Emergency departments - welcome to hell

If anyone wants a sneak preview of some of the likely findings of HIQA's newly-announced safety probe into Tallaght Hospital's emergency department, they can look at the stark comments from some patients made over the past year on irishhealth.com's Rate My Hospital website.

For example:
"My husband went to Tallaght A&E on a Monday night with his x-rays and a letter from a private health clinic stating he had a broken fibula and dislocated ankle. His treatment was a disgrace and costly to the health service. On seeing the triage nurse at 11pm....he was then transferred to a ward at approximately 4pm the next day to await surgery... however, when the surgeon saw the ankle he said this should have been operated on fairly soon after admission, as if you do not operate within six hours he would have to wait six days...as the week went on the pain got worse...finally four days later the doctor said he would like to x-ray...finally at 5pm they brought him back into theatre to pop the ankle back into place..the next day they said they would do the surgery to insert a plate and screws into the fibula...come 4pm the next day, they said surgery was cancelled due to an emergency...we were then told he wasn't scheduled for surgery the next day so it would be the day after that...in total, for a simple broken fibula he spent eight days in hospital..this is a disgrace and is costing everyone money."

Or this comment:
"Privacy in discussing the condition with doctor severely compromised by being on a trolley in a corridor for 54 hours through no fault of staff."

Or this:
"Three days on a trolley before getting a bed in a ward... the nurses do a great job under difficult circumstances. They are short-staffed, under a lot of pressure and I think as a result sometimes the patients might suffer...if they could just sort out the trolley problem - when you're ill and upset, being on public display, with no proper wash facilities, it would help matters greatly."

Or this:
"A post-op infection developed after my release and I was offered readmission but only through A&E, which is third world. I declined and my GP arranged treatment in a private hospital where I was treated as a customer/patient and not just a bed occupant."

Finally, this:

"There was a woman oozing some stuff from her foot in the middle of the corridor. She was on her second day. My trolley was shoved out of the way multiple times as I was dumped in front of x-ray. I was left with a dirty bedpan at my head the whole time I was in A&E. No wonder there is disease spreading through the hospitals when basic hygiene is ignored.".

And if you need any more convincing about the need to look into safety and quality at Tallaght's pressurised ED, look no further than comments made at the inquest last week into the death of a 65-year-old man on a Tallaght Hospital corridor to where he had been moved due to pressure of space in the A&E:

'A dangerous place'... lack of facilities such as oxygen outlets'...'appallingly poor standards of sanitation'...'poor infection control on the corridors'...'complaints to HSE, Human Rights Commission, HIQA etc...'

Add to these recent statistics on high trolley numbers and long trolley waits at the beleaguered south-west Dublin hospital and the the theme of HIQA's report could accurately be predicted as 'welcome to hell'. How to extricate patients and staff from this hell, however, is another matter.

Health Minister James Reilly is correct in stating that the announcement of the HIQA safety inquiry into Tallaght Hospital is significant.  Unfortunately, it's not the type of significant health service development you would be quick to boast about.

For let's be in no doubt about the significance of the State safety body's intervention. This is a new nadir for our health service.

Let's get it into perspective. The health service watchdog has become so concerned about the safety of patients attending for emergency care at one of the country's largest urban hospitals that it is ordering a probe into possible threats to patient safety and the quality of care as a result of the pressurised conditions there. It really doesn't get much worse than that.

And let's remember, this is the second major patient safety inquiry into Tallaght in a little over a year. There was that small matter over the unreported x-rays and unprocessed referral letters, which the hospital and the HSE didn't see fit to inform the public about until the scandal broke in the media three months after hospital management and the HSE first learned of it.

Fills you with confidence, doesn't it?

HIQA had been expressing concern to Tallaght for the past year about safety issues in its ED as well as possible deficiencies in governance and management.

Hold on , were we not told last year that these governance and management issues were being sorted out in the wake of the Tallaght x-ray scandal? This was certainly the impression given in the Hayes report into the scandal published last November.

The crises at Tallaght hospital certainly cannot instill much confidence in the patients who must use its services. They can only hope that the HIQA probe will lead to improvements in governance structures, policies and resourcing

And you cannot but feel sorry too for frontline staff at the hospital, because they will be among the first to suffer from the fall-out from the latest dilution of public confidence in Tallaght's services.

This confidence has been dented, largely through no fault of theirs, but through a tangled amalgam of failed health service planning, poor governance and administration, flawed hospital systems and chronic underesourcing.

Put starkly, if HIQA had similar concerns about a nursing home, as it has about Tallaght's A&E, it could and would order that such a home be closed down.  It's obviously difficult to do this with a hospital or a hospital unit that thousands of people rely on for vital care.

In any case, in the absence of a hospital licensing system, HIQA cannot at present threaten to withdraw a hospital's licence or to close down areas of its services if they don't satisfy set safety and quality standards.
There are many issues HIQA will have to grapple with as it draws up its report. Its findings will have implications for many other hospital A&Es, as we shouldn't kid ourselves that A&E overcrowding and safety problems are unique to Tallaght.

The Tallaght A&E scandal is part of a nationwide problem common to many (but not all) emergency departments.

This problem goes way beyond the issue of exactly how many junior doctors will be staffing A&E units from July 11 or the availability of GP services in a locality, or unnecessary use of A&Es, significant though these issues undoubtedly can be. The A&E crisis is at the heart of our health service's dysfunctionality.

Some of the key factors are -

* Shortage of beds. At least 1,300 acute beds are closed around the country at present, plus a further 500 or so long-stay beds.

* 'Bed-blocking' by delayed discharged patients who have not been provided with alternative care facilities. Over 600 beds are currently unavailable due to delayed discharges.

* Poor service planning leading to hospitals being unable to cope with the demands of their catchment population. This is certainly true of Tallaght and Our Lady of Lourdes in Drogheda.

* Shortage of assessment unit-type facilities to house some ED patients.

* Shortages in key nursing staff/shortages in junior doctor numbers.

* Deficiencies in some hospitals in ED patient processing, admission/discharge policies.

* Lack of 'senior decision-making' in EDs, leading to an over-reliance on inexperienced junior doctors less willing to make key decisions about treatment. More consultant-level appointments are needed.

* Disagreements between doctors and nurses on the best way of dealing with extreme A&E pressure. Doctors say it is safer in these circumstances to place ED patients on wards than to leave them on trolleys or chairs in the ED or in corridors, but nurses disagree with this.

These are issues HIQA will have to grapple with as it draws up its report.

But ultimately, these are issues James Reilly's newly-established Special Delivery Unit will also have to tackle as it embarks on its mission to sort out the A&E problem before tackling waiting lists.
Finally, the results of a recent study from Canada tell us the most uncomfortable truth about our pressurised emergency departments. It showed that people who have to wait on trolleys for vital care are more likely to die or get sicker than those who don't.

The study, published in the British Medical Journal, found that long emergency department waiting times are,  among less well patients, associated with an increased risk of the patient dying or getting sicker.

Ultimately, sorting out our emergency department and hospital capacity crisis is a matter of life and death.

'HIQA to probe Tallaght board, HSE'



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