Doctors make raft of recommendations to end Emergency Department trolley crisis permanently

Hospital consultants want to avoid return to the old norm

Conor Ganly

Reporter:

Conor Ganly

coronavirus covid-19

Emergency Department

Doctors at Emergency Departments around Ireland has issued a series of recommendations to avoid a return to crowded  A&E / ED units at hospitals which were eliminated by Covid-19.

The Irish Association for Emergency Medicine (IAEM) has issued a series of recommendations as to how Emergency Department (ED) care should be provided in the phase in which COVID-19 is endemic in Ireland and subsequently.

This series of recommendations has been forwarded to Senior Management in the HSE and the Department of Health and represents the expert view of those who are specialists in Emergency Medicine on the steps that must be taken to ensure the safety of patients and staff in Ireland’s 29 EDs.

Much of what passed as “normal” in the period before the outbreak of COVID-19 was clearly unacceptable, even then. In the light of the social distancing requirements for both patients and staff, these “norms” are all the more unacceptable and cannot be allowed to recur. While there is nobody who can or will regard the crowding which was so regularly and dramatically manifested in Ireland EDs as normal, the Irish Emergency Medicine community has serious concerns that the healthcare system will just passively return to these unacceptable “norms”.

This series of recommendations is intended to ensure that steps are taken now, as a matter of urgency, to lessen the chance of a return to these dark days which now, more than ever, will place patients and staff at considerable and wholly avoidable risk.

RECOMMENDATIONS AS FOLLOWS.

In response to COVID-19, IAEM issued a statement Resetting Care in Ireland’s Emergency Departments on 12th May 2020.
The Association now makes a number of important recommendations to ensure the safety of both patients and staff in our
Emergency Departments (EDs) in the COVID-19 era.

1. Ireland achieves the necessary acute hospital bed capacity

• The incoming Government must address the deficit in acute hospital beds described in the findings of Health Service
Capacity Review 2018, ensuring that the 25-30% of patients that need hospital admission from the ED move from the
ED to a hospital bed immediately. All hospital beds opened during the pandemic must be retained. All beds currently
under construction must be prioritised for completion and a programme of new builds commissioned without delay.
The experience of COVID-19 requires that any project to be designed from now on is built to the appropriate
Infection Control standard. In parallel, the HSE must immediately commence recruitment of the staff needed for
current and planned capacity so that the opening of completed facilities is not delayed.


2. The principle that ‘the right patient is seen at the right time by the right clinician so the patient gets the right care’ is adopted and applied in Irish Healthcare


• Every patient should be registered with a GP so that patients don’t attend the ED for care that should be provided in
the community. Primary Care should be supported in its decision making with appropriate access to diagnostics as
well as senior decision makers in all specialties, not just Emergency Medicine. Digital technology and virtual
consultations may be of assistance.
• The ED cannot be a replacement or surrogate for a variety of non-emergency outpatient and diagnostic services.
Using the ED for functions such as these is an inefficient use of resources and undermines the safety of those
patients who attend the facility as an emergency.
• Only patients in need of Emergency Medicine expertise should attend or be referred to an ED. Therefore, patients
with severe symptoms and those with time-critical illness or injury should continue to attend the ED but alternative
pathways should be identified for lower acuity presentations. Same day direct contact between the referring GP and
hospital-based specialists should be facilitated and GPs must be able to get timely access to diagnostics and
outpatient clinics for their patients. Referring patients to the congregated setting of an ED to access care that should
be available in an outpatient setting is no longer acceptable.
• It should be easier for patients to know where to go for care. A national information campaign and a helpline may
assist patients in deciding where and when to attend for healthcare. Regional expertise with access to the myriad of
services across the community and the acute hospital could direct patients to appropriate care. The Clinical Hub
model developed by the National Ambulance Service in response to lower acuity call outs is an example of good
practice that could be extended.
• Patients should not be directed to the congregated setting of an ED for a portion of their care e.g. registration for
non-EM specialty care. Likewise other specialities arranging to review their patients in the ED should no longer occur
as this is more properly provided elsewhere in the organisation or the hospital.
3. The length of time each patient spends in the ED must be minimised
• The HSE must finally implement its own Patient Experience Time target that 95% of patients spend less than 6 hours
in an ED from the time of registration to the time the patient physically leaves the ED (either to be admitted to a
hospital bed or to go home). IAEM requires that reported PET data accurately reflects the patient’s experience. All
parts of the patient pathway from arrival in ED to when they physically leave the ED should be tracked and improved.
• Pre-hospital and ED Triage processes should be able to apply adequate infection prevention & control standards
from the point of first patient contact. This requires adequate physical infrastructure and staffing levels, social
distancing capacity, appropriate protective equipment and rapid turnaround laboratory testing for particular
infections. COVID-19 is not unique in its mode of transmission and appropriate infection control measures will
reduce hospital-acquired infections (HAI) for patients and staff. This is particularly critical in the ED which sees
undifferentiated patients in whom the diagnosis may not be clear. The current ED experience where a patient with a
condition which merits isolation waits in an ED (often in an open area) until a suitable isolation area becomes
available on a ward is entirely inappropriate and must end immediately.
• Hospitals must have sufficient Consultants in Emergency Medicine to lead the multidisciplinary team, so that
patients arriving in the ED are assessed and treated in a timely fashion. Every ED has access to data that can be used
to predict its pattern of patient attendance (time and number of attendances) and staffing levels should match this.
• Hospital Management Teams should establish the maximum acceptable occupancy in their ED to allow enough space
to accommodate incoming new patients. EDs that clearly do not have adequate space should have immediate
solutions found and longer-term builds commissioned to definitively address this capacity constraint. ED staff should
not be required to reduce the safety or compromise the care of existing ED patients in order to care for the newly
arriving.
• Decision making in the ED must be adequately supported by rapid access to laboratory and radiology diagnostics so
that patients spend the minimum time waiting for results. Every diagnostic result should be available within 2 hours
of request. There must be sufficient capacity to ensure competition between emergency and non-emergency
diagnostic needs does not delay decisions about emergency patient care.
• The practice of admitting a patient for a diagnostic test is neither patient-centred nor an appropriate use of
resources and contributes to crowding. Early supported discharge should be facilitated with access to timely
outpatient diagnostics, specialist clinics and community allied health and home supports
• Clinicians from all specialties must become more involved in the urgent and emergency care pathway so that
patients can receive early specialist opinions and reach the appropriate site for definitive care more rapidly.

• The long-planned roll-out of electronic records for patients in all parts of the healthcare service must occur without
further delay in order to reduce repetition of tests, standardise pathways including diagnostic pathways and
facilitate referrals and transfers.
• Patient care delivered in the ED must be included in hospital case mix data from now on, to ensure that all work is
recognised and suitably funded. Mechanisms such as Activity Based Funding have the capacity to support hospitals
to deliver patient-centred, efficient care pathways that reduce the need for hospital admission when alternative
pathways could be utilised.
COVID-19 has been, and will continue to be, a huge challenge for Ireland, made all the more difficult by longstanding and
well-flagged deficits in Irish healthcare, particularly the lack of bed capacity; infrastructure that is not fit for purpose and
significant staffing constraints when compared with international comparators. Hopefully, it has also brought some focus on
the importance of public healthcare, accessible to all when they need it.
As we move from a pandemic to an endemic state, the Irish Association for Emergency Medicine believes it is imperative
that, as experts in Emergency Medicine (EM), we set out our position on how care in Irish EDs and hospitals generally must
be reset to allow EM to continue to care for those patients that need EM expertise in a way that is safe for patients and staff
alike and produces the best possible outcomes for our patients.