The HSE has outlined its reasons against reopening Accident & Emergency Units in Ennis, Nenagh and St. Johns.
It comes as the Health Service Executive has issued a written response to the MidWest Hospital Campaign following their public petition to reinstate the region’s three former Emergency Departments.
In November, the MidWest Hospital Campaign presented at the Oireachtas Public Petitions Committee after their appeal to have Accident and Emergency Units reinstated in Ennis, Nenagh and St. Johns garnered over 15,000 signatures.
The campaign group has now received a written response from the HSE’s Chief Clinical Office that states that the clinical advice given would be against changing this policy.
The letter goes on to outline five reasons to support this , the first of which being ‘The needs of the patient’, stating that a patient presenting with an apparent serious emergency condition, would likely require , time critical intervention that could not be provided in a “Model Two Hospital”.
The second reason is ‘the relationship between emergency teams providing high volume of service and better outcomes’, the HSE claims that “there is accumulating evidence in relation to better outcomes in time critical conditions where the clinicians delivering that care treat high volumes of such patients.”
The letter also claims that services such as an intensive care unit, access to emergency surgery and timely access to diagnostic modalities such as point-of-care ultrasound and CT scanning) would be required as a minimum to provide a 24-hour Emergency Department.
The HSE has also cited “Advances in resuscitation at the scene of the emergency” and that The hours of opening of Injury Units, (LIUs) reflect that 80% of people registering for care at an ED do so between the hours of 8am and 8pm and claims the small number of people who suffer injuries other than major trauma during the night opt to await the opening of the Injury Unit a few hours later rather than travelling to an ED.
The HSE’s Chief Clinical Office says that after consultation with the Clinical Lead for the Emergency Medicine Programme, it was informed that the ease of transfer of patients who are clinically stable, with clear care plans in place, from UHL to the JENS hospitals (St John’s, Ennis and Nenagh), including direct transfer from the ED, is “at least as good as anywhere else in the country, if not better.”
The Clinical Lead also highlighted the synergy of recommendations from the EMP and other National Clinical Programmes such as Surgery, Critical Care and Trauma & Orthopaedics in relation to the Networking of Emergency Care.
In summary, the HSE says that the position from clinical experts and programmes, in line with policy development, is against the reopening 24-hour Emergency Departments in Ennis, Nenagh and Saint John’s hospitals in the Midwest.
Full letter from the HSE:
Based on the advice of relevant National Clinical Programmes there is clinical engagement with the Mid West. The advice from the National Clinical Programmes is reflected in healthcare policy, and the clinical advice given would be against changing this policy for the following reasons:
1. The needs of the patient with an apparent serious emergency condition, the nature of which is as yet unclear (undifferentiated), who is quite likely to require time critical intervention of a nature that cannot be provided in a Model 2 hospital (e.g. surgical intervention for life-threatening bleeding or other surgical emergency, complex critical care interventions for patient suffering from septic shock). Experience shows this can lead to the loss of several hours in the patient gaining access to definitive care, despite the best efforts of all staff involved, to the detriment of the patient.
2. The relationship between emergency teams providing high volume of service and better outcomes: There is accumulating evidence in relation to better outcomes in time critical conditions where the clinicians delivering that care treat high volumes of such patients (e.g. emergency abdominal surgery and major trauma).
3. Minimum required supporting services (e.g. Intensive Care Unit on site, access to emergency surgery and timely access to diagnostic modalities such as point-of-care ultrasound and CT scanning) in a hospital providing a 24-hour Emergency Department service that receives undifferentiated emergencies.
4. Advances in resuscitation at the scene of the emergency. There have been great advances in the chain of emergency care over the last decade, allowing bystanders to begin resuscitation of patients in need of cardiac massage under the expert guidance of the call taker in the National Emergency Operating Centre of the National Ambulance Service, placing of automatic external defibrillators in the community, the dispatch of advanced paramedics on motorbikes, rapid response cars or helicopters, while the situation is analysed and a decision made as to the best destination for the patient depending on the nature of the emergency presentation.
5. The hours of opening of Injury Units, (LIUs) reflect the fact that 80% of people registering for care at an ED do so between the hours of 8am and 8pm. More than a decade of experience of Injury Units shows that, in areas where there are Injury Units, the small number of people who suffer injuries other than major trauma during the night opt to await the opening of the Injury Unit a few hours later rather than travelling to an ED. Injuries suffered during night-time hours are often associated with other factors complicating the assessment and needs of the injured patient e.g. interpersonal violence or intoxication.
HIQA’s Report into the MidWestern Regional Hospital (MWRH) Ennis (2009) highlighted the need for the DoH and HSE to consider any required changes in hospitals with a similar profile to MWRH Ennis. The report remains as valid today when increasing numbers of patients experiencing multiple complex conditions are surviving for longer in the community and the range of emergency treatment options has increased, particularly in the areas of highly specialised minimally invasive therapies resulting in faster recovery times. The report made the following recommendations (quote):
- “Change for safety must happen. It is unsafe to keep the configuration of services at MWRH Ennis as they are, and these changes must take place safely and effectively.
- Acute, complex and specialist services are not sustainable at MWRH Ennis. This is because there are not sufficient numbers of patients presenting with these conditions to enable professional healthcare teams to maintain their clinical skills and expertise. Continuing these acute services, including acute and complex surgery, cancer surgery, level 2/3 critical care and 24-hour emergency department services, in their current structure, exposes patients to potential harm.
- MWRH Ennis does not have sufficient volumes of patients attending out of hours to justify an Emergency Department and operating theatre resources being available on a 24-hour basis.
- In the course of the investigation, a number of patient safety issues were identified by the Authority. The HSE was notified and interim recommendations were made to address these issues, Appendix 6, https://www.hiqa.ie/sites/default/files/2017-01/investigation_report_mid-western_regional_ennis.pdf. These recommendations must continue to be implemented as an immediate priority.
- The provision of more staff and resources at MWRH Ennis will not address the fundamental issue of professional teams maintaining their clinical skills and expertise in the area of surgery, critical care, emergency care, children’s and maternity services. This is dependent on sufficient numbers of patients attending MWRH Ennis with certain conditions”.
The report: Securing the Future of Smaller Hospitals: A Framework for Development (2013) was the DoH and HSE’s considered and necessary response to HIQA’s report. The report outlined a Smaller Hospitals Framework, which described the important role of the Model 2 hospitals in the delivery of scheduled and unscheduled care while outlining ways in which to minimise the risk of a patient presenting at the hospital whose time critical needs clearly exceed the capacity of the hospital to meet them.
The establishment of Medical Assessment Units has allowed for many patients with acute medical illness to still be managed in their local Model 2 hospital, once they have been assessed by an appropriate healthcare professional (usually their GP) as having a condition that can be safely treated in a Model 2 hospital.
The establishment of LIUs, with explicit selection criteria, has demonstrated that patients and their carers understand these criteria and receive care for broken bones, dislocated joints and other forms of non-major trauma ‘as locally as is safely possible’. The numbers of patients attending Injury Units has increased year-on-year and is heading towards 150,000 for 2023.
Notwithstanding these arrangements that allow for significant numbers of people seeking urgent and emergency care in the Mid-West to continue to attend their local hospital within clearly defined guidelines, there are clearly capacity issues in the Mid-West which need to be addressed. This is the subject of ongoing planning while the Hospital Group makes the best use of the beds currently open and continues to develop alternatives in the community, which may reduce the requirement for hospital admissions in certain conditions. The Emergency Medicine Programme (EMP) is clear and consistent in its advice that reopening small Emergency Departments to
receive undifferentiated emergency patients with time critical needs is not a solution to these capacity issues.
The Chief Clinical Officer consulted with the Clinical Lead for the EMP and was informed that the ease of transfer of differentiated patients who are clinically stable, with clear care plans in place, from UHL to the JENS hospitals (St John’s, Ennis and Nenagh), including direct transfer from the ED, is at least as good as anywhere else in the country, if not better. The Clinical Lead also highlighted the synergy of recommendations from the EMP and other National Clinical Programmes such as Surgery, Critical Care and Trauma & Orthopaedics in relation to the Networking of Emergency Care.
In summary, the position from clinical experts and programmes, in line with policy development, is against the reopening 24-hour Emergency Departments in Ennis, Nenagh and Saint John’s hospitals in the Midwest.
