Update 03: EMP Report – First Draft Completed

emp_logo The Emergency Medicine Programme is progressing well. We hope to have the Programme plan ready for general consultation by early July. We hope you all like our new logo!

Background issues

Department of Health and Children: Dr Reilly, the Minister for Health has confirmed his support for the programmes. He has also emphasised his commitment to addressing the ED overcrowding issue. We can anticipate that trolley waits will be a key area of focus for the Special Delivery Unit that the Minister intends to introduce. The EMP Working Group (WG) has met representatives of the office of the Chief Medical Officer and our update on “work in progress” was well received.

HSE: The former Directorate of Quality and Clinical Care has become the Directorate for Clinical Strategy and Programmes, with Dr Barry White as National Director. Dr Philip Crowley is now the National Director for Quality and Patient Safety. Mr Tony O’Brien, who was the interim director of the National Cancer Control Programme, is now working with Dr White in his directorate. The Programmes are to be the primary drivers of HSE strategy for the foreseeable future. The Emergency Medicine, Acute Medicine and Surgery Programmes are to be prioritised for implementation.

NCHD staffing: The worsening shortage of NCHDs is a major threat to our specialty and will undoubtedly have a significant negative impact on patient care. This failure of workforce planning is evidence of the need for the comprehensive national EM strategy that the EMP is developing. We can’t sort out the immediate problems with ED staffing but will try to ensure that contingency planning by the HSE is consistent with EM national strategy and to prevent the recurrence of workforce problems in EM the long term.

ED overcrowding: It has been made clear to all the acute care national programmes that they must reduce in-patient length of stay and improve acute hospital access. The Minister’s recent decision to use the ED Taskforce definition of an inpatient boarder on which the INMO trolley count is based is a positive development and was prompted by representations from EM. A study undertaken by our colleagues in the Mater in 2007 demonstrated that the INMO count was a closer representation of the real trolley burden than the HSE figures.

Programme Issues

EMP Report: The EMP Report is now at the stage of a completed first draft and is being edited and reviewed. An implementation plan will be circulated to all EDs and hospitals in conjunction with the report. I think you will find that there are few surprises in the report. The WG has consulted broadly with groups such as HIQA, the HSE RDOs, the Directors of Nursing and Midwifery, the national Clinical Directors, patient group representatives, the therapy professions and medical social workers. Overall, there has been tremendous support for the development of EM which given the personal experiences of many of us over the years is gratifying.

National Clinical Guidelines: The Academic Committee of IAEM has been working on the development of guidelines for the programme. The programme is committed to producing 20 guidelines in 2011, covering PEM, Prehospital Care and General EM. It is appropriate to recognise their hard work in developing robust guidelines which stand us in good stead for the future.

Consultant Posts: The Programme secured funding for new Consultant in EM posts for 2011. We have made it clear that this must be considered a first phase of Consultant expansion in our specialty and we have estimated that we would need 180 Consultants in EM in the longer term to have staffing levels approaching those in Australia. Clearly it will take years to achieve this and we will need to significantly expand training in EM to achieve this Consultant workforce. We need to make EM in Ireland a popular career choice for young doctors. Below is a list of hospitals to which posts have been allocated. I am aware that many people will be disappointed not to see their units included in the list. The EMP working group took the allocation of posts very seriously, knowing that it would be impossible to please all our colleagues. We acknowledge that the relative shortage of suitably trained individuals may make recruitment to all posts an unachievable goal. Our general approach was to prioritise EDs that had relatively fewer Consultants than others with comparable patient volumes and acuity and to distribute our scarce Consultant resource in as effective a manner as possible. Many units that will play lead roles in future Emergency Care Networks did not receive new posts in this first allocation but will do so in the next tranche of proposed appointments. We are progressing the initial posts to seeking Consultant Appointment Unit approval at this time though a small number of posts may be delayed while the thorny issue of NCHD suppression is resolved. The EMP developed a National Job Description for Consultant in EM posts that will be used as a template for all future Consultant appointment applications in general EM and PEM. (This is available as an attachment). The PEM job description reflects the excellent work done by Ronan and colleagues in conjunction with the Faculty of Paediatrics of the Royal College of Physicians of Ireland in agreeing training pathways for Consultants in PEM from either EM or Paediatric backgrounds. The Consultant Appointment Unit has accepted these requirements for current and future Consultant in PEM appointments. This is a significant development for PEM.

Sharing Innovative Practice: Many of you participated in the workshops that we held between December and March. The feedback from these sessions was fantastic and will be circulated to participants shortly. It represents an “ideas board” of how EM needs to be developed and has helped to inform the work of the Programme. Many people suggested current good practices that we plan to disseminate in the coming months. I will circulate a template to gather information on examples of innovative practice that can then be shared.

EMP Groups: Dr John Cronin, SpR, has been nominated by ACEMT as the Trainees’ representative on the EMP Advisory Group. An Emergency Nursing Interest Group has been set up and includes over twenty CNMs from EDs around the country. They have developed a competency framework for emergency nursing and are currently working on the development of a National Paediatric Triage system. Strong team work between doctors, nurses and other ED staff members will be crucial to the development and implementation of our programme strategy.

ED Documentation Project: Many consultants and nurses were involved in the work done a couple of years ago on the development of standardised ED documentation. The document will undergo modification to ensure it is coherent with EMP recommendations. Peadar Gilligan, Iomhar O’Sullivan and Cyrus Mobed will continue to represent EM in this project.

ICT and Data Issues in EM: Performance measurement is a core component of the programmatic approach to service development and the EMP plan will require EDs to set up monthly Clinical Operational meetings to review performance with regard to the 6-hour Total ED Target along with other quality measures. The lack of appropriate ED Information Systems is a barrier to monitoring and improving our practice. The Programme has begun discussions with the HSE to develop a national ED ICT strategy. Unfair comparisons between EDs based on inaccurate and misrepresentative data is another issue the EMP will address. We are setting up a subgroup to develop a national registration dataset and a single diagnostic coding system/casemix measure and have liaised with CEM in this regard. Standardised datasets will also support future research in EM.

EM and Primary Care: Collaborative training opportunities between EM and Primary Care are to be explored by ACEMT and the ICGP. The EMP is also in the process of developing a structured approach to trained GPs working in EDs on a sessional basis.

Overview

I think it is fair to say that EM has “boxed above its weight” in terms of the external support we have achieved thus far for our Programme. The successful implementation of the plan will rely on support from within our specialty. All indications are that the next 12 months will be a crucial one for Irish Emergency Medicine. Please give lots of feedback once the draft plan becomes available to enable any obvious and potential problems to be addressed up front. This is a team endeavour! We will keep you updated more often in the coming months – the EMP will have a dedicated website on which all information relating to the Programme will be made available and I will send address once available.