Significant disconnect between Emergency Dept and wards at Tullamore hospital - review

A strongly worded independent review of unscheduled care at the Midland Regional Hospital in Tullamore carried out between 2018- 2019 has found that while the demands and capacity shortfall at the hospital was stressed by staff they did not ''provide sufficient assurance to convey an impression of operational grip'' or of being ''sufficiently solution focused.''

Tullamore was one of 9 hospitals reviewed in The Keane Report. Delays in publishing the review by the HSE have been criticised by the Irish Patients Association.

The report indicated that at the time of the review 7 patients on trolleys were waiting up to 25 hours for a bed. It said the Emergency Department expects that up to 9 patients will wait on trolleys along the corridor on a daily basis. ''The way this was described to the review team suggests that their presence has become normalised,'' the report stated.

The team also noted that all patients attending the ED - Emergency Department are triaged on arrival. The aim is for a 15-minute triage but this target often slips as investigations are started during triage which delays the process.

The review team said the ED acts as ''a mini hospital within a hospital''. It stated that 15% of medical patients are cared for there ''reflecting a significant disconnect with the wards.''

The ED information system operates as an excel spreadsheet on a laptop as there is no other electronic system or whiteboard. The review team described this as ''suboptimal to support effective patient flow. There is no telemetry. Meanwhile nurses can manage up to 12 patients each,'' the review found.

High admission rates at the hospital is attributed to either the perceived need for medical input, the lack of a day hospital, limited rehab facilities (3 community rehab beds) or an inadequate number of health and social care professionals in the community.

30% of discharges are COPD - chronic obstructive pulmonary disease related. There is a respiratory nurse in the community but there is no respiratory consultant. Clearly, this is an area to be addressed,'' the review team emphasised.

Both Medical and Surgical Wards were visited. Multiple consultants have patients located on the ward with little evidence of cohorting of specialities leading to safari rounds and prolonged lengths of stay. There are plans in place to commence cohorting of patients at ward level starting with the Age Related service. Despite the hospital being on 'Full Capacity Protocol,' beds were also closed ''but it was uncertain why'' the team commented.

Medical discharges appear to occur late in the afternoon with poor visibility of any Multi Disciplinary Team led Predictive Date of Discharge (PDD).

Nurses expressed their frustration that there are very limited rehab facilities and few places for patients to transition to prior to going home. Nevertheless, ''there did not appear to be any visible initiatives within the hospital such as ‘Get up, get dressed and get moving’ – patients were in bed and in their pyjamas.''

Commenting on the findings of the 9 hospital reviews, Stephen McMahon co-founder of the Irish Patients Association said ''There is a culture at the top of the HSE which sets up the conditions for error and mishap due to poor systems design, leadership, oversight, and intent on implementation which is at the core of Sláintcare. This issue clearly points to a lack of appetite for engaging in meaningful reform from the top and a narrow focus on capacity and resource without attending to the many other elements which impact performance,'' he said.

''It perhaps sheds further light on why senior executives leading Slaintecare resigned. It also highlights a culture of secrecy, indeed a lack of respect towards other stakeholders,'' said Mr McMahon.

In a recent open letter to the Minister for health Stephen Donnelly, Mr McMahon said “You are well aware of our long-standing view on the need for management to be regulated in the same way as medical and allied professionals. In addition, corporate and clinical governance must move beyond a comfort seeking way of working and closing their eyes, to one of being attuned to a keen sense of problem sensing and putting solutions in place.''

Continuing Mr McMahon said: ''The days of commenting on problems by those remunerated and charged with solving them must be called out and stopped. Patients everywhere in Ireland deserve better, much better, performance. We can all play an important role in bringing real reform to our health services.”