A group of non-consultant doctors at University Hospital Limerick has warned that some practices in the hospital are detrimental to and, at worst, potentially catastrophic for patients.
The group of 17 registrars and specialist registrars also argued, in a letter sent last week, that the Limerick hospital is the worst top-level centre in the State for medical registrar training.
However, senior medical management at the hospital, speaking to The Irish Times, have strongly rejected charges that there are increased risks for patients.
In the letter, the registrars argued that the hospital is the sole “Model 4” hospital for 400,000 people, which placed a strain on all services and employees and caused a “disproportionate” amount of stress.
The acute medical assessment unit (AMU) is “not fit for purpose”, they argued, adding that they also had concerns about the referral of patients from the emergency department.
They complained, too, about IT difficulties, training requirements, staffing problems and roster gaps, as well as arrangements for transferring patients between midwest hospitals.
Appropriate treatment
The AMU is currently “running as a medically-staffed emergency department, whereby patients are triaged as ‘medical’ and therefore not seen by ED doctors prior to transfer”.
“In practice, we frequently see patients being inappropriately triaged to the AMU. At best this is inconvenient for medical staff and costly for the hospital,” the group said.
The referral of patients for admission without initial investigations (ie, lab results and imaging) is “dangerous and is not consistent with the standard of care nationally”.
“Because we cannot make appropriate treatment plans or decide which patients need to be seen first without knowing the results of these investigations. At worst, it is potentially catastrophic for patients.”
Saying he had carefully read the examples put forward, the hospital's chief clinical director, Prof Brian Lenehan, said he was satisfied emergency patients receive excellent care.
Responding to questions from The Irish Times, he said care had to be reimagined after the onset of Covid-19 and working arrangements had changed also.
“What used to be our acute medical unit essentially became our medical emergency department for stable patients but it was staffed by staff who were traditionally looking after patients who were referred from the emergency department or from a GP or looking after a patient who had been admitted.”
Concerns
Personnel there are now “looking after patients as if they too worked in the emergency department”, he said, adding that is not how they were trained, but “but that is where they found themselves. A lot of it stems from that”.
Operations in the hospitals were “discussed at length” after the virus struck, he said, and patient care was always at the top of the concerns of hospital medical and administrative management.
Dr Alexander Fraser, clinical director of medicine at the hospital, said consultant numbers had grown by 12, there were more specialist registrars, too, and a new 60-bed block.
Nationally-collected data produces evidence that the hospital is not a poor place for doctors to train. It has 450 non-consultant doctors, while just 25 were involved in drawing up the letter, he said.
Case study: 'He had been referred without blood results'
In one case raised by the hospital registrars, a middle-aged man with left ankle pain was triaged to University Hospital Limerick’s (UHL) acute medical assessment unit (AMU) to rule out a deep vein thrombosis (DVT).
“On examination one could clearly see this man was tender over his ankle joint, and had no signs of a DVT. He then had to stay in overnight to wait for a radiologist’s report on his ankle X-ray to ensure there was no fracture [because medics are not appropriately trained to read joint X-rays].
“Had this man been seen by a doctor in the emergency department he would likely have been discharged within a number of hours, thus saving the hospital money,” they said.
Responding, UHL’s chief clinical director Prof Brian Lenehan said he would accept the assertion that a medical doctor was not qualified to interpret an X-ray.
However, it should have been relatively straightforward for one of the on-call orthopaedic non-consultant doctors to look at the X-ray and decide if the patient could have been sent home.
In another case, a man in his 50s was triaged to the AMU with new hand twitching, but this was later found to have been severe hypocalcaemia requiring critical care and cardiac monitoring.
However, Prof Lenehan said the need for cardiac monitoring would have been there had the patient been seen and assessed in the emergency department, or seen and assessed in the medical emergency department or what is referred to as the AMU.
“The bottom line is that the patient was treated appropriately and the diagnosis was made after a comprehensive history, clinical examination, and tests and then the care escalated appropriately,” he said.
The same outcome would have been reached if the man had been seen in the emergency department: “It is just that our acute medical unit is currently a medical emergency department for patients that are stable.”
Meanwhile, the registrars said a man in his 60s referred with gastroenteritis lay in the emergency department for six hours “with a new rise in creatinine from 100 to 500 and no appropriate IV fluid therapy as he had been referred without blood results”.
“This delay lessened his likelihood of recovering his kidney function and increased his chances of requiring dialysis,” they complained.
