No one-size-fits-all fix for trolley crisis

THERE is not a single “fix it” remedy for hospitals grappling with the trolley crisis. There is the obvious and clear need for more acute beds on wards, intensive care and other areas in a hospital.

More beds are also essential in the community including badly needed facilities for patients who need rehabilitation.

But a diagnosis of what will make a difference during the darkest winter days and a spike in flu – not to mention summer months – shows there is no one-size-fits-all formula.

However, it’s also the case that some hospitals did not suffer the same level of gridlock in the first week of January as others.

Beaumont Hospital and Connolly Hospital in Dublin as well as Our Lady of Lourdes Hospital in Drogheda and Cavan Hospital have been pointed to as examples of hospitals that avoided the worst chaos.

All are in the Royal College of Surgeons of Ireland hospital group.

Dr Emily O’Conor, emergency consultant at Connolly Hospital, said yesterday it prepared before Christmas to enhance patient flow and has recovered well after last week’s trolley spike.

It’s not down to any one measure, but throughout 2017 it improved its discharge practices. The number of patients who were medically fit and suitably resettled increased to free up beds.

They were transferred to nursing homes or convalescent beds.

It means the number of these delayed discharges in the hospital went down from 40 to 20, creating precious space for incoming patients.

“In some areas in the group there has been an increase in acute bed capacity.”

In Connolly the group has focused on having an experienced consultant available in the emergency department from 8am to 8pm every day.

One of the weaknesses in many hospitals has been the over-reliance on junior doctors, who do not have years of experience behind them and tend to be more cautious so they keep patients in and admit them to a ward.

“We also have a clinical decision unit. Not all emergency departments have one. It is a way to manage the process.”

It is an area where patients who will just need a shortstay are kept under the care of the emergency doctor.

It means they are not sent up to a ward and managed by other specialists.

This is also in place in Cork University Hospital.

Dr O’Conor (inset) said: “Emergency medicine brings skills in rapid decision making. So that maximises our skills.

“It’s not that there are not solutions out there.

“We are not describing anything new. There are lots of practices we are aware of.

“We are not short of ideas but the main issue we are concentrating on is more acute beds.”

She said the whole solution, however, would be made up of many components. For other hospitals the prescription varies. This includes a need for more nurses to open extra beds to take surge patients.

Some hospitals have seen a particular rise in older patients who are particularly frail and have several illnesses.

This means they have a longer length of stay.

Others may have vacancies for GPs in their areas which can lead to more patients who could be treated outside of hospital having to be sent to A&E. In other areas there has been a closure of public nursing homes due to safety reasons and the state of the building. This has closed off avenues for discharge.

A key weakness for many is the lack of access to diagnostics out of hours, so the patient is having to wait for hours overnight on a trolley until regular service resumes.

The numbers of staff in many of the smaller hospitals mean the same flexibility with rostering is not available. Hidden factors are management style and also the policies of the clinical director who is overseeing the hospital.

All of this has been well pinpointed by health officials and ministers over the years. The wonder is that we are still talking about it.