Hundreds of patients are unable to be discharged - which means hundreds are unable to be treated, writes Eithne Donnellan, Health Correspondent
IN APRIL 2003 a headline on an article in The Irish Times declared: "30,000 bed days lost at Dublin hospital over late discharges".
The piece detailed how the Mater hospital had lost thousands of bed days in 2002 because of a lack of long-term, rehabilitation and hospice beds to which patients could be discharged.
The data came from an internal hospital report which stated bluntly that if the lost bed days had been available to the hospital, waiting lists could have been virtually wiped out.
In February 2003, when the report was discussed at a meeting of the hospital board, there were 101 patients in the hospital who had finished their treatment but whose exit from the hospital was blocked as a result of a lack of step-down beds.
On November 10th, 2008, just over two weeks ago, the number of patients inappropriately occupying beds in the very same hospital as a result of delayed discharges was 95, practically the same as in 2002 when the problem, the factors contributing to it and the havoc it was causing in terms of overcrowding in the emergency department, elective surgery having to be cancelled and patients being denied timely rehabilitation, were well ventilated.
When Mary Harney took over the health ministry in late 2004 a number of plans were quickly put in place to tackle overcrowding in emergency departments as well as its root causes.
In her first round of pre-budget health estimates in November 2004 she detailed "10 actions to improve accident and emergency services" and among them were the transfer of 100 high-dependency patients to private nursing home care. Other elements of it were home care packages and planned negotiations with private nursing homes about providing short-term step-down beds for about 500 people a year waiting to be discharged home with appropriate supports.
In 2005 the HSE removed more than 1,000 patients whose discharges had been delayed from the main Dublin hospitals by placing them in step-down beds and giving them home care packages.
But the hospital beds they vacated were quickly taken up by other patients - many but not all of them elderly - who, after being treated, had nowhere to be discharged to. As a result, there were still about 400 patients in acute beds in Dublin who didn't need to be there by March 2006 when the crisis in emergency departments was declared a "national emergency" by Harney and a taskforce was established to come up with further solutions.
A new HSE report seen by The Irish Times shows some 438 patients were still inappropriately occupying acute beds in these Dublin hospitals on November 10th last as a result of delayed discharges. In other words, the problem is now as bad as, if not worse than, ever.
The blocking of these beds has already contributed this year to many operations, including surgery on cancer patients, being cancelled. It has also led to a delay in the transfer of patients from smaller hospitals to specialist centres, which could impact on patient outcomes. And, of course, there's the potential impact on the patients themselves whose discharges have been delayed.
Harney has herself said hospitals are dangerous places, with those staying too long in danger of picking up infections.
So what's gone wrong with the grand plans to eliminate the bed-blocking problem?
Well, the emergency taskforce report, published last year, wasn't heeded for one. It said there was an ongoing requirement for 46 long-stay beds per week to meet the needs of post-acute patients in Dublin. They weren't provided.
According to Fine Gael's health spokesman, Dr James Reilly, the investment in public long-stay beds just hasn't been put in.
"The startling fact that there are only three public long-stay beds per 1,000 people over 65 in north Dublin compared to 22 per 1,000 people over 65 nationally is the major factor behind the fact that 57,000 bed days were lost last year at the Mater and Beaumont hospitals alone, which is the equivalent of a 150-bed hospital closed for a year," he says.
Janette Byrne of Patients Together says one of the first promises Harney gave in 2004 was to relieve overcrowding in emergency departments by providing adequate step-down beds and home care packages "and if anything we have seen a cutback in home care services".
She points to the axing of the hospital in the home scheme.
Last December HSE boss Prof Brendan Drumm announced plans to open 860 new public nursing home beds nationwide in 2008. Figures provided by the HSE indicate that target will not be met. It says 295 have come onstream so far this year, with additional 65 due to open before the end of the year.
Also this year, as HSE budgets got tighter, it curtailed the numbers of private nursing home beds available to the Dublin hospitals.
A doctor in St James's Hospital says its stock of step-down beds from the HSE has been cut sharply, especially after this year's general election.
He adds that he is aware of at least one case recently in a large Dublin hospital where a patient with an "ovarian mass" suspected to be cancer had her operation cancelled as a result of so many beds being blocked. And, at the same time, the way people are being treated in corridors in AE is "criminal", he says.
Nancy Browne, a Kildare woman in her 60s, who ended up on a trolley on a corridor at Tallaght hospital earlier this year after breaking her elbow while recovering from cancer, says it was totally degrading and humiliating trying to protect her modesty getting off a trolley with a surgical gown on to make her way to the toilet. "It was the worst experience of my life and I've gone through chemo and two operations for cancer," she says.
Turning to the actual number of hospital beds currently out of commission as a result of delayed discharges, St James's Hospital alone had 134 unavailable on November 10th last - one-fifth of its total bed stock, Beaumont had 103, the Mater had 95, Tallaght had 81 and St Vincent's had 25.
Nationally, the number of delayed discharge patients in our hospitals on that date was 756, which is the equivalent of having two Limerick Regional Hospitals unavailable as a result of being full of patients who do not need expensive acute hospital beds, costing about €1,000 a day.
Keeping them in these beds makes no economic sense, Nursing Homes Ireland points out. Its members have 1,810 vacant beds in private nursing homes around the State which could be used to alleviate the problem, its chief executive Tadhg Daly stresses. Those beds would cost about €1,000 a week. The HSE simply doesn't want to pay for them.
The HSE's own report indicates the numbers of delayed discharge patients across the State grew by almost 200 from an average of 576 in September 2007 to 762 in September 2008. It says 226 of the 756 delayed discharges now in the system are because the patients or their families are requesting publicly funded long-term care beds which are not immediately available. Another 144 require public residential care due to higher care needs, 60 are awaiting external rehabilitation and 122 patients await the processing of applications for nursing home subvention and home care packages.
The HSE argues the number of delayed discharges has risen because 135 public long-stay beds are currently unavailable as they are being refurbished.
It stresses that additional home help hours and home care packages were provided this year.
And while it claims the majority of hospitals have eliminated excessive waiting periods in emergency departments, it accepts some hospitals in the greater Dublin area and the northeast still have problems. It is working with these to try to rectify the situation.
It also admits there were more than 1,765 inpatient cancellations during September and October. "These cancellations reflect a variety of reasons and circumstances and include the prioritisation of emergency work over elective work, changes in patients' medical conditions, availability of medical or nursing staff, infectious disease outbreaks in hospital and/or a significant number of admission waits within the emergency department," it says.
Dr Fergal Hickey of the Irish Association for Emergency Medicine claims overcrowding "foisted on" emergency departments is now as bad as ever but the political focus has gone off it. He says the delayed discharges are just accentuating a chronic problem that has never been addressed.
Donal Duffy of the Irish Hospital Consultants Association observes that a report back in 2002 on bed capacity by Dr Mary Codd put the number of extra hospital beds that could be realised if delayed discharges were eliminated at 675. "We are now up to 756. You could argue in one sense that no measures have been taken or if they have been they have not been effective," he says.
He adds that the occupation of these beds has an impact on elective admissions but says "some commentators would believe that delayed discharges are used as a budgetary control mechanism" because if elective patients were admitted to the delayed discharge beds for surgery it would cost the HSE even more.
Delayed discharges: the figures
St James's Hospital 134
Beaumont 103
Mater 95
Tallaght 81
St Columcille's, Loughlinstown 34
Blanchardstown 33
Cork University Hospital 32
Waterford Regional 29
St Vincent's Hospital 25
Our Lady of Lourdes 23
St Michael's, Dún Laoghaire 16
Naas General 16
Wexford General 16
St Luke's, Kilkenny 16
Kerry General 10
Mercy Hospital, Cork 10
Louth County Hospital 10
Our Lady's, Navan 10
South Infirmary 8
Sligo General 8
Portlaoise 6
Tullamore 6
Monaghan General 4
Cavan General 4
Bantry General 4
Limerick Regional 4
South Tipperary General Hospital 3
Mallow General 3
Ennis General 3
Portiuncula 2
Roscommon 2
Mullingar 2
Letterkenny 2
Mayo General 1
University Hospital,
Galway 1
Merlin Park 0
Nenagh 0
St John's, Limerick 0
TOTAL 756
• Data compiled by the HSE for week commencing November 10th, 2008