Niamh Cahill examines output, waiting lists and recruitment challenges at Ireland’s cardiothoracic units
Over 3,000 cardiothoracic surgeries are performed in Ireland’s six public cardiothoracic units every year.
Some 19 public hospital consultants, along with specialist medical teams, conduct the surgeries, with varying output levels and procedures performed at each unit.
Figures from the National Treatment Purchase Fund (NTPF) show that almost 500 patients nationally were awaiting cardiothoracic surgery at the end of January, with 11 individuals waiting over 18 months.
The waiting list figure is the result of a host of factors impacting units. More theatre space and beds are required in some centres, while more staffing is needed in others.
Patients undergoing cardiothoracic surgery are reliant on intensive care beds being available and if they are not, planned surgeries are cancelled.
All specialties in Ireland are grappling with system problems such as those listed above, but for patients who require heart or lung operations, the problems are unfortunately all too real.
The HSE lists cardiothoracic surgery as the field of medicine involved in surgical treatment of organs inside the thorax — generally, the treatment of conditions of the heart (heart disease) and lungs (lung disease).
There are five adult and one paediatric cardiothoracic centres in Ireland.
Adult cardiothoracic surgery is performed in the Mater University Misericordiae Hospital (MMUH), Dublin; St James’s Hospital, Dublin; St Vincent’s University Hospital (SVUH), Dublin (thoracic only); Cork University Hospital (CUH) and University Hospital Galway (UHG).
The Heart and Lung Transplantation Programme and the Ventricular Assist Programme are delivered in the Mater. All paediatric cardiothoracic surgery is undertaken at Our Lady’s Children’s Hospital, Crumlin.
According to the NTPF, 478 patients were awaiting cardiothoracic surgery at the end of January, including the 11 individuals waiting over 18 months.
The figures show that St James’s Hospital has the highest numbers waiting, with 139 patients on its list for cardiothoracic surgery.
The next was the Mater with 125 individuals listed for surgery, followed by CUH, which has 99 patients waiting.
Our Lady’s Children’s Hospital, Crumlin, has 58 children waiting, Galway University Hospitals 47, and 10 at SVUH.
The Mater Hospital has nine cardiothoracic surgeons in place, seven of whom work full-time at the hospital.
The hospital carried out 1,068 cardiothoracic procedures last year, including cardiopulmonary bypass surgery and valve surgeries at its two cardiothoracic theatres.
A hospital spokesperson told the Medical Independent (MI) that a business case has been submitted to the HSE seeking funding to resource a third theatre.
Commenting on NTPF waiting times for cardiothoracic surgery at the hospital, the spokesperson said that both cardiothoracic theatres are “presently working to full capacity in conjunction with the heart and lung transplant service”.
They added that a third theatre would help to reduce waiting times.
Prof David Healy, Consultant Cardiothoracic Surgeon and Associate Clinical Professor at St Vincent’s and the Mater hospitals, said finding the additional nursing and ancillary staff would be difficult if more theatre space was provided.
“At the moment for the theatre capacity we have, we’re staffed. But one of the limits to increasing that [is] if we had more theatres, would we have staff?
“I think across the board, and it’s not that the hospital [Mater] don’t want to recruit… but they do have problems finding people. The nursing staff that have higher-level skills like theatre or intensive care are hard to find.”
Consultant staff numbers in cardiothoracic surgery in Ireland are not low, unlike other specialties, according to Prof Healy.
“The problem for us is we have five working days in the week and many cardiothoracic surgeons in Ireland only get one operating day a week and heart operations are very long. So you only get two heart operations done in a day through one theatre.
“Our problem is not manpower; it’s facilities,” he said.
“For a surgeon, their entire public opportunity might be just one theatre session a week, which in a perfect world gives them two cases a week, whereas in the real world there are bed problems where people don’t get admitted. Again, we’re very intense on intensive care, so if we don’t have an intensive care bed afterwards, we can’t start the procedure. If the intensive care is busy, you might want to do two cases a day, but you might only get one done or none done.
“For example, in the Mater Hospital, there is the exact same amount of operating time now with nine surgeons as there was with four. Back in the days of Maurice Neligan and Co, when four surgeons were working there, they had the exact same operating space as we have now. We have fewer beds than they had with four surgeons and we have nine surgeons now.
“At this stage, on the transplant side we are doing one transplant a week, which is very intensive in terms of intensive care and beds. It takes up a lot of time.”
At SVUH, over 200 cardiothoracic surgeries took place in 2016, according to the hospital.
There are four medical staff members in the cardiothoracic unit — two consultants, one registrar and one intern. The hospital performs lung surgeries only, it is understood.
Moving south, a spokesperson for the South/South West Hospital Group (SSWHG) said that three consultant cardiothoracic surgeons and their respective medical teams are employed at the Cardiac Renal Centre in CUH.
Meanwhile, there are 29 nurses and two healthcare assistants employed in the cardiothoracic ward at the centre, the spokesperson added.
Around 450-to-500 major cardiac surgery procedures are performed at the centre in CUH annually, while approximately 250-to-300 thoracic lung surgeries/interventions are undertaken there every year, the spokesperson said.
Coronary artery bypass grafting (CABG), heart valve replacements/repair procedures, combined CABG and heart valve procedures, heart dissection procedures, aneurysm repairs and emergency surgery interventions are the main types of cardiac surgeries performed.
Lobectomies, pneumonectomies, thoracotomies/thoracoscopies, bronchoscopies, pectus repairs and video-assisted thoracoscopic surgery (VATS) make up the bulk of thoracic lung surgeries at the centre.
On the issue of extra funding for the centre, the spokesperson stated that Intensive Care/High Dependency Unit bed requirements “are being discussed from a South/South West Hospital Group and National Critical Care Programme perspective to include the provision of additional capacity for Cork University Hospital requirements”.
Cardiothoracic training is run through the RCSI. The six-year specialty training programme links up with London, Edinburgh and Glasgow in an intercollegiate system with common standards and exams.
“The standards are very good in terms of training. Then, in terms of regulation, we are actually very heavily regulated. We’re regulated across a joint system with Ireland and England,” Prof Healy noted.
Cardiothoracic surgery output is reported to the Society of Cardiothoracic Surgery in Great Britain and Ireland. “They mostly put up English data but the standards are the same and we get benchmarked in terms of our outcomes against the UK outcomes and they’re fine. They’re just as good,” Prof Healy stated.
The National Children’s Heart Centre in Our Lady’s Children’s Hospital, Crumlin, sees in the region of 10,000 children as outpatients, and operates on about 500 of these children annually.
“One in every 100 babies born in Ireland is born with a congenital heart defect and all come to Crumlin to be operated on, including Northern Ireland, some within hours of being born,” said a spokesperson.
“Recent advances in heart surgery have meant that children with complex heart conditions who previously would not survive now have a chance at life.”
The hospital performed 509 cardiothoracic surgeries in 2016. In outpatients, it saw 3,020 new cardiology patients and 4,854 return cardiology patients last year.
There were 148 new cardiothoracic surgical outpatients seen in 2016 and 448 return patients.
In addition, 612 cardiac catheterisation surgical procedures were carried out in 2016.
A new hybrid cardiac catheterisation laboratory opened at the hospital last year, funded by the HSE at a cost of €5.6 million.
At UHG, three consultant cardiothoracic surgeons work full-time alongside five registrars, of which one will be a training specialist registrar from the RCSI in July 2017. Two SHOs and one intern are also in place.
Some 21 whole-time equivalent (WTE) cardiac ICU nursing staff and 15 WTE nursing staff in the cardiothoracic ward work alongside two WTE healthcare assistants there.
A spokesperson for the Saolta University Health Care Group said “challenges in respect of theatre staffing” is the main issue affecting the centre at present.
The unit, which opened in 2006, carried out 336 surgeries last year and 322 in 2015. It is aiming to perform between 350-to-400 heart operations a year.
In May 2007, it performed its first coronary artery bypass graft and the development of cardiothoracic surgery at UHG has benefited patients from other specialties, including respiratory and oncology.
Cardiac surgery undertaken included coronary bypass surgery; valve surgery, including valve replacement as well as valve repair procedures; aortic disease, including aneurysms and dissections; and combined procedures.
Thoracic surgery included major lung resections, surgery for pleural disease — pneumothorax and effusions — chest wall diseases and thoracic trauma.
St James’s Hospital was the only cardiothoracic unit not to provide any data at the time of going to press.