Delays in ambulance response times have been much in the news recently and, while there may be a number of contributing factors, a significant one is the length of time ambulances can be held up at hospital emergency departments.
For years, those working in the health service have highlighted how large numbers of patients on trolleys in emergency departments can have knock-on effects.
These are not just on patients who suffer the indignity of waiting hours and even days in overcrowded A&Es, but also on the problems for ambulances when they arrive with new patients – finding a place for the patient so the ambulance team can take the patient off its trolley and depart to attend a new 999 call.
Just exactly how much time has not been clearly documented up to now.
Previously unpublished figures obtained by The Irish Times under the Freedom of Information Act indicate many ambulances are routinely being held up for an hour or more at emergency departments when the HSE's own target turnaround time for these ambulances is 20 minutes.
In every region of the country in 2012 and 2013, these targets were being missed.
The HSE’s own figures show that, in the east, ambulances were constantly delayed at least an hour in about 40 per cent – and up to 48 per cent – of cases in the first eight months of 2013.
By December 2013, the situation had improved but still almost one in 10 ambulances had a turnaround time of greater than 60 minutes in the final month of last year.
How much longer than 60 minutes they had to wait is not documented in the figures.
In the northwest, 18 per cent of ambulances in December had a turnaround time of greater than 60 minutes.
Wait-times were longest in the midlands last year.
Ambulances were waiting at least an hour in more than 80 per cent of cases in January, March, May and July, before being able to leave patients in emergency departments and depart on a new call.
In February, April, June, August and September, they were waiting an hour or more in over 79 per cent of cases.
While the situation had improved by December to hold-ups of an hour or more in 29 per cent of cases, this means one in three ambulances are still being held up for that period in the midlands.
The data is not broken down to reveal which hospitals had the longest delays.
Targets
Looking at where targets were met, in the east in December 42 per cent of ambulances had turnaround times of 20 minutes or less; in the northwest the target was met in 19.5 per cent of instances; it was met in just over a quarter of cases in the southeast; and the best performance was in the Dublin Fire Brigade ambulance service, where 55.7 per cent of ambulances met the target turnaround time.
The HSE, in its December 2013 National Performance Assurance Report , identifies the problem as a key obstacle to improvements in ambulance response times.
“The issue of hospital turnaround times will be an area of particular focus by the National Ambulance Service in 2014,” it says.
HSE ambulance paramedics across the State have told The Irish Times of having to wait well over an hour on a regular basis at emergency departments before being able to depart. Their experiences are borne out by these new figures.
Glen Ellis, advanced paramedic with Dublin Fire Brigade, recently told the Oireachtas Committee on Health: "We face, on a weekly basis, delays of three and four hours outside hospital emergency departments waiting to hand over patients.
“There can be delays of 10, 14 and even 16 hours because our nursing colleagues in the hospitals are struggling to get beds, which has a knock-on effect on our vehicles being able to leave and attend to life-threatening situations.”
The closure of smaller emergency departments around the State has lengthened ambulance turnaround times as the larger ones are left taking up the load.
Dr Paul MacMullen, senior medical registrar at St Vincent’s University Hospital, Dublin, says the impact of the closure of the emergency department at St Colmcille’s hospital in Loughlinstown on November 27th was “immediate”.
“There has been a 50 per cent increase in ambulances parked up outside and a 40 to 60 per cent increase in GP referrals into A&E in Vincent’s.”
The daily “‘trolley count” by the Irish Nurses’ and Midwives’ Organisation indicates there were no people on trolleys in St Vincent’s emergency department the week before Loughlinstown’s closed. The following day, St Vincent’s had four people on trolleys. By December 3rd, it had 16 on trolleys. Numbers were steady until December 17th when there were 26 people on trolleys.
So far this month the hospital has had the highest number of people on trolleys in Dublin hospitals on three occasions, at about 25. Similarly, since the emergency departments at Ennis and Nenagh closed in 2012, the trolley count at the Mid-Western Regional Hospital in Limerick grew from 3,626 in 2012 to 5,504 last year.
Dr Chris Luke, an emergency consultant at Cork University Hospital, says the closure of smaller A&Es has led to a "deterioration in care for the majority of people who need to go to A&E" and was based on "false health economics".
Being addressed
Martin Dunne, director of the National Ambulance Service, said delayed turnaround times were being addressed. No ambulance should be delayed for more than 20 minutes.
“When vehicles are backed up at hospitals we go into escalation mode,” he said.
This meant the ambulance service would send “resource managers” to hospitals where delays were building “to engage with the various hospital managers, with the bed managers, and we have a conversation to try and release the vehicles as quickly as we can . . .”
He added: "We are looking at 20 to 30 minutes maximum, and that would be our trigger point."
kholland@irishtimes.com
