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IAEM statement on ongoing Emergency Department overcrowding

The recent letter to HIQA from Specialist Trainees in Emergency Medicine highlighted the fact of continuing and unacceptable overcrowding in the country’s Emergency Departments (EDs) and the risks to patients and staff associated with it. We welcome this advocacy on behalf of patients by Consultants of the future. Their message echoes similar statements from this Association over recent years and reiterates the unacceptability and risks associated with this phenomenon. At this stage, it is widely recognised and accepted that ED overcrowding is associated with increased risk of avoidable death, inferior medical outcomes and unnecessarily prolonged hospitalisation.

The immediate response of the HSE is disappointing. Rather than acknowledge the serious and, in some places, worsening problem, it reported a 34% decrease in ED overcrowding with admitted inpatients, choosing 2011 as the comparator year because that year saw the greatest number of inpatient boarders in EDs. The true reduction is actually 22% – laudable but of scant consolation to the 67,863 inpatients who endured being on a trolley instead of being treated in a bed on a ward. Of more concern is the fact that compared to 2012 there is a 2% increase in the number of inpatient boarders in EDs or trolley inpatients on wards.

The inevitable increase in frail elderly patients admitted to hospital as emergencies at this time of year is consistent and predictable and should be amenable to advanced contingency planning. However it is simplistic to dismiss this as the only factor affecting numbers of inpatient boarders in EDs.

The solutions are known – improved patient flow through the hospital system and matching bed capacity to demand, however the solutions have not been implemented. There are a number of reasons for this: inefficient use of beds, competing demands between emergency and elective (planned) activity, reduced staff numbers, fewer hospital beds, lack of access to long term community care, lack of alternative pathways to admission, increasing age profile and disease complexity etc. The contributing causes each require different solutions and until all are addressed ED overcrowding will remain. HIQA, in its report on Tallaght hospital, made clear recommendations.

The fact that overcrowding continues represents a failure of the HSE to proactively manage this predictable situation and should be openly acknowledged as such rather than dismissing the legitimate concerns of doctors about the welfare of their patients.

The Special Delivery Unit (SDU) has had some limited success by addressing process measures however such improvements tend to be reversed during surges in demand of the kind experienced at this time of year. We believe additional bed capacity is required in many acute hospitals to manage this increased demand.

Patient safety is of paramount concern and it is compounded by increasing difficulty recruiting and retaining appropriately trained Medical and Nursing staff to work in Ireland’s EDs. The extremely difficult working environment and the restricted ability to provide patients with high quality care in an environment that respects patient dignity are major contributory factors to this problem. We have repeatedly warned of a crisis in staffing which is of grave concern to Consultants in Emergency Medicine.

Rather than criticise or dismiss those who raise concerns, or attempt to deny the accuracy of those concerns, the government and senior healthcare management should address the underlying problem and adhere to the ‘zero tolerance’ commitment to ED overcrowding with admitted inpatients. This commitment was made as long ago as March 2006 when Mary Harney TD, the then Minister for Health, declared ED overcrowding ‘a national emergency’. In 2006, there were 55,720 admitted patients on trolleys in EDs compared to 67,863 patients on trolleys in EDs and wards last year.

It is time now for the HSE and SDU to once again adopt “zero tolerance” and unequivocally implement the HIQA recommendations in every hospital.

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