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The high numbers of patients on trolleys in emergency departments (EDs) countrywide has almost been matched by the amount of reports published on the subject over the years.
Since 2006, when former Minister for Health Mary Harney declared ED overcrowding to be a national emergency, there has been the Emergency Department Taskforce Report (2007); the Report of the National Acute Medicine Programme (2010); the National Emergency Medicine Programme Report (2012); and the Unscheduled Care Strategic Plan by the Special Delivery Unit (2013), to name a few. The problem has also been referenced in numerous other reports on the health service produced by the HSE and others.
The most recent document to specifically address ED overcrowding was the Emergency Department Taskforce Report 2015. The Taskforce was established in December 2014 by then Minister for Health Leo Varadkar against the backdrop of a well publicised increase in the number of people waiting on trolleys.
Former Minister for Health, Leo Varadkar
Supported by the Special Delivery Unit (SDU) and clinical programme initiatives, hospitals achieved a significant and sustained reduction in the number of trolley waits in the period 2011 to 2013. Specifically, there was a 33 per cent reduction in the Irish Nurses and Midwives Organisation (INMO) national daily trolley count in this time.
However, it was acknowledged that unacceptable levels of overcrowding still existed in a number of hospitals.
As was noted in the Emergency Department Taskforce Report 2015: “During 2014, ED performance in terms of trolley waits deteriorated and for the first time in three years the downward trajectory was reversed in September 2014. According to INMO figures, the number of trolley waits was 6.5 per cent worse than it was in 2013.”
The Taskforce report, published in April 2015, offered various reasons for the increasing numbers on trolleys. These included a growth in the wait time for the Nursing Home Support Scheme (NHSS) from four weeks in January 2014 to 15 weeks at the end of November 2014; an increase in the total number of delayed discharges in the order of 30 per cent during 2014; significant changes in management structures in hospital and community services “with resulting loss of corporate experience and context to drive and oversee consistent hospital performance”; and challenges in attracting and retaining senior clinical decision-makers at NCHD and consultant levels.
The Taskforce was co-chaired by HSE Interim National Director for Acute Services Mr Liam Woods and INMO General Secretary Mr Liam Doran. It comprised of stakeholders in emergency medicine including clinicians, hospital managers, and medical representative body members.
INMO General Secretary, Mr Liam Doran
The recommendations in the Taskforce’s report were designed to address the fundamental factors causing ED overcrowding. These recommendations were similar in scope to those published in other reports. For instance, the agreed national target of 95 per cent compliance with a six hour patient experience time (PET) was re-stated; with the recognition of an interim target of no patient waiting more than nine hours for admission set for 2015.
It was agreed that the total number of delayed discharges would not exceed 500 in 2015 and that no hospital would have delayed discharges in excess of 10 per cent of their available beds.
The report also recommended that metrics be developed to ensure agreed targets for delayed discharges were being met consistently at national and hospital level. There was a recognised need – which again had previously been expressed – to push for additional residential care capacity, both in terms of long-stay and short-stay, to support the continuum of care requirements and “in particular in key locations where there was an identified shortfall in such capacity, both currently and over the coming years”.
Targets were set to reduce length-of-stay and measures formulated to avoid emergency admissions where possible through the use of community intervention teams (CITs).
The Acute Medical Assessment Unit (AMAU) model was to be strengthened and expanded, according to the report. In terms of the ED itself, the recruitment of more consultants was identified as a priority. Other measures were announced aimed at supporting rapid access to inpatient care and to diagnostics; improved access to senior decision-makers; integrated discharge planning; and improved chronic disease management.
‘Minister Varadkar queried the ability of hospitals to ‘flex up’ quickly enough to respond to a surge’
Based on the Taskforce’s Action Plan and in view of experience to date, additional funds were provided on a strictly ring-fenced basis to reduce overcrowding. In April 2015, Minister Varadkar announced that €44 million would be allocated to the NHSS to provide an additional 1,600 places and reduce the waiting time for approved applicants from 11 to four weeks for the rest of that year.
In addition, €30 million was to be provided to cover the cost of additional transitional care beds (temporary contract beds) through to June 2015 and additional community, convalescence, and district hospital beds on a permanent basis, both of which facilitate more rapid discharge from hospital.
There was also a premise that temporary transitional beds in use to address ED overcrowding would be replaced by sustainable, more cost-effective beds under the Fair Deal scheme. In addition, up to 250 community care beds were to be made available around the country.
A group was established to oversee implementation of the recommendations. The ED Taskforce Implementation Oversight Group was also co-chaired by Mr Woods and Mr Doran when it first met in July 2015, with Minister Leo Varadkar in attendance.
In October 2015, HSE Director General Mr Tony O’Brien replaced Mr Woods as co-chair. According to the Department of Health, this was to ensure that all relevant parts of the health services including acute, social, and primary care, were optimising resources in order to deal with the particular ED challenges associated with the winter months.
The group mainly contains representatives from the HSE and the Department of Health.
Clinicians on the group include Clinical Lead of the HSE Emergency Medicine Programme Dr Gerard McCarthy and Clinical Lead of the HSE Acute Medicine Programme Prof Garry Courtney.
At its meeting in July 2015, HSE Deputy National Director of the Acute Hospital Division, Ms Angela Fitzgerald, presented an update on the status of the eight target sites identified as highest contributors to the trolley waits.
It was agreed that the “Surgical and Medical Programmes” were to visit Beaumont Hospital, Dublin, together to “review and advise on where patient flow could be improved including rapid access, use of ‘day hospital’ model, increased use of ‘outreach’ model and availability of dedicated slots for radiology”.
Options in relation to admission avoidance, such as an AMAU and rapid access, were to be explored in Galway.
The meeting also heard that CITs were having a beneficial impact and it was agreed that all hospitals should be closely monitored to ensure maximum use.
Mr Pat Healy, HSE National Director for Social Care, presented an update on the status of additional public bed provision, which was to number 173. Some 146 of these beds were in place with the remainder to be brought on-stream when staff were available, stated the minutes.
At the September 2015 meeting, Minister Varadkar questioned the accuracy of data being presented on implementation of ED Taskforce recommendations. The meeting included presentations by Hospital Group CEOs.
In response, Ms Fitzgerald advised that information was validated by Hospital Group CEOs in advance of the meeting but the presentations “may differ due to timing of reports”.
Mr Woods noted to the Minister and members that the HSE’s Acute Hospital Division Team was working closely with Hospital Group CEOs and all were acutely aware of the need to deliver on the ED implementation plan.
He advised that the development of the Hospital Groups, improved accessibility to Fair Deal, and the enhanced working relationships with Social Care and Primary Care at national level, would improve the ability of the service to respond to surges throughout the winter and build sustainability into the future.
At the next meeting, in October 2015, Ms Fitzgerald noted that winter planning had begun much earlier than usual as a result of the Taskforce report and implementation, and the formation of Hospital Groups. The meeting heard the uptake of CITs by some hospital sites could be improved. The risk to delivering on the additional capacity due to challenges in recruiting and retaining staff was discussed. Mr Doran also queried the delay in the implementation of extended day working and weekend rostering for consultants.
In December 2015, Ms Fitzgerald delivered a positive presentation stating that more beds were becoming available than originally provided for.
She said 201 of the 301 beds were available but not all were open. Minister Varadkar queried the ability of hospitals to ‘flex up’ quickly enough to respond to a surge, noting in particular that St Vincent’s University Hospital, Dublin, was regularly overcrowded.
Ms Fitzgerald said this would be addressed with an agreed escalation policy, which she expected to be agreed shortly with the INMO. Mr Doran said staff were working in a “very unsatisfactory situation” in St Vincent’s.
At the first meeting of 2016, in January, it was reported that trolley performance had deteriorated 10-11 per cent in the previous two weeks, which directly correlated to an increase in overall numbers attending EDs noted as 10 per cent.
Mr Stephen McMahon, a patient representative on the group, stated that if it were not for the additional capacity and focus in winter 2015/16, it was likely trolley performance would have been significantly worse given the overall increased demand, according to the meeting minutes.
Ms Fitzgerald outlined that 204 of the winter initiative beds were available, while 111 closed beds had re-opened.
Mr Doran raised a query regarding recruitment locally and referred to feedback from local sites that there was a financial impediment to progressing recruitment. Mr Woods said there “should be no impediment to progressing posts that have been sanctioned” as part of the winter initiative to support EDs.
Head of the SDU Ms Grace Rothwell, who had been appointed to her role the previous month, noted that staffing was an issue in all sites.
She said there was a demand/capacity mismatch and the use of ‘real time’ data remained variable. Ms Rothwell said a culture of acceptance of trolleys was evident across hospitals and a cultural shift was required.
The work of the Taskforce Implementation Oversight Group is not taking place in a vacuum, but rather within the context of the constantly evolving and sometimes chaotic world of hospitals and EDs.
Minister Varadkar admitted publicly in January 2016 that EDs were being “overwhelmed”. Although the figures were below the all-time high national trolley figure of 601 seen in January 2015, which led directly to the creation of the Taskforce, they were worryingly close.
That month the Irish Association for Emergency Medicine (IAEM) launched its own contribution to the growing list of ED improvement documents with IAEM Ten Steps to Improve Emergency Care in Ireland.
The INMO organised strikes at seven hospitals affected by understaffing and overcrowding, although this was averted following agreed proposals with the HSE.
The union subsequently secured HSE and Department of Health agreement under the Workplace Relations Commission to implement the ED agreement, namely that vacant nursing posts needed to be filled immediately.
The INMO warned that overcrowding was getting worse, with 9,381 patients on trolleys in March awaiting admission for inpatient treatment. This represented a five per cent increase compared to March 2015. March 2016 saw a 100 per cent increase in trolley overcrowding compared to March 2008 when 4,701 patients were on trolleys.
The formation of a new partnership Government following the General Election saw the appointment of a new Minister for Health, Simon Harris. Like his predecessors, Minister Harris said tackling ED overcrowding would be a priority. He said the implementation group should be more action-focused and target-driven.
In September 2016, the Minister launched the HSE Winter Initiative Plan 2016-2017, which provides €40 million to manage the expected winter surge in demand for hospital care. This initiative seeks to strike a balance between hospital avoidance measures, supporting patient flow through acute hospitals, and increased availability of social care.
An important element is a focus on governance, management, and improved processes in order to bring about sustainable process improvement changes in how the system operates.
These include the implementation of improvement plans and deployment of SDU Improvement Leads to all Hospital Groups to drive process improvement in target hospitals.
Among the key measures is the provision of an additional 950 home care packages targeting 10 specific hospitals (Our Lady of Lourdes, Drogheda; Midland Regional Hospital, Mullingar; Cork University Hospital; South Tipperary General Hospital; University Hospital Waterford; University Hospital Galway; Tallaght Hospital, Dublin; St James’s Hospital, Dublin; Beaumont Hospital, Dublin; and University Hospital Limerick). An additional 55 acute beds are being provided in the Midland Regional Hospital in Tullamore, Beaumont Hospital, Naas General Hospital, University Hospital Waterford, and Midland Regional Hospital, Mullingar.
Delayed discharges must not exceed 500 and the maximum number on trolleys is set at 236 (8am TrolleyGAR).
The Minister has also established a weekly performance meeting with the Department of Health and HSE at the highest level in order to monitor performance of the winter initiative, scheduled and unscheduled care and drive the delivery of targeted improvements within the health system.
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Success or failure?
The most recent meeting of the implementation group was on 6 September and the provisional date for the next meeting is 5 December. At the September meeting, the group made its contribution to the development of the 2016-17 Winter Initiative.
However, a source close to the group admitted to the Medical Independent (MI) there is very little happening in terms of group meetings and at ground-level in implementing the recommendations in the Taskforce report. Reasons cited include organisational lethargy and an inability to change work practices due in part to the high number of locums working across the hospital system.
According to Dr Fergal Hickey, Consultant in Emergency Medicine in Sligo University Hospital and IAEM communications officer, the predominance of members from the Department of Health and HSE is a problem, while the targets it sets are not ambitious.
“The implementation group has it within their gift to do a lot of things to fix a lot of the problems, yet I get the sense, and I get the sense from people who have been at meetings, is that they are very limited and very unambitious in their view,” Dr Hickey told MI.
“If 600 [delayed discharges] is bad, then we will improve it to 500. We will make that commitment. They are afraid almost to make the commitments that are necessary to fix the problem. In many ways, what they are hoping (is) it won’t get worse. And that is probably as good as it gets.”
Mr Doran, co-chair of the group, told MI that progress in implementing the report recommendations was slower than he had hoped.
“It is hindered by a mix of inadequate resources, increased activity levels, and I have to say, a continued reticence to change work practices in hospitals, to recognise the daily crisis that is emergency departments. It is a mixture of the three.”
The number of ED attendances has increased by over five per cent this year, which is above the statistical norm and has proven difficult to manage, he added. The increase in frail elderly patients is posing a particular challenge.
“I think the Winter Initiatives have now become annualised events, which correctly try to mitigate predictable surges in activity,” he explained.
“Last year it was primarily geared towards opening extra beds, which didn’t happen in its totality because we had inadequate staff, and this year it is more geared to expanding or maintaining community-based services, with home help, home care packages, and so on, and I think that is welcome.”
Mr Doran said the overcrowding situation has improved “significantly” in Dublin, where the numbers on trolleys have decreased, although they have increased in other parts of the country.
“You can argue that without the Taskforce report, without the ED agreement involving the INMO, the situation would be a lot worse because the attendances are higher,” he argued.
“But we have held onto about the same number of trolleys, less in Dublin, more down the country. But what would it be like if we hadn’t got all the attention? Where I think the system is still failing to do what can be done within existing resources, is regarding work practices.
“One area of that is delegated discharge, cross consultant discharge, particularly at weekends. The level of discharge at weekends hasn’t changed over the last number of years. We have repeatedly said in order for the ED system to never sleep the hospital can’t sleep. So you have to have the same number of consultants and senior clinical decision-makers so people can be discharged on the Saturday or the Sunday.”
Another problem cited by Mr Doran is the failure to expand the role of the nurse in long-stay facilities to avoid hospital admissions for frail elderly residents.
He said these issues are something the health system urgently needs to address. Overall, Mr Doran admitted progress on the major recommendations in the Taskforce report has not occurred. But he still sees a role for the implementation group, stating that the Minister’s weekly meetings with the HSE do not consign it to irrelevance.
“With respect, the Minister can meet every day with HSE senior management, he can meet twice a day with HSE senior management, that is not going to change what happens on the frontline,” Mr Doran contended.
“It is only when the system engages on the Taskforce recommendations, not in Dublin, not in Dr Steevens’ Hospital or Hawkins House, but every day, all day, in each acute hospital that we will see a change.”
Minister for Health, Simon Harris
Minister Harris still attends the meetings of the group. Mr Doran welcomed the more action-oriented focus the meetings have as a result of the Minister’s instructions. He said the next meeting will be a crucial “barometer” in predicting its future success.
In October, in his speech to the IAEM Annual Scientific Meeting, Minister Harris presented a relatively optimistic picture of ED activity.
The number of patients on trolleys had reduced by four per cent in 2016 to date, compared with the same period in 2015, in spite of the increase in attendances, he said.
Compliance with the national PET target, which aims to eliminate waiting periods of over 24 hours in EDs, had improved from 95 per cent to 97 per cent this year.
The Minister stated these were notable achievements considering the increased activity many hospitals had faced in 2016. He said this was not to “deflect from the unacceptably high numbers of patients still on trolleys”.
Mr Doran acknowledges that the health service and the implementation group have significant work if the Taskforce report is not to fall by the wayside like so many others.
“The best achievement so far is that the Taskforce necessitates both the political system and senior management to prioritise dealing with emergency department overcrowding, it never goes off their agenda,” Mr Doran said.
“That is probably quite disappointing, but in the absence of the Taskforce report and all of the media attention on it, then it is my firm view that the situation would be much worse today than it actually is… I am staying with it because there is no other alternative.”