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Irish Association for Emergency Medicine Annual Scientific Meeting

Harris ‘obsessed’ with reducing delayed discharges

Minister for Health Simon Harris has told emergency medicine consultants that he “makes no apology for being obsessed” with placing strong emphasis on the need to solve the problem of delayed discharges in hospitals.

Speaking to delegates at the Irish Association for Emergency Medicine Annual Scientific Meeting, which was held in Dublin last week, the Minister said progress has been made regarding delayed discharges  as  a result of weekly meetings his Department is having with the HSE to drive the implementation of measures to address pressures and overcrowding in emergency departments (EDs).

“As a result of those weekly meetings I mentioned earlier, we have made some recent progress in this area, but the number of patients in this unenviable position is still 604,” according to Minister Harris.

“I think we need to think about that as being equivalent to another Mater Hospital. I want to see a greater focus on this and to encourage a culture of greater co-operation between primary, acute, and social care to address it.”

The Minister pointed out the number of patients on trolleys has reduced by almost five per cent in 2016 to date, compared with the same period in 2015.  

Also, Compliance with the national Patient Experience Time (PET) target, which aims to eliminate waiting periods of over 24 hours in EDs, has improved from 95 per cent to 97 per cent this year.

“In acknowledging this I am in no way attempting to diminish the challenge we face, particularly in the season ahead, or deflect from the unacceptably high numbers of patients still on trolleys and the impact that has on them,” Minister Harris said.

“However, the improvements we have seen have resulted from your hard work and also from a concerted and integrated approach across primary care, acute hospitals and social care.”

Minister Harris spoke about the recently launched HSE Winter Initiative 2016 – 2017, which provides €40 million of additional funding to manage the expected winter surge in demand for hospital care.  

He said timely patient discharge from hospital is being enhanced by increasing overall homecare and home help provision, and also 950 extra homecare packages targeted at nine specific hospitals.  

The Minister briefly referred to the Programme for a Partnership Government commitment to commence the design of a new ED at Beaumont Hospital, Dublin, stating funding provision will be made available for the planning and design phase of this project in preparation for the Capital Plan review in 2017.  

He added there is a similar commitment to progress the ongoing design of a new ED at Galway University Hospital.

“There is little point talking about more beds either without recognising the challenges we face with recruitment and retention of staff in our hospitals. It is worth saying we have succeeded in recruiting approximately 80 consultants and increasing nurse numbers by just over 200, so far this year,” according to the Minister.

“Furthermore, there are over 7,000 more staff employed in the health service than there were in 2014.  In that timeframe, the number of consultants employed has increased by 187, the total number of medical staff by almost 900, and the number of nurses by nearly 1,200.”

Problem of ‘frailty’ needs to be recognised 

The Clinical Lead for the HSE’s National Clinical Programme for Older People Dr Diarmuid O’Shea, told the Irish Association for Emergency Medicine Annual Scientific Meeting that identifying the problem of “frailty” is vital in the assessment of older patients.

Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes, including falls, incident disability, hospitalisation, and mortality.

Dr O’Shea said it is important for physicians to realise that frailty is a “distinctive health state”. “We need to think about it, we need to recognise and understand it, and we need to do something about it,” according to Dr O’Shea.

He said the gold standard for the management of frailty in older patients is comprehensive geriatric assessment, which identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a co-ordinated plan to maximise overall health with ageing.

Dr O’Shea said that capturing frailty in emergency department patients can be challenging and there are a lack of agreed tools to aid physicians and medical staff.

“We all think we know it when we see it, but capturing it is a challenge, and there aren’t yet agreed tools for doing it, but there are tools that we are beginning to look at,” he said.

Speaking in general, Dr O’Shea spoke about the well known demographic figures, which show that the older population will significantly increase in the coming decades. According to current statistics, the number of people aged over 65 years is increasing by almost 20,000 a year.

He told the meeting it is vital that physicians and local health teams are aware of demographics in their area, if not the population at large.

“Ultimately I don’t mind particularly that the population of older people is going to get to 1.23 million over the age of 65 in the next 25 years in Ireland. What I care about is what is happening in my patch in Letterkenny, or my patch in Dublin, or my patch in Kerry. So locally knowing your own figures is critically important.”

Dr O’Shea also spoke about an initiative, also mentioned by Minister for Health Simon Harris, where St Luke’s Hospital in Kilkenny has been chosen as a pilot site to implement a case management approach on the acute floor with a corresponding liaison role in the community.  

The intended impact of a front-door nurse for frail, older persons and a winter care co-ordinator in the LHO is to reduce the length of stay for older persons and facilitate integration of services to improve overall outcomes. This pilot will support a seven-day service. It is planned to extend this further, once it is running smoothly in Kilkenny.

Dr O’Shea said it is important to adapt and build upon existing models to improve care for older people.  

Emergency departments still under pressure – IAEM President

The President of the Irish Association for Emergency Medicine (IAEM) Dr Mark Doyle, has said that staff working in emergency departments are still under severe pressure, in spite of recent statistics showing fewer patients waiting on trolleys compared to last year.

Minister for Health Simon Harris referred to the statistics during his speech to the IAEM Annual Scientific Meeting, which was held in Clontarf Castle last week.

“Unfortunately, the problem with the statistics is the quality of some of the data isn’t good,” Dr Doyle told the Medical Independent (MI).

“We are not actually measuring like with like a lot of the time. There are different systems in place in different hospitals, which kind of distort the picture. The feeling on the ground would not be that things are remarkably better than they were.”

Dr Doyle also said that measures announced as part of the HSE Winter Initiative to relieve pressure on emergency departments are needed throughout the year.

“Calling it a Winter Initiative is also a misnomer because we have this problem all year around,” stated Dr Doyle.

“Trolleys in emergency departments are a fixed part of the system at this stage. It is not like an exceptional thing. It is the way the system has responded to lack of capacity. They are endemic. And it is not going to go away until the capacity issue is dealt with. I take the Minister’s point that it is not just about beds, but we do need beds now as a short-term acute measure to just deal with today. We all accept that we have to look at processes and deal with the older population demographic, that is really with us now and it is growing. We have to manage that cohort of patients well and the system as it is currently configured is not able to cope with that particular pressure.”

However, Dr Doyle said that there were positives to take from the Minster’s conference speech.

“I thought his speech showed a pretty good grasp of the issues,” he said.

“In fairness, he certainly covered a lot of ground in a short time. I think he is well briefed and getting a good grasp of the issues. Certainly of course he was anxious to play up the positives. Some of us older characters would have a slightly more jaundiced view of the world, but he certainly hit on the issues and from our point of view, that was the most important thing. He gets what the issues are in terms of overcrowding, in terms of patient flow, and in terms of the recruitment difficulties right across the board. From that point of view, you have to be optimistic. He seems willing to engage and willing to talk to us further. I think he has a really good grasp of the need for integration between the different aspects of the service, the lack of which has bedevilled us for a long time.”

Pilot for falls and blackout units proposed 

There is a need for Irish hospitals to develop properly resourced falls and blackout units to reduce the burden on emergency departments and acute beds, according to the Director of Mercer’s Institute for Successful Ageing, Prof Rose Anne Kenny.

Speaking to the Medical Independent (MI) following her presentation to the Irish Association for Emergency Medicine Annual Scientific Meeting, Prof Kenny said discussions were taking place with the Minister for Older People Helen McEntee, to pilot units in hospitals in Ireland that do not have such facilities, to show the impact that they can have on admissions, quality-of-care and fracture prevention.

“Once we have successfully piloted and evaluated these units, I am very hopeful that we will be able to roll them out nationally because it is a quick fix to some of the huge emergency department pressure problems we have in Ireland at the moment,” she told MI.

She maintained that the cost of rolling out falls and blackout units are not significant.

“You do need to identify doctor time,” Prof Kenny said. “You do need to identify at least one specialist nurse, and initially kit out the unit with equipment. The initial cost of setting up the equipment in a hospital such as Drogheda, for example, would be no more than €120,000. Then having identified physician time and nursing time, the running cost is between €50,000 and €60,000 a year. 

“We showed in a similar study in Newcastle Upon Tyne that the savings in running a unit like this is the equivalent to closing a 31-bedded medical unit ward. That’s how good the savings are. We really do need to give this breathing space in Ireland and it will be hugely successful if we can just have the scope to develop these in other hospitals.”

Prof Kenny stated that the evidence base for establishing these units is strong.

“There is very good evidence that having a falls and blackout unit in a hospital reduces admissions of all ages, but particularly older patients,” she explained.

“In addition to providing better quality-of-care, in addition to preventing re-attendance and re-admission, it prevents admission at the door. It prevents fractures and possibility even dementia, because if you have got repeated falls because of low blood pressure it eventually affects your brain health. 

“I have just chaired a European group where 38 countries have signed up to guidelines on blackouts and falls prevention. There are only a handful of such units in Ireland, and even the ones that are here are poorly resourced.”

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