Recently a representative of the Royal College of Physicians in Ireland (RCPI) wrote to hospitals threatening ‘the removal of medical trainees’ should a hospital continue to refer patients for evaluation by its doctors without them first having been ‘reviewed and appropriately worked up by Emergency Department doctors.’ This tone deaf circular comes at a time of unremitting, unprecedented demand, manifested as excessive wait times to be seen by a doctor for patients presenting to our hospitals with an emergency or urgent medical problem.
The ‘traditional’ pathway of care for a patient who needs to access care at our hospitals urgently, is that the patient either self presents or is brought by ambulance to hospital. The patient is triaged by a trained Emergency Department (ED) nurse using a standardised, internationally accepted triage process. This assessment is designed to pick out the sickest patients and ensure they are treated first, lest they deteriorate or die in advance of receiving medical care. The Emergency Medicine doctor then sees the patient, initiates investigations (blood tests etc., if not already ordered by the ED nurse) and provides emergency treatment. In 70-80% of the 1.4 million patients seen in Ireland’s EDs per year, the patient is ultimately discharged from the ED. Those 20-30% of ED attendances who need admission for ongoing treatment and investigations are referred on to the on-call team for admission – the vast majority of these admissions being medical rather than surgical. Unfortunately, such patients end up on trolleys in the ED waiting an inpatient bed for protracted periods of time. Indeed a recent HIQA publication has noted that patients may wait for up to 3 days for hospital admission which is a national scandal.
This ‘traditional’ pathway is overwhelmed when the numbers of patients presenting and their acuity or complexity exceeds the capacity of the ED medical staff to see, treat, discharge or refer in a timely fashion. Streaming of suitable patients from triage to Acute Medical Assessment Units to avoid this bottleneck occurs in many hospitals to alleviate this. Indeed, this very model is described in the Acute Medicine Report in 2010 and has historically been strongly supported by RCPI! Furthermore, in the recent Christmas and New Year period, where hospitals were inundated with emergency presentations, the HSE’s Chief Clinical Officer advised that a system of distributing patients to on-call teams happen earlier in such patients’ care in response to large numbers of very sick (triage category 2) patients not being seen in a timely manner and the associated risk of death while waiting to be seen.
Unfortunately, it would seem that RCPI has very inappropriately targeted these important patient-centred patient safety developments in their threats to hospitals of withdrawing medical trainees. It must be remembered that such trainees and training programmes are actually funded through the HSE by the tax payer. The Association is aware that the HSE CCO has since written to hospitals advising that his guidance remains in place, notwithstanding RCPI’s intervention and the Association therefore calls upon RCPI to withdraw its ill-considered missive and focus on the needs of patients.