The perennial hospital emergency department trolley and beds crisis peaked with unprecedented intensity this week. According to the Irish Nurses and Midwives Organisation Trolleywatch survey, at one point more than 600 people were on hospital trolleys in emergency departments waiting for an inpatient bed to become available. With the winter flu season yet to gather momentum and mild weather ensuring falls and fractures are not the source of additional pressure on emergency departments, this year’s peak cannot be blamed on triggers of previous crises.
The timing suggests more endemic factors in the health system as a whole may be the source of the current surge in demand. According to the director general of the Health Service Executive (HSE), Tony O'Brien, the cause of the problem is the number of people in acute hospitals whose treatment has been completed, but who cannot be discharged until appropriate home support or nursing home care has been identified.
Mr O’Brien and his senior colleagues must look more deeply if they wish to identify the factors leading to this logjam. For example, has the HSE analysed the availability of community services in the period from Friday December 19th 2014 to Monday January 5th 2015? There is strong anecdotal evidence that occupational therapy, physiotherapy, social work and some public health nursing services essentially shut down for a two-week period over the festive season.
This means patients admitted to hospitals in the run-up to Christmas who have not been placed in the community are effectively “frozen” in acute beds during at least two weeks of discharge inactivity. This seems both an inevitable and remediable cause of the hospital bed sclerosis. Putting this right does not mean additional staff; efficient rostering by local managers could readily put an end to a practice that serves staff rather than patients.
The HSE must similarly analyse the availability and sustainability of out-of hours GP services in order to maximise the alternatives to emergency department self-referral by patients. And in the longer term, it must commit multi-annual funding to re-orientate the care of people with chronic illness from hospitals to the community. By investing in primary care staff and infrastructure the initial management of acute deterioration in people with chronic illness could successfully be undertaken without the need for hospital referral.
In the short term, adequate funding is needed to speed up the transfer of inpatients to long-term beds. The nursing home umbrella group has confirmed these beds are readily available; it is a question of more efficiently matching supply and demand so that money truly follows the patient. Realistically, much of what needs to be done may not benefit patient safety until next winter. But definitive action must begin now.