IT HAPPENS EVERY year, every month, every week, every day: people on trolleys in Irish hospitals – often hundreds of them.
The overcrowding crisis usually peaks in the winter – with a record high of 612 people on trolleys recorded earlier this month.
So, what can be done? Here, representatives from the Irish Association for Emergency Medicine (IAEM) and the Irish Nurses and Midwives Organisation (INMO) explain what doctors and nurses on the frontline in our hospitals’ emergency departments (EDs) want to see happen.
The number one thing they want? More beds. Now.
Ireland has 2.8 acute hospital beds per 1,000 of the population, whereas the OECD average is 4.3. Japan, for example, has 13 beds per 1,000 people.
“The reality is that there are not enough acute hospital beds, so people who need to be admitted to hospital end up on trolleys,” Dr Fergal Hickey, the IAEM’s Communications Officer, explains to TheJournal.ie.
Hickey says the fact we “end up here every year” is “one of the most demoralising and disappointing things”.
“This is a 12 months of the year problem. It happens even during summer, we hit new records in July and August. It comes to the public’s attention typically in January, February and March because that’s when it goes from bad to worse.”
The HSE’s Winter Initiative Plan has introduced a number of measures aimed at tackling the overcrowding situation.
Speaking to RTÉ’s News at One on Thursday, Health Minister Simon Harris said the health service has “gone through an extraordinarily difficult January” and the number of people on trolleys is “still too high”.
“I found myself as health minister having to answer the same question that maybe health ministers have been answering for 20-30 years this January … I want to make sure that next January and the one after that I or my successor doesn’t.”
It’s not people with minor injuries clogging up the system
Hickey says “an awful lot of nonsense” is told by some commentators discussing the situation, adding that incorrect information is often given as the reasons behind overcrowding, such as that many of the people who end up on trolleys are those with minor problems or drunk people.
Hickey, a consultant in Emergency Medicine at Sligo University Hospital, says the majority of people who are seen at EDs are sent home. It’s the people who need hospital admission who end up on trolleys because there aren’t enough beds for them.
“There are a number of commentators who say that better primary care would solve the problem, that if we dealt with drunks – if we had a drunk tank – we wouldn’t have this problem. Yes, we would.”
Primary care
Hickey says both EDs and primary care need substantial investment in their own right, noting the latter could ease overcrowding in the long-term, but not today or tomorrow.
“Eventually investment in primary care will help … not this winter or next winter but in 20 years time.”
Hickey tells us a lack of beds isn’t the only issue that needs to be addressed but it’s “the main one”, adding: “Without sorting that you’re just tinkering around the edges.”
He says around 1,600-1,800 beds were lost in hospitals due to austerity-era cutbacks. While short-term savings are made by closing beds, it costs more money in the long term and “the price you pay is worse mortality outcomes”.
“Some years ago a decision was made that they didn’t want to invest in health. They see it as an expense rather than an investment. The Department of Public Expenditure and Reform makes the decisions about money, not the Department of Health. They see it as a great black hole that if you gave €100 million extra you would still spend it.”
Hickey says funding needs to be targeted in a different way.
“Ireland spends the second or third highest amount in the OECD on health and yet we have poorer medical outcomes. At the minute you have the crazy situation of people on trolleys for longer and longer.
“If you’re over 75 and on a trolley over 12 hours your chances of going home are much less, you end up having a longer stay in hospital and then your chance of returning to independent living is decreased.
“What we force people to endure, both patients and staff, leads to the worst possible outcomes.”
‘This is killing people’
Anne Burke, the INMO’s Industrial Relations Officer in the west (Galway, Mayo and Roscommon), agrees with this.
“There’s no doubt about that. People are being delayed care, through no fault of the nurses, but there’s no avoiding that fact.
“If you only have two nurses on a ward – something I saw on many occasions in my former life as a nurse manager in an ED – with about 30 patients, there is a delay in patients getting IV antibiotics and other treatments.
“Delayed treatment affects patients’ health and increases their risk of morbidity and mortality. Nurses repeatedly record that on patients’ forms. That’s a fact.”
Burke notes the INMO has been counting the number of people on trolleys in Irish hospitals for over a decade, telling us: “The problem exasperates year on year.”
“The backlog is a huge challenge in terms of providing nursing care – not just in emergency departments, throughout the hospital.”
In response to the current crisis, dozens of extra beds have been made available nationally. However, some hospitals have new beds but can’t open them due to staff and funding shortages. A case in point here is University Hospital Galway (UHG).
Burke, who previously worked in UHG, notes that 28 additional beds were opened there in December.
A new block with 75 single-occupancy beds has been built at UHG, but only 25 of those beds have been opened due to a lack of funding and staff.
Burke explains that a male infection control ward from elsewhere in the hospital was moved into the new facility, while this ward was cleaned and is now being used to boost capacity.
This means 50 beds are lying idle, ready to be used. Burke says this situation is extremely frustrating for nurses and other hospital staff members.
If you’re looking at 50 empty beds, and seeing people lying on trolleys that is very frustrating. It’s like being in a desert and seeing the well but not being able to pick up the water.
Burke notes that legislation introduced in 1989 required hospitals to remove some beds from wards for health and safety issues.
However, many hospitals are now having to place trolleys in wards to free up space in EDs under a process known as “full capacity protocol”.
“There are different codes – black, red, yellow. If it’s code black that means every conceivable bed and trolley space is used so the hospital is working at 100% bed saturation rate,” Burke explains.
She notes the INMO’s position is that no patient should be on a trolley. Although, given how unlikely this prospect is, putting trolleys into wards is the “lesser of two evils”.
“Otherwise our EDs wouldn’t be able to function.”
Hickey says this is “much safer” than a very overcrowded ED, but not a long-term solution – rather “a sticking plaster”.
“Most people would prefer to be 31st patient on 30-bed ward than be on a trolley, like sardines in a tin, in an ED.
The reality is that on any given day you come to work in the morning and see patients that were there the previous day. In clinical spaces where you would normally treat people, there are admitted patients waiting for beds.
“There are three people in a space designed for two, people in corridors, people literally in the way of the wind – if external doors open the wind blows on them.”
Hickey says it can be difficult to access patients or have a conversation with them about sensitive issues due a lack of privacy.
Another knock-on effect of the lack of space is that ambulances often have to queue up to drop off patients as there are no trolleys for them to get onto.
Buildings not fit for purpose
Hickey says Ireland, at 29, has too many EDs, with a lot of the buildings not fit for purpose.
“Some really aren’t worthy of the name [ED], but historically they’re there and, politics being politics, it’s very difficult to move them.”
He uses the current flu epidemic as an example, whereby some commentators have said people with the flu should be segregated from people with other conditions.
“There are no EDs, probably bar the Mater, that could happen in. Isolation is not an option … we don’t have the facilities.”
Hickey notes that some EDs have been refurbished in recent years but “not to a high enough standard”.
You could maybe say they were fit for purpose 10 years before they were built … They badly need to be replaced with more modern facilities.
Hickey adds there aren’t enough consultants working in EDs, stating: “The level of provision is very, very poor by international standards.”
He notes that sometimes people are sent home from EDs when they should stay, while others are kept there when they should be sent home. “If there were more consultants working they could make the right call,” he says.
Emigration and low staff morale
Another major issue that has to be tackled is losing medical professionals to other countries.
Hickey notes there is “a huge amount of interest in emergency medicine at medical student level”, with a large number of students wanting to work in this area.
“We can recruit at lower level, but we have serious difficulties recruiting at specialist and consultant level.
We are training people to lose them. They see the alternative – like Australia for example, they have beautiful facilities that are well-staffed and well-resourced. They look at Ireland and see no comparison. We are losing people, they vote with their feet.
“The only thing that will incentivise doctors and nurses to stay in this country are better terms and conditions,” Burke adds.
“Colleagues say no money would pay you to work in this environment. You have departments where managers have offered overtime like never before but people aren’t interested because they are exhausted and so burnt out. You’re making up a skeleton staff.”
The INMO recently balloted for industrial action, in which 90% of members voted in favour of it, in a dispute over staff shortages, working conditions and other issues. The organisation this week decided to defer industrial action to allow more time for talks with management.
On Monday, Siptu will ballot members for strike action in selected hospitals in a dispute concerning what the union describes as “breaches of the national public service agreements and their exclusion from concessions provided to other emergency department workers”.
In a statement, Siptu Health Division organiser Paul Bell said: “These issues include a failure by management to adhere to the fully binding provisions of the Lansdowne Road Agreement and Haddington Road Agreement.
“The most crucial elements that have not been adhered to include the reintroduction of a job evaluation scheme and the application of incremental credit to interns.”
Burke tells us staff morale is at an all-time low.
“The effect of this on staff morale is clear. I’ve never witnessed it as low in my life, we witnessed it very, very clearly in the balloting. You see their heads down, their body language speaks volumes.”
Burke notes that the INMO arranged for balloting to take place between 7-9pm so it would suit nurses due to finish their shift at 8.30pm. However, the voting time had to be extended as so many nurses were delayed leaving work, “trying to do paperwork and tie up loose ends” because they were so busy during the day.
Staff being so overworked and tired also means mistakes are more likely to be made.
“It’s a very, very dangerous juncture to be at. You cannot afford to be a professional nurse or midwife and be distracted by tiredness,” Burke states.
Revolving door
Echoing Hickey’s comments, Burke notes the majority of people on trolleys are “frail and elderly”, not people with minor issues or drunk people.
She says there is a “revolving door” of elderly patients in hospital EDs as the pressure for beds means some of them are sent home with their issues only “partially dealt with”, meaning they end up being readmitted.
“Until we have a holistic approach taken to patient care in the community the problem won’t be addressed.”
In terms of investing in care in the community, she thinks much more needs to be done, noting that primary care teams need to consist of several people including a doctor, a public health nurse, an occupational therapist, a physiotherapist and a social worker – not just a nurse and a physio.
Burke says staff in EDs are generally very efficient in dealing with people with minor injuries.
She is particularly familiar with the situation in UHG and Portiuncula University Hospital, both in Galway, where she notes advanced nurse practitioners deal with people with minor issues in a “very, very efficient” way.
Burke says patients with minor issues are, obviously, not given priority over people with more serious issues. “They never give higher priority to a broken toe over chest pain, they’re triaged at a lower category,” she says.
Burke says this is one of the most dynamic and efficient sections of the ED, with “very short waits” the norm for people in this category between the hours of 7.30am and 8.30pm.
‘Unacceptable’
Harris has previously said his department and the HSE have “been driving a range of integrated initiatives to alleviate overcrowding in EDs”, including:
Speaking in the Dáil in December, the health minister said: “It is unacceptable that patients wait on trolleys for long periods. Over the coming months it is essential that the health service plans effectively for expected surges in emergency care demand. My department, working with the HSE, has been driving a range of measures to improve patient ED experience times.
Following the formation of government an additional €40 million was provided to assist in the management of winter pressures. Utilising this additional funding the HSE developed the Winter Initiative Plan 2016 – 2017 which was published in September. Key aspects of this plan are being implemented at hospital and community services level across the country.
“Recently, the HSE convened a Winter Initiative health summit and I met with hospital group CEOs, as well as hospital and community health organisation managers, to reinforce the importance of driving key performance improvements across primary, acute and social care to reduce ED overcrowding and to plan for expected surges in demand in our EDs in the new year.”
During the week, the HSE published an update on the Winter Initiative’s progress.
In terms of EDs, the update says about 3,300 patients enter HSE EDs daily. Of these, around 800-900 people are admitted, the majority “without delay”.
The statement notes: “On average around 10% of those who need to be admitted need to wait for admission and their waiting time is recorded. The majority (over 70%) of these wait less than 12 hours.
“Between 2015 and 2016, there has been a 4% rise in ED attendances with many hospitals experiencing a greater than 4% rise in attendance rates.”
The HSE says the percentage of patients waiting over 24 hours decreased from 8.9% in May to 3.8% in December, noting: “These patients were concentrated in a small number of hospitals, notably Drogheda, Mayo and Beaumont. During the early days of December, both Drogheda and Mayo have shown some improvement.”
In terms of delayed discharges, the statement notes: “The most recent information available indicates that the national delayed discharges figure has fallen to 482, compared with 559 in August. Patients in the major Dublin teaching hospitals account for almost two thirds of this number.”
A cross-party Oireachtas committee is currently looking to devise a 10-year plan for the future of healthcare in Ireland, which will include actions to tackle waiting times and overcrowding in EDs.
Hickey says committee members “need to make sure to hear all voices” and not “go in with the preconceived notion that primary care is the answer to everything”.
“Politicians see it as cheaper, but that’s not the right reason for doing everything,” he notes.
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