Beating the A&E queues

As Dublin's casualty departments struggle to cope, a hospital in Kilkenny is pioneering a new idea. Dr Muiris Houston reports

As Dublin's casualty departments struggle to cope, a hospital in Kilkenny is pioneering a new idea. Dr Muiris Houston reports

Imagine a hospital where you could go straight to a bed if you became acutely unwell. Even better, imagine a unit in that hospital, separate from the accident-and-emergency department, that would make a quick decision about whether you needed to be admitted. And imagine arriving on the ward, with treatment already under way, within four hours of entering the hospital.Some far-flung healthcare Utopia, such as Canada?

Not at all. Welcome to St Luke's General Hospital in Kilkenny, pioneer of a concept called the medical assessment unit.

If you live in the Dublin area you are probably having difficulty believing this. With most of the capital's accident-and-emergency departments lurching from crisis to crisis - and in many doctors' opinion on the brink of meltdown this winter - how can a hospital 70 miles away be operating in such a patient-friendly way?

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Last week the main north Dublin hospitals had to go off call from ambulance emergencies, such were the backlogs in their casualty departments. On Tuesday it was reported that a patient at Beaumont Hospital had been on a trolley, waiting for a bed, since 7 p.m. the previous Friday.

At least two patients had to be treated in ambulances in the car park of the Mater Misericordiae Hospital when its accident-and-emergency unit became grossly overcrowded.

Even on good days, if you have a serious health problem you can no longer go to casualty at a Dublin teaching hospital in the expectation of being admitted to a bed in an appropriately short time. As the filters for most hospital admissions, the city's casualty departments have become ever constricting bottlenecks.

The same week in Kilkenny, a 73-year-old arrived at the medical assessment unit with chest pain at 6.15 p.m. Referred by his GP, he was rapidly assessed and was awaiting treatment in the hospital's coronary-care unit by 7.30 p.m.

Another patient, a woman whose worsening chronic bronchitis meant she was having extreme difficulty breathing, arrived at 11.20 a.m. Three hours later she was sitting in a bed on the medical ward. By the time she reached it the medical assessment unit had already administered her first cycle of chest physiotherapy, as well as giving her intravenous antibiotics and steroids to ease her breathing. As winter approaches, this type of patient will arrive in our hospitals ever more often.

The medical assessment unit (MAU) has six beds and is open from 8 a.m. to 8 p.m. seven days a week, according to Anne Slattery, the South Eastern Health Board's general manager for acute hospital services in Carlow and Kilkenny. On a typical day it sees between 20 and 25 patients, two-thirds of whom are admitted to the hospital.

The brainchild of Dr Jennifer Carroll, a consultant geriatrician at St Luke's, the concept, she says, "is one of rapid access to a bed, make a diagnosis, treat and discharge the patient where appropriate". She remembers the awful winter of 1999-2000, when the hospital had up to 27 beds in its corridors, and thinking that there must be a better way.

She worked on the concept with key nurses and Dr Gary Courtney, a consultant physician with a special interest in gastroenterology and St Luke's present clinical director. He says: "It's working even better now than when we started, in 1999. Everyone benefits from the MAU. And the South Eastern Health Board deserves kudos for backing us with the money required to develop the unit."

Walking through the hospital, he points out its separate accident-and-emergency department, which is relatively quiet. As well as having the medical assessment unit to relieve pressure, the hospital has a clinic in the outpatients' department as another alternative to casualty.

Ian Wilson, one of St Luke's three consultant surgeons, operates a rapid-access surgical clinic, a surgical assessment unit in all but name and location. He is about to see a woman with a suspicious lump. Amazingly, she first went to her GP only four hours earlier, yet here she is, about to hear a consultant's opinion.

Back in the medical assessment unit Dr Colm McGurk, a consultant physician with an expertise in diabetes, is the duty consultant for the day. He and his senior registrar are discussing the management of a patient in the unit. They decide he does not require immediate admission but does need an urgent gastroscopy, an examination of the upper digestive tract using a flexible telescope. A quick call secures an appointment within days. Before the patient returns home the necessary "work-up" will have been completed, allowing him to return straight to the endoscopy unit for the test.

One of the spin-offs from the medical assessment unit and a natural part of its development was the realisation that it could be used to prepare patients for specific investigations.

During the quietest part of the day, for example, between 8 a.m. and 11.30 a.m., Dr McGurk and his team can test newly diagnosed diabetics without having to admit them overnight. They can also prepare patients for procedures such as bronchoscopy, when a flexible scope is inserted into the lungs.

The consultant cardiologist at St Luke's, Dr Michael Conway, uses the unit to prepare patients for coronary angiography, a dye test, before travelling with them to St James's Hospital in Dublin, where he carries out the procedure.

As Jennifer Carroll explains, older patients benefit particularly from the unit. She has noticed how few patients dehydrate or develop pressure sores compared with those who previously had to wait for long periods on hard trolleys. "By the time an older person spends 24 hours on a hospital trolley their mobility has decreased by 50 per cent," she says.

It's a point echoed by Dr Richard Brennan, a local GP, who says the initiative has helped smooth the interface between hospital and primary care. "Patients are saved from sitting on trolleys or in a corridor. A GP may decide to continue to manage a patient until the following morning if the unit is particularly busy the previous evening."

Carmel Dwyer, the clinical nurse manager - or sister - of the unit, says it has three main aims: to allow patients to be evaluated quickly away from an already busy accident-and-emergency department, to facilitate equal access to multiple specialities and procedures, and, as a result, to avoid overcrowding and bed crises.

Dr Courtney sums it up well when he describes the concept as a hospital without walls. "There are no artificial barriers: the MAU is responsive, accessible and patient-centred."

On the fast track

Marie is a 60-year-old widow who lives about 15 miles from Kilkenny city. She went to her GP last week after her calf swelled overnight. She has had problems with varicose veins in the past.

When the GP examined Marie, he found her left calf was markedly swollen and quite hot to touch. Although the problem could have been caused by cellulitis, an infection of the skin and the structures just under it, he was concerned that she might have a deep-vein thrombosis.

At 10 a.m. he rang the bed manager at St Luke's General Hospital, who asked for Marie to be sent to the medical assessment unit. She was seen without delay, and an ultrasound investigation to check for a deep clot in the vein was set up.

By 2 p.m. the test results showed a below-knee deep-vein thrombosis. Treatment began straight away with a shot of the blood-thinning drug heparin. Oral warfarin therapy was then started; because the clot was below her knee, Marie could go home later in the afternoon.

Her GP is monitoring her response to warfarin, and her leg is no longer swollen.