedly from 4,430 in January 2008 to 5,341 in January 2009. The HSE report added, “The drop in attendances was mainly in the lower triage categories, which would explain why the lower numbers did not result in a reduced number of admissions to hospital.”
Has the penny finally dropped for the HSE? The international emergency medicine literature is littered with studies confirming that diverting low acuity patients from emergency departments has no impact on the departments’ overcrowding. A paper from Ontario in 2005, which looked at 4.1 million visits to 110 such departments, showed that each new low acuity patient added just 0.6 minutes to each patient’s total length of stay in the department.
There is little honour in hiding behind current economic difficulties to justify the continuing inhumane conditions many of our sick and elderly citizens endure while waiting on a trolley for a hospital bed. We know what needs to be done. Even at this late stage, now is the time to do it. – Yours, etc,