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J’accuse…!

It’s very confusing.

Journalists talk of ‘over-crowding in A&E’. In the one sentence, they mention ‘trolleys’ and ‘patients waiting hours to be seen’.

Do they realise that’s two very different problems?

Most patients attending emergency departments (EDs) will be seen and discharged. They may be ‘waiting several hours’ but they go home.

Then there are the patients who are ill. Usually they are seen without delay, start treatment, and should then move to a ward. But modern hospitals have fewer ward beds than the old hospitals, so the patients stay in the ED. They are the trolley patients and they can be there for days, not hours.

They’ve all been seen by ED doctors, and by on-call teams who have decided that discharge is not appropriate. (That’s a pretty high threshold.) The patient is receiving specialist care but remains on a trolley.

There’s constant talk too about waiting lists – as if that’s linked to the trolley problem. There’s no connection, unless a ward bed is needed.

From some radio discussions, you’d think that ‘trolley patients’ are all drunks, or GP cases like sore throats, or old folk who need a home help. Not true.

Yes, there’s misery on waiting lists but it can be life or death on a trolley. Treating very ill patients on ED trolleys is bad medicine

Apart from critical care, trolley patients are among the sickest patients in the hospital. Yes, there’s misery on waiting lists but it can be life or death on a trolley.

Treating very ill patients on ED trolleys is bad medicine and leads to more deaths. No wonder survival rates for cancer are lower than expected, despite remarkable improvements in treatment. And hospital bugs will thrive as long as patients with difficult infections are crowded together in EDs.

There’s confusion too about the doctors. Patients ‘waiting for hours’ will be seen and (hopefully) discharged by an ED doctor. In contrast, patients on waiting lists need a surgeon to fix them.

Who looks after trolley patients? A few, such as abdominal pain cases, are under the care of surgical teams, but the overwhelming majority are under the medical specialist teams. Now that’s a surprise.

At the RCPI recently, we heard about the wonderful work being done for heart attack, stroke and cancer patients, under the HSE’s Acute Medicine Programme. Modern medicine in Ireland is truly amazing.

But a cancer patient who develops serious sepsis is also a medical team case, as is severe pneumonia in a stroke survivor, or heart failure and rhythm problems following a heart attack. They’re all on trolleys.

There’s a peculiar new trend to re-define these episodes of illness as ‘chronic disease management’, not acute cases. The idea is that they should be looked after by GPs, and not need hospital care.

I don’t get it. It seems like black magic to me.

Why is there such confusion about trolley patients? I think it’s a computer error.

Unless they go to a ward bed, all trolley patients are ignored by the computer. They don’t count as medical admissions, the cases are not HiPE coded after discharge, and they do not qualify for activity based funding.

So that’s the answer to Minister for Health Leo Varadkar’s comment that the hospitals appear to be doing ‘less with more’. Actually we’re doing more and more, but the extra patients are on trolleys, so we’re not allowed record the work.

It means length of stay data is nonsensical. COPD cases appear to stay too long in hospital – it’s because there’s no record of the easier cases, discharged after two nights on a trolley.

And given that national statistics are so flawed, it would be difficult to draw sensible conclusions about major changes such as reconfiguration, or medical assessment units, or even bed numbers.

There are other reasons for the confusion.

I blame the nurses. Every morning, the INMO diligently counts the number of patients on trolleys. They forget to say that the patients need beds, but the wards are all full.

I blame the ED consultants. They speak out constantly for these unfortunate souls, so you’d think they’re looking after the patients. But they’re not.

I blame the medical consultants. They slog around EDs on post-take wards, reviewing and treating dozens of ill patients on trolleys. And they say nothing.

I blame the Acute Medicine Programme for not noticing a big hole in their data.

But most of all, I blame the computers.

Let’s stop giving out about the drunks in ED. Leave them there overnight on trolleys to make sure they’re not ill. Instead let’s get rid of the sick people – they should be tucked up in ward beds.

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