Crisis in emergency departments

 

Sir, – I read Joyce Hickey’s account of her overnight experience as a patient in an emergency department with a mixture of relief and despair (“A patient’s experience: my night on a hospital trolley”, January 10th). Relief that it is clearly not my department (based on the physical description), and relief that the staff described were doing Trojan work in heroic circumstances. Despair knowing that, while difficult to achieve, the solution is clear. Flow through emergency departments can, and must be, unblocked.

To suggest that improving primary care, or chronic disease management programmes, will take a huge part of the burden of unexpected, critical deterioration in health status is overly optimistic, and preventive public health, while also playing a part, takes decades, or even generations, to make its effects felt.

The description of the aggressive, belligerent person, interfering with the care and comfort of others, was very real to me and appears to be the widespread image of emergency departments, but it represents a relatively small proportion of the people present.

Much of the dysfunction in emergency departments is due to overcrowding by patients who do not fit the pejorative picture of the drunk, the worried-well, or the social misfit.

The patients who take up most space are those whose clinical problem cannot be dealt with in the community setting, and who require acute hospital admission to save their life, to prevent further deterioration of an already dangerous disease or injury, or simply to enable them to recover function. Because of lack of functional bed capacity, they must wait, in hope and increasing despair, for the bed to be vacated, cooled, cleaned, changed and declared available.

The average length of stay in Irish hospitals is about six days. But a small percentage of patients need longer. When they cannot leave for independent living, this creates a problem. For every week spent in an acute hospital bed, another person is denied access to that bed for their procedure or episode of illness. Some of these unfortunate long-stay patients, denied independence by their illness or injury, are young but most are elderly. And the elderly cohort is increasing dramatically in proportion. This problem will not simply go away.

The cost of keeping an elderly person in an acute hospital bed is significantly less than in a nursing home, speaking purely in financial terms. There is, however, a much greater personal cost in terms of sleep deprivation, loss of personal dignity and control, and loss of social networks.

Most people will cope with this for the average length of stay, which amounts to just under a week. On return home, they will need to recover from their episode of sleep deprivation, just as they would from jet lag after a trans-continental flight.

But the frail elderly person, often with some degree of dementia, will find this sleep deprivation to be even more terrifying than the fit young man with a leg fracture. They have no one with whom to develop a relationship, as the other patients constantly change and staff also change about. Those waiting – for three, four, or even more months – in these conditions to have central funding released to allow nursing home care might well be described as victims of institutional abuse. Remember that these people are also required to surrender 80 per cent of their liquid assets and continuing cash flow to obtain a “Fair Deal”.

We have been through a very lean period, and have now turned the fiscal corner, so to speak. We, as a nation, must invest in the infrastructure and running costs of the care of all our citizens.

The Minister for Public Expenditure and Reform has seen a marked reduction in staff numbers, a cut in salaries, an increase in hours worked and an increase in proportion returned to the exchequer, from those very staff who are trying desperately to work in these appalling conditions. Surely it is time for him to reform and to improve public expenditure?

Let us leave the blame-game behind us and work collectively and collaboratively to enable improvement in all parameters of health. But remember that bricks made without straw will crumble. – Yours, etc,

PATRICK K PLUNKETT,

Clinical Professor

of Emergency Medicine,

St James’s Hospital,

Dublin 8.

Sir, – I was obviously flattered that Prof Tom O’Dowd (January 10th) read my opinion piece “Australian emergency care the State’s best template” (January 8th). However I found many of his contentions not to accord with either the international evidence or my personal experience as a consultant in emergency medicine. Perhaps his continued use of the term “A&E” some 14 years after our departments were retitled emergency departments (EDs) suggests that he may not be fully familiar with the situation in EDs across the country in 2015.

I would expect an academic general practitioner to advocate strongly for investment in primary care; however the notion that better resourcing of GPs (and I agree that this is something that should be done in its own right) will have an impact on the current trolley crisis is misguided.

What Prof O’Dowd and your readers should appreciate is that the current crisis which is manifested in Ireland’s emergency departments is a problem of admitted hospital inpatients. These are patients who have had their emergency care and now require in-patient hospital care; therefore their care is beyond the capability of our colleagues in general practice (and indeed many have been referred to hospital by their GP).

The current trolley crisis has therefore little to do with the emergency departments – the plight of patients warehoused in our departments awaiting a hospital bed is simply a symptom of problems elsewhere in the healthcare system.

It is often stated as a fact that emergency medicine and primary care are interchangeable and that optimally resourcing primary care will obviate the need for emergency department care. The evidence contradicts this. Even where primary care-based alternatives with sophisticated diagnostics are provided, the number of patients attending local emergency departments inexorably rises. Australia is a particularly good example of this phenomenon.

The UK’s Primary Care Foundation report Primary Care and Emergency Departments published in 2010 suggests that 10-30 per cent of patients attending emergency departments could be treated in primary care, a figure which is far lower than the figure regularly trotted out.

Ironically, many of us working in Ireland’s emergency departments recognise that some of these patients are actually referred to emergency departments by our primary care colleagues.

Prof O’Dowd’s line that if we resources primary care we would be able to do with fewer, smaller emergency departments is not supported by the evidence. There is undoubtedly a need for some rationalisation of emergency departments, particularly in the eastern half of the country, but not for the reasons Prof O’Dowd suggests.

Primary care and emergency medicine are two distinct branches of medicine; Ireland needs both and both need to be adequately resourced to do their respective jobs – different but distinct with a small degree of overlap. – Yours, etc,

FERGAL HICKEY,

Consultant in

Emergency Medicine,

Sligo Regional Hospital,

The Mall, Sligo.

Sir, – My colleague Prof Tom O’Dowd somewhat misses the point: “What rightly upsets Dr Hickey and his colleagues are the vast numbers attending A&E that could be dealt with by general practitioners”.

It is true that some patients attending emergency departments could be better cared for in primary care.

However the 601 patients waiting for admission last week are not this group. These patients have been seen and assessed by both an ED physician and another admitting speciality who both concur that the patient requires hospitalisation.

These patients have heart attacks, strokes, pneumonias, collapses, fractures and many other conditions which require acute care in hospital.

Better resourcing of primary and community care is a must, particularly after hours. Like so many things in healthcare, the dividends of this will not be instantly apparent.

But the current crisis is one of flow. We need to be able to get those patients who need admission into hospital and that means we need to be able to get those whose care is completed back out. – Yours, etc,

Dr DAVID MENZIES,

Bray,

Co Wicklow.