Opinion: the historical public health disaster in Irish emergency departments has been compounded by the pandemic
Our son was very subdued on Stephen's Day, but we initially thought it was just exhaustion after all the excitement from Santa. That is, until he woke screaming inconsolably at 4am with a temperature of 42 degrees. Within a few hours, our baby couldn’t even tolerate fluids and his temperature continued to spike.
As it was Christmas, GP clinics were closed so we tried to contact an out-of-hours doctor, but none was available. With no other options, we rushed our sick toddler to hospital, and he became one of the 1.4 million patients to attend an emergency department in Ireland last year. But we were "lucky": our son was admitted immediately to a paediatrics ward and he did not become one of the 70,275 Irish patients who suffered on a trolley in 2021.
A public health crisis has existed in Ireland for decades, and it has arguably claimed more lives over the years than the Covid-19 pandemic. Our health service is critically ill and crowding in emergency departments is a symptom of that illness. Emergency department crowding is widely considered to be the canary in the coalmine for healthcare systems; a clear indicator that all is not well in primary care, general practice and public hospitals.
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From Claire Byrne Live, interviews with doctors, nurses, porters and others on the Covid frontline at Dublin's Mater Hospital in January 2021
The trolley crisis also impacts on the delivery of prehospital care in the community because patient offload delays at hospitals can result in prolonged ambulance response times. Therefore, over-crowding and the practice of "corridor medicine" is a significant patient safety issue which is associated with adverse outcomes including increased morbidity and mortality. Recent research from the UK indicates that there is one excess death for every 67 patients that stay in the emergency department for 8 to 12 hours. According to data from the Patient Experience Time survey in 2020 over 30% of patients were still waiting to be discharged or admitted after waiting for more than 6 hours in Irish emergency departments.
There are many intersecting factors which contribute to the trolley crisis. Input factors reflect patient inflow and the demand for services which is increasing at a rate of almost 1,000 admissions per year. This is largely driven by an aging population, with an increasing prevalence of chronic diseases. Other input factors include the use of emergency departments for non-urgent attendances and under-development of alternative care pathways in primary care and general practice.
Throughput factors relate to processes in A&E where staffing is a key factor of concern. The number of emergency department consultants in Ireland is two per 100,000 population, compared to 4.1 per 100,000 in England. Understaffing is also detrimental to staff wellbeing with a recent study reporting that that 78% of nurses and 70% of doctors in Irish emergency departents met the criteria for burnout.
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From RTÉ One's Claire Byrne Live in March 2018, Dr. Jim Gray, an Emergency Consultant from Tallaght Hospital, on the ongoing trolley crisis at the hospital
Output factors relate to bed capacity and flow in the hospital system. If beds are not available, this results in a bottleneck or "exit block" of patients in the emergency department. Ireland has one of the lowest hospital bed capacities in the OECD at 2.9 per 1,000 population and the highest rate of bed occupancy at 95% meaning there is little to no surge capacity in the system.
It's clear that emergency department crowding is a public health crisis which has been worsening in Ireland year on year. Last year, 1.4 million patients turned up in emergency departments, with 70,275 treated on trollies. In 2006, then Minister for Health Mary Harney declared a national emergency when there were 384 patients waiting for a bed in a single day. 15 years on, the trolley crisis reached new levels with a record of 760 patients on trollies waiting for admission in January 2020. This was immediately before the onset of the pandemic. A public health disaster waiting to happen…
As Covid-19 cases increased worldwide, emerging data suggested a decline in patients seeking emergency medical care for other reasons. While the effects of lockdown were a factor in this, the consensus was that patients avoided seeking medical attention in emergency departments due to fear of infection. This raises concerns about delayed care leading to increased morbidity and mortality in conditions such as stroke and myocardial infarction, a phenomenon referred to as collateral damage from Covid-19. Later in the pandemic the trolley counts rose once more in Irish emergency departments, and some hospitals have been recently forced to initiate escalation protocols, advising patients to avoid hospitals if possible and avail of primary care or general practice.
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From RTÉ One's Nine News in October 2021, record numbers are attending emergency departments in children's hospitals
There are clearly no simple solutions to the trolley crisis. For far too long, emergency departments have been the safety net for our health service, but the pandemic has pushed them to breaking point. In the short to medium term, increasing the healthcare workforce, bed capacity, resourcing primary care and general practice and the provision of alternative care pathways with additional diagnostic facilities in the community could ease the burden on our emergency departments.
But we also need to cast the net wider and earlier in the form of public health interventions at population level. Addressing the social determinants of health and initiating policies which will improve health outcomes will have an impact on hospital crowding in the long term. The burden of chronic diseases such as cancer, cardiovascular disease and diabetes could be reduced through evidence-based strategies focused on behavioural risk factors, such as physical inactivity, diet-related factors including obesity and the use of tobacco, alcohol and illicit drugs.
Emergency department crowding is a symptom of illness in our health service, but health inequity is a far more serious disease and one which requires urgent treatment in our communities. Is it time to resuscitate our social conscience so that our loved ones are not treated on trollies suffering a lack of privacy and dignity when they are at their most vulnerable? Patient-centred, sustainable, system-wide solutions are required to tackle crowding. If not urgently addressed, this will remain a significant public health threat far beyond the Covid-19 pandemic.
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
Dr. Niamh Cummins is a Lecturer in Public Health at the School of Medicine at the University of Limerick
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