I will give an overview of the role of accident and emergency departments, the perceived overcrowding and the accident and emergency crisis over the past ten years. The primary role of the accident and emergency department is resuscitation and stabilisation of acutely ill or injured patients. Another role is the management and assessment of less seriously ill or injured patients. The department should not be used as the main route by which general practitioners can gain access to hospital services. In recent years, the workload of the departments has increased in terms of complexity and interventions, particularly those of a time-critical nature involving the use of clot-busting drugs to manage heart attacks, and they are filled with inpatients lying on trolleys waiting for hospital beds.
I wish to recount the history of how this problem arose. The first recorded incident occurred on 21 October 1991 in the Adelaide and Meath Hospital, when the consultant, Mr. Keye, received a letter from three members of staff complaining about a patient who should have been in a hospital bed but who remained in the accident and emergency department overnight. The problem initially occurred in Dublin during the winter months before spreading to peripheral hospitals and becoming a year-round phenomenon. This mirrors what happened in all other countries, particularly Australia. In Ireland and other countries, closure of hospital beds preceded this trend.
While attendances at the accident and emergency department at University College Hospital Galway have not increased in the past year — between 2004 and 2005 there was a slight reduction in attendances and a 4.5% reduction in the number of emergency admissions — there was, however, a 45% increase in the number of patients lying on trolleys in the department waiting to gain access to beds. This is reflected in other departments throughout the country, particularly that in Limerick, which was cited by Professor Drumm and the Minister for Justice, Equality and Law Reform, Deputy McDowell, as not having a bed problem. To date this year, Limerick hospital has had 727 patients on trolleys overnight in the accident and emergency department. On the worst evening there were 32 such patients.
I wish to refer to the effects of this on the functioning of accident and emergency departments. Patients expect appropriate treatment in a timely fashion. People are frightened to go to accident and emergency departments because they believe they will be obliged to wait for hours. It has been shown that the length of time patients, including those discharged, spend in accident and emergency departments is directly related to the occupancy level of the hospital. When there are no beds available in a hospital, waiting times in the accident and emergency department, even for patients discharged, increase.
We have suspected for many years that this has an adverse effect on patient outcomes. Recently published papers have confirmed this. If a patient is admitted to an accident and emergency department when the hospital is overcrowded and its bed occupancy rate is greater than 90%, there is a 20% to 30% excess patient mortality rate. This study was conducted in the greater Perth area and has been circulated to members. The study considered an area with a population of 1.4 million people, equating to 120 excess deaths per year in an area the size of the greater Dublin area.
The media recently referred to contagious diseases. A paper from Canada addressed the recent outbreak of the sudden acute respiratory syndrome, SARS. In one Canadian hospital, 78 patients were infected and five died. All of those individuals were contaminated by one patient who should have been admitted to an appropriate isolation facility but who stayed overnight in an emergency department. We see this as a significant public health problem. It is no longer a crisis, it is an emergency that must be dealt with quickly.
I wish to briefly address some misconceptions, one of which is that this is an accident and emergency department crisis. It is not an accident and emergency department crisis. The causes and most of the solutions lie outside the accident and emergency departments. The workload coming through such departments in terms of emergency admissions is largely predictable, except where a major incident occurs. The problem is that when a patient has completed his or her episode of emergency care, a bed is not available in the hospital. This is called "exit-block" or "hospital access block" in some countries.
It is interesting that we do not have such a trolley problem during holiday periods when elective work slows down. Over the Easter period, there was not as serious a trolley problem as there had been in previous weeks. Some people attribute this to the announcement of the accident and emergency task force. However, it was predictable and came about because work relating to elective procedures had slowed down and more beds to which patients could be admitted were available.
Other misconceptions I wish to address include the recent discussion in respect of the hours during which patients attend emergency departments and that fact that most of them do so outside normal working hours. In fact, 75% of attendances occur between 8 a.m. and 8 p.m. Only 30% of attendances occur between 5 p.m. and 1 a.m. The point was raised that working practices are inefficient and that patients must be seen by five doctors before they are admitted. Certain small groups of seriously ill patients are seen by five or more doctors and this is perfectly appropriate. However, it is not the normal practice for the vast majority of patients who attend emergency departments.When patients are brought to hospitals following major traumas, the services of intensive care, orthopaedic and general surgical specialists and, perhaps, plastic surgeons will be necessary.
There has been much discussion in the media to the effect that the problem is due to inappropriate attendances, such as those involving people who are drunk attending accident and emergency departments. Those who are drunk still require care if they have a medical problem. They account for a small percentage of attendances. If we removed all of the drunks and patients with supposedly inappropriate conditions — most of whom are ambulatory — who come to emergency departments, we would still have large numbers of elderly patients waiting on trolleys for admission to hospital beds.
The other misconception is that the trolley problem is due to outbreaks of flu or the vomiting bug. The latter place extra strains on the system but the problem with bed capacity is year round in nature. It is not related to significant seasonal variations, other than during holiday periods when elective surgery slows down and more beds become available.
I re-emphasise that overcrowding is not due to the number of attendances at accident and emergency departments. The number of attendances per 1,000 of population in Ireland is similar to that in the UK. During the past five years, the UK spent a large amount of money on developing minor injury units, walk-in centres, out-of-hours GP co-operatives and NHS Direct. None of these has been shown to have made a significant impact on emergency department workloads. The recent Tribal Secta report confirmed that in Galway, where I work, the establishment of the Westdoc GP co-operative two years ago had no significant impact on accident and emergency department attendances.
The problem involves a lack of acute inpatient beds. There are three acute beds per 1,000 of population in Ireland. The UK figure is 3.5 beds and the OECD average is 4.1. To match the UK figure, we require 2,000 extra beds. To meet the OECD average, 4,000 new beds will be needed. In her report on acute hospital bed capacity in 2002, Dr. Mary Codd recommended the creation of 3,000 new beds. She stated that even if we increased efficiencies by 30%, we would still need 3,000 new beds. Internationally, it has been shown that the problem is based on bed occupancy. Once bed occupancy rates exceed 85% — the hospital in which I work runs at a 94% rate — there will regularly be days when there will not be enough beds for emergency admissions.
What is the solution? The first part of the solution is to accept that the cause of the problem is that there are not enough beds in the acute system. Everybody seems to be shying away from that. One can tinker around the edges and try to divert people from hospitals, but the vast majority of these patients required admission. On Tuesday morning, 28 patients were on trolleys in the accident and emergency department at UCHG. After the post-take ward round by two consultant physicians, which was completed by 10 a.m., no patients were fit for discharge and the vast majority required acute hospital beds.
We must accept the cause of the problem and apply a policy of zero tolerance in respect of trolley waits in emergency departments. We accepted one person on a trolley, then two and then three. The general manager of a hospital must be responsible and accountable for trolley waits. Resources must be allocated towards solving this problem. Fundamentally, we need an increase in beds and relative capacity to reduce our occupancy rate to below the accepted international norm of 85%.
Much debate has taken place on whether we have a total or relative lack of hospital beds. If an 85 year old lady needs admission to a hospital bed, it is irrelevant whether that lack is total or relative. Not having a bed available for her at that time means we, as a society, have failed her. I thank the committee.