Hiqa: patients at risk from ‘grossly overcrowded’ Limerick emergency department

Chronic overcrowding and significant nurse and bed shortages left University Hospital Limerick’s emergency department trying to treat twice as many patients as it was designed to cope with on a day in March.

In a damning report by the State’s health service watchdog, the “grossly overcrowded” emergency department was found to be placing people at risk of harm, jeopardising the quality and safety of care, and compromising the dignity, privacy and confidentiality of patients.

The “very significant concern” expressed by the Health and Information Quality Authority (Hiqa) over what three of its inspectors witnessed during an unannounced inspection on March 15th last led the watchdog to escalate concerns about the potential risk and effect on the quality and safety of care within the hospital’s emergency department to the HSE’s chief operations officer.

In the 39-page report, Hiqa found that the “persistent and prolonged” high volume of Covid and non-Covid attendances at the Limerick hospital’s emergency department had resulted in “overcrowding becoming a chronic and prevailing characteristic of the department”.

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The watchdog said that although the fact there were not enough beds for the number of patients requiring care was a major contributing factor to the overcrowding, inspectors found insufficient staffing levels also contributed to the severe overcrowding during the inspection.

One patient had been waiting on a trolley for more than 116 hours, or almost five days; a second patient was waiting 85 hours, or more than three days; and a third 71 hours or three days.

University Hospital Limerick — the only 24-7 emergency department in the midwest region serving a population of 385,000 — regularly tops the list of patients-on-trolley numbers.

Last year, Hiqa said it had the second-highest rate of attendance in the country with 76,473 attendees — a 7 per cent increase on the number who passed through the department in 2020.

On the day of its inspection, the regulator found the number of patients in the resuscitation area of the emergency department was double its intended capacity as it was holding patients who were waiting for an inpatient bed on a ward.

Inspectors expressed concerns this could have affected the department’s capacity and ability to deal with acutely ill patients or major trauma and emergencies.

The watchdog found patients were waiting an “excessively long period of time” to be triaged and that this was a “significant concern” given the potential risk to the health and welfare of patients.

Eight people were waiting more than an hour, with one person waiting three hours.

The prolonged delay in triaging was attributed to understaffing with Hiqa finding a 17 per cent shortfall in the number of agreed number of nurses rostered on the day of the inspection.

This was found to be a regular problem over preceding weeks with the nursing shortfall running as high as 33 per cent over a four-week period.

“Hiqa was not satisfied that the hospital was adequately planning, organising and managing their nursing workforce in the emergency department to ensure high-quality, safe and reliable healthcare in the department,” the inspection report says.

Of 139 people attending the emergency department at 11.30am on the morning of the inspection, 60 — or 43 per cent — were “boarding” in the department awaiting an inpatient bed.

Most were on trolleys in corridors with “very limited space” between them, and patients on trolleys were found to have “little to no privacy or dignity,” the report says.

Efforts to ensure patients who required end-of-life care in a setting other than in the overcrowded emergency department “were not always effective”, the regulator said.

One person was left in a wheelchair for 14 hours while waiting for a trolley. Another arrived at the hospital in an ambulance and waited more than three hours for a trolley.

Another patient was in the emergency department for 45 hours awaiting an angiogram, a routine test using dye and an X-ray to see if the coronary arteries are flowing freely.

The watchdog said it was “not assured” that the hospital had measures in place to manage the overcrowding sufficiently and the patient safety risks posed by the overcrowding.

Training records showed that between 60 and 71 per cent of nurses were up to date on training on basic life support training, on the hospital’s early warning system and in sepsis training.

Hiqa carried out the inspection ahead of March 17th-18th public holiday because it believed the hospital would experience additional severe overcrowding over that weekend.

UL Hospitals Group, which operates UHL and five other sites in the midwest, said it accepted the report’s findings. Its chief clinical director Prof Brian Lenehan apologised to patients and families and acknowledged UHL’s responses to overcrowding were “not sufficient to meet the unprecedented increase in demand on our service”.

A UHL spokesman said overcrowding could be significantly reduced by “resourcing the heath service in the midwest, including acute bed capacity, in line with the size and the health needs of the population it serves”.

The hospital is, among other things, “redeploying additional staff” to the emergency department and triage area, and conducting an “external review of patient flow”.

Additional staff have been recruited since the inspection, the spokesman pointed out, adding some staff were absent on the day of the inspection due to Covid-19.