INSIDE A WELSH HOSPITAL UNDER EXTREME PRESSURE
Morriston Hospital in Swansea is just one of the busy hospitals in Wales. RICHARD YOULE goes behind the scenes to find out what happens on a daily basis
IN A room deep in the heart of Swansea’s Morriston Hospital, a briefing is under way about bed numbers, staffing, how many patients are in the emergency department and how many ambulances are waiting outside.
There is no natural light and managers and clinicians sit or stand as they give their 8.30am update to Rebecca Davies – the lead clinical site matron.
The daily patient safety huddle, as it is known, is brisk and businesslike.
Miss Davies has set the scene in clear terms.
“We had an extremely challenging week last week, and that continued into the weekend,” she says.
“Yesterday was very high pressure in ED (emergency department) and across the wards.
“This morning we are level four 20. The M4 corridor is also at level four.
“The stack is seven, and we’ve had several pre-alerts during the night.”
It is an introduction to the linguistic shorthand I’ll hear throughout the day, and I learn that level four 20 means the most extreme pressure a hospital can be under.
A screen displays a snapshot of relevant information, and Miss Davies collates information from her colleagues about the emergency department, critical care, theatres, cardiac intensive care unit, medicine, orthopaedics, cardiology and infection control.
We hear that three ambulances are waiting outside with patients – one for 11 hours 20 minutes – while all planned operations are on hold, eight out of 11 agency nurses didn’t turn up for a shift, a patient died overnight in one of the wards, and brown water is coming through a ceiling in cardiology.
Miss Davies adds that 125 patients were, as of the previous Tuesday, medically fit for discharge but still in the hospital – that’s more than one in six of Morriston’s 721 beds taken up by people who don’t need to be there.
Trying to get these medically fit patients home or into care will become a key theme of the day.
“We are in negative capacity,” says Miss Davies, referring to the bed situation.
“Safety is paramount today. We need to get the (patient) discharges out.
“Happy Monday – let’s go for it.” The pep talk is over, until followup briefings at noon and 3pm.
My eyes are drawn by a clock on the rear wall with an image of a teapot and the words, “Keep calm/Take a break”.
Miss Davies, of mother of two from Abercrave, tells me an internal conference call will take place at 10.30am prior to an external one at 11am, when the health board will see if neighbouring ones can take some of its patients.
I’m ushered to the emergency department, where matron Rebecca Price and Welsh Ambulance Service operations manager Jeff Morris explain how patients are triaged on arrival.
Ambulance crews press a button in the corridor to set the clock ticking.
The target is for 95% of patients to be admitted, transferred or discharged within four hours.
Morriston, like many Welsh hospitals, is a considerable way behind – and the Swansea Bay University Health Board figure for November was 73.2%.
“The crew talks to the triage nurse, and hands over the patient records,” explains Mr Morris.
“But we might have to look after the patient in the back of the ambulance.”
Mr Morris says crews are released to deal with “red” life-threatening calls, while a lower proportion are freed for “amber one” calls, which could be as serious as a stroke.
Mrs Price says the triage nurse makes a decision about the patient, although some will go straight for resuscitation – and children are taken to paediatrics.
She says: “We are always functioning above our core capacity.”
She adds: “Currently we have a shortage with nursing in ED – historically that’s never been a problem.”
Mrs Price says the knock-on effect is being felt by staff, and that sickness rates are higher than normal.
Meanwhile, walk-in patients are sitting in a separate emergency department waiting area, where another triage nurse will prioritise them.
Mrs Price says there is a higher level of patient “acuity” these days, which translates as the seriousness of the condition or conditions a patient presents, and how much medical and nursing input will be required.
Asked about staff morale in the emergency department, Mrs Price replies: “We do try and stay positive. The team are absolutely fantastic.
“Generally morale is quite high, I think. But it is a bit relentless and challenging.”
She adds: “You do get abuse, when patients have been waiting for 10 hours. You understand the frustration.”
But she says a new room for people with mental health difficulties has been “very helpful”, and welcomes the presence of Swansea council social worker Rob Burnard.
“If patients need support or input from social services when they leave hospital, it’s my role,” says Mr Burnard.
“It could be somebody struggling to look after themselves, or family members starting to struggle.”
Asked what he does if the council cannot arrange the right care or support for a patient, he replies: “Then it’s about trying to find a plan B or plan C.”
Mr Burnard liaises with a small clinical team which focuses on emergency department patients aged over 65.
This older person’s assessment
service has physiotherapy, occupational therapy and geriatrician input. It tries to prevent readmissions and halt “de-conditioning” – the process by which elderly patients rapidly lose muscle mass while in a hospital bed.
Dating from the Second World War, the hospital now has a £240 million annual budget and 3,500 staff.
My next rendezvous is with hospital manager Deb Lewis, who describes demand over the summer as “unprecedented”.
She adds: “We have not seen a reduction in the acuity of patients.
“We have had a problem with the back door – predominantly the level of discharge.
“And flu and norovirus have come early.”
Asked how receptive other health boards are to taking Morriston Hospital patients, when required, Mrs Lewis says: “They understand we would not be asking if we didn’t need to.
“It’s often about finding the least worst place for a patient.
“We are all running ‘hot’ – and here we are consumed by our own demand.”
Mrs Lewis says she would like to “knock a few walls down” in the emergency department to create extra space for patients, thereby freeing up ambulance crews.
She welcomes a new “hospitalto-home” initiative which allows certain patients to go home to be assessed for their needs, and adds that a GP has been helping to triage emergency department patients since the start of December.
Mrs Lewis, of Brecon, starts her working day at 7.45am and says she is sometimes still there at 8.30pm.
“My husband has threatened to make a cardboard cut-out of me!” she says.
Asked what keeps her awake at night, she replies: “It’s the ambulances (waiting) at the front door.
“That’s the first thing I check on at night, and the first thing I check in the morning.”
Medics look after patients while they are waiting in ambulances, but Mrs Lewis said the pressure was such the previous Wednesday that there were none available for the community.
I grab another chat with Mr Morris, of the Welsh Ambulance Service. The blockage outlined by Mrs Lewis, he says, is not unusual.
“We’ve got 12 or 13 ambulances available at any one time,” he explains.
“The crews want to deal with eight or nine incidents each shift.
“But sometimes (because of delays at the hospital) they only do one or two.”
Worse, says Mr Morris, crews can hear the incoming calls from ambulance control.
“They want to go out and respond, but they can’t help,” he says.
“That causes stress and anxiety. My sickness levels are the worst in Wales.
“When you have these difficulties offloading patients, it’s very difficult to provide a safe and effective sevice.”
But he says the ambulance service has a very good relationship with the health board, which covers Swansea and Neath Port Talbot.
An ambulance service team leader helps out at the emergency department, and an extra vehicle has been funded this winter to deal with patients who have fallen and hurt themselves.
Further along the corridor, after a couple of twists and turns, is Morriston’s surgical decisionmaking unit.
Here, medics operate on and treat around 35 patients a day.
They could need bowel, facial or dental surgery, or an emergency procedure for an aneurysm.
“We have expanded and expanded – I don’t think I have ever worked so hard,” says ward manager Arlene Davies. “It’s as busy as A&E.”
Mrs Davies says she loves her job, and is full of praise for her nursing staff.
“They work so hard – I am often taken aback,” she says.
“It is a very successful unit, and I’m very proud of it.”
But Mrs Davies says two of her nurses are leaving to become agency nurses, where the pay can be considerably greater.
“Tonight I have got four agency nurses alongside my staff nurses,” she says.
Nurse recruitment, retention and development is one of Mark Madams’ roles.
The hospital’s nursing director is five weeks into his job after moving from King’s College Hospital, London.
“There is a national shortage of nurses,” he says.
Nursing capacity at Morriston is assessed twice a day.
Mr Madams says vacancy rates from ward to ward range from 10% to 25%.
Action is taken, he says, to address higher-vacancy wards, including drawing on the health board’s “bank” of nursing staff.
Mr Madams says the use of agency nurses is “a last-gasp” measure.
He says Morriston Hospital has less of an infection control issue than his previous place of work, but more of an ambulancequeuing problem.
“We don’t want this to be the case,” he says. “The problem is not the flow into the building – it’s the flow out of the back.”
The average age of Morriston Hospital patients is over 80.
Away from the numerous daily demands, Mr Madams says he was heartened by how many patients nominated nurses at the health board’s recent patient choice awards.
Every interaction, he says, should make an impact.
I’m then led to one of Morriston’s medical wards but staff there are too busy to speak, so it’s back to the co-ordination centre for the 3pm briefing.
The briefing has happened early, but I learn that there are now nine ambulances waiting outside – six more than the morning – while the stack of amber calls is up from seven to 22. There are 71 emergency department patients, 10 more than the morning, and the longest wait is 21 hours.
The hospital’s pressure level remains at four 20.
I leave the building, my head spinning.