We are failing when people aged 102 are left on trolleys
Analysis from the Irish Independent on 10 June 2015 on ED over-crowding
Nine weeks after the publication of the Emergency Department Task Force Action Plan and nine years after then-health minister Mary Harney declared A&E overcrowding a ‘national emergency’, some of our oldest citizens are being exposed to ‘forms of torture’ in this country’s Emergency Departments (EDs).
Reports of two women, both over 100 years of age, having to wait on trolleys for over 24 hours in the last week has put this endemic issue of unsafe bottlenecks in EDs back on the public and political radar. There is no excuse or justification for any older person waiting this long for a bed.
Anyone who presents at an Emergency Department who needs to be admitted is by their nature an ‘acute’ hospital admission. They need a bed immediately, not to wait 12 or 24 hours on an unsuitable trolley in a totally inappropriate place.
Rose O’Halloran, aged 102, waited 26 hours for a hospital bed in Tallaght hospital on June bank holiday Monday. Dr James Grey, a consultant in emergency medicine in Tallaght, described the woman’s treatment as a “form of torture… a national disgrace, a human rights abuse”.
A week later, another older woman, aged 101, waited 25 hours on a trolley for a bed in Limerick hospital.
Dr Grey spoke of their treatment as human rights abuse because both women would have experienced constant light, been sleep-deprived in a noisy, busy ED, without privacy, confidentiality or dignity.
Such long waits for a hospital bed in over-crowded EDs have potentially fatal effects. It is well proven nationally and internationally that older people who wait over 12 hours on a trolley will have longer hospital stays, more medical complications, greater levels of confusion and anxiety, and are less likely to return home. Evidence from Australia shows that high numbers of people waiting a long time in EDs results in increased adverse events and errors, poorer health outcomes and excess deaths.
Given the political attention and public outcry for over a decade, why can’t the powers that be fix this problem?
It is a truism that the problems in EDs are symptomatic of dysfunction across the health system. Poor access to essential diagnostic tests in primary care and the community means people end up in EDs either needing those tests or as an emergency because they did not get them earlier. These are typically public patients who are not insured and cannot pay for such tests privately. Inadequate and under-resourced social and community services result in high numbers of people who did not have their care needs met in the community, presenting at ED with medical problems.
Most people who are admitted through EDs are in need of urgent medical care but funnelling them all through the ED door does not make sense.
Then when people need to be admitted, there are not enough beds due to seven years of cut-backs to the hospital system, while many beds are occupied by people who no longer need to be in hospital.
Simultaneously, hospitals are also under huge political pressure to meet unambitious, but hard to reach, waiting lists targets for record-high numbers of outpatient, inpatient and day-case appointments.
The 2006 and 2015 task force reports both diagnosed and prescribed a raft of measures to tackle ED over-crowding. For such plans to work, there needs to be sustained political attention, good local and national leadership, sufficient money, people and services, as well as, changing how some things are done.
This did not happen in 2006 and it is too early to tell if the current plan can work. However, this week’s cases are not a good indicator. No hospital should leave anyone so old waiting so long, no matter what.
When Health Minister Leo Varadkar launched the ED task force report in April, he also announced an extra €74m to assist making it happen. This included €44m to provide extra nursing home places, while a further €30m was allocated to provide temporary beds, extra community, convalescence and district hospital beds, as well as, 400 home care packages.
This has had some effect, with waiting times for a nursing home bed down from 11 weeks to four weeks, and Government is committed to keeping it there.
There are 144 more public community beds for people to transition from hospital to home or a nursing home and so far this year, over 2,500 people got this care or are about to get it. The numbers of people stuck in hospital has been reduced from a high of 830 in December 2014 to 631 in early June. Most of these delayed discharges are waiting for a nursing home bed.
Yet, despite these positive impacts, the number of patients on trollies remains persistently high in some hospitals, especially for mid-June.
But the big test will be next winter. The ED plan will have had eight months to ‘fix’ the problems. However, it is unlikely to be enough to stem pressures on hospitals. Quite simply, demand is still exceeding the ability of the health system to supply pretty much every aspect of care. And it is improbable that this will change by Christmas.