PERSISTENT overcrowding in the emergency department; delays in transferring patients to intensive care; hold-ups in transferring casualties from ambulances; inappropriate settings for the care of children; significant infection risks and failures in corporate governance have all been highlighted in a detailed review by HIQA of the UL Hospitals Group.
While the watchdog concedes governance will be a problem in any organisation undergoing transformation – and acknowledges management has not been given the necessary legal footing to implement some of the changes – HIQA reserves its strongest criticism for aspects of care across the hospitals it has already asked the HSE to address.
Chief among them is the overcrowding in the emergency department (ED) in Dooradoyle.
“The periods of significant overcrowding in the ED were negatively impacting on both staff and patients in the department and were causing considerable challenges to staff who were trying to provide the requisite standard of care for all adult and paediatric patients in this suboptimal physical environment,” the report states.
“Persistent overcrowding in the ED was negatively impacting on the care of all patients. It was impeding access to patients for care and observation, reducing privacy and dignity, increasing the risk of transmission of infection and it was preventing adequate cleaning of the department. Such persistent overcrowding adds to the challenge of providing effective care to critically ill and paediatric patients.”
UL Hospitals Group said it had already acted on a recommendation in the report to separate paediatric emergency patients from the others in the ED.
HIQA is also critical of delays in transferring patients out of the ED and into intensive care and high dependency beds.
The longer such patients were mechanically ventilated in the ED, the greater the potential risks. But a review of the records of 50 ventilated patients from July 2013 to February 7 found targets were not being met. For 14 patients, there was no record of how long they had been on a ventilator in the ED and in almost half of the cases for which there was information, the patients were found to have been waiting four hours and longer.
Delays were also a concern in relation to the ambulance service and overcrowding in the ED was reducing the capacity of paramedics to respond to emergencies out on the road.
“Hospital data shows that pre-hospital emergency response ambulances were being significantly delayed when waiting to transfer patients from the ambulance trolley to an ED trolley,” the report stated.
“Consequently, at the time of the authority’s review, pre-hospital emergency care services were potentially unable to respond to critical calls within a safe timeframe.
Efforts by management to spread the workload of the group across the six sites - Ennis, Nenagh, St John’s, Croom and the Maternity as well as Dooradoyle - are positively remarked upon but the inspectors did find that the local injury clinics at Ennis, Nenagh and St John’s were under-utilised at times when Dooradoyle was under immense pressure.
The local injury clinics are supposed to be for less complex cases with Dooradoyle, as the only Level 4 hospital in the group, supposed to be taking the most complex cases.
But an “undifferentiated” stream of patients was still presenting in the region’s only 24-hour ED, creating knock-on effects across the system.
HIQA has already suggested to the HSE nationally that more use of the Ennis and Nenagh clinics should be made - including by patients in Limerick city and county.
This should be communicated not only to the GPs who routinely refer less urgent cases to Dooradoyle but to the public at large.
“Such a communication campaign should emphasise the reduced waiting times in the local injuries units and the benefits of restricting use of the ED in University Hospital Limerick to those who require services that can only be accessed there,” the report says.
Fortuitously, the HIQA inspectors were in Dooradoyle when the storms of last February resulted in a surge in admissions and the activation of the regional major incident plan.
“The activation demonstrated the ability of ULH to respond effectively to a crisis. It is noteworthy that activation of the major incident plan released capacity that was not previously available to ULH and resulted in 50 extra discharges from the system which reduced the number of patients who were waiting on trolleys in the emergency department from 37 to six within approximately eight hours,” the report states.
While HIQA notes the plan to open a new ED in 2016 - which management says will be the most modern in the country - action is required now for the benefit of patients, it said.
“The Authority acknowledges and welcomes the fact that longer term solutions for this issue are vested in the development of a new facility. However, the risk to patients attending the emergency department is an issue for now and the intervening period. UHL, in consultation with the National Director of Acute Hospitals in the HSE, must find a range of interim solutions to deal with bed capacity, excessive trolley waits and overcrowding within the emergency department.
Responding to the report, the UL Hospitals Group pointed to a number of such measures it has already taken.
n The opening of a short-stay unit on April 25 designed for patients that can be discharged within 48 hours and which will soon grow in capacity from 17 to 48 beds
n Increasing the workload of the medical assessment and surgical assessment units across the hospitals, which handle patients who might otherwise end up in the ED
n Twice-daily formal bed meetings to review potential discharges and improved liaison with diagnostics to ensure speedy investigations to free up beds
n Improved communication with community care teams to see if patients can be accommodated in community settings
n The appointment of three patient flow nurse managers to co-ordinate the transfer of patients from UHL to Ennis, Nenagh and St John’s Hospital as appropriate
Ann Doherty, CEO of the UL Hospitals Group, commented: “I welcome this extremely important HIQA report of the governance arrangements; the first such review in Ireland. I am delighted that HIQA acknowledged the commitment that our staff have to ‘providing good safe care and to improving the services’. Staff have been exceptional in their drive to make our hospitals as the best they can be.
“I am very aware that the emergency department is not acceptable for our patients or staff and I have acknowledged that for some time. However we are in the middle of the construction of our new emergency department which is being built to 21st century standards and will be a vast improvement on our current ED. The new ED is opening in 2016 and will be a modern, patient focused facility.”