Friday 28 October 2016

It's not unusual to see a patient I treated still on a trolley a day later'


Dr. Peadar Gilligan, Emergency Medicine Consultant. Beaumont Hospital, Dublin.
Dr. Peadar Gilligan, Emergency Medicine Consultant. Beaumont Hospital, Dublin.

It is not unusual for Dr Peadar Gilligan to come into work and see a patient sitting on a chair who he treated the day before on an ambulance trolley.

The 48-year-old is one of a dedicated team of consultants in emergency medicine working in Beaumont Hospital's overcrowded emergency department.

However, he believes that the issue of overcrowding in our emergency departments can be changed.

"I worked in the UK, and when I first went there, they had an issue with overcrowding," he says.

"Over the period of about four years that was addressed, and addressed in a very definitive and ongoing manner whereby there was a zero tolerance for patients having to remain for prolonged periods in the emergency department.


"There is a huge difficulty in Ireland that we don't have enough beds for the scheduled care and the unscheduled care of patients.

"Hospitals have been under-budgeted and the hospitals in Ireland have had their budgets cut recurrently over the last number of years with a huge, negative impact on the way we can deliver care for patients."

Quite a number of things need to be done, he adds, including increasing bed capacity within the system, as well as increasing bed availability at nursing home level, at convalescence level and rehab level.

"I suppose the concern with regard to overcrowding is the impact it has on our ability to deliver safe care - because if we don't have an available clinical space then our ability to provide timely care and optimal care is very, very compromised," he says.

"The most common reason we don't have an available space is that essentially all our clinical care spaces are already occupied by patients who are admitted.

"They have been seen by the emergency department staff, they have been referred on to the on-call team. The on-call team have agreed that admission is required.

"A bed has been requested and they wait - and we have previously researched this: we found that over two-thirds of the time a patient spends in our emergency department is actually waiting for a bed, having gone through all of the processing.

"So that's time that could and should in a properly functioning system be spent on the ward with care being provided on the ward," Dr Gilligan says.

"That doesn't happen in Beaumont hospital, and in many other hospitals around the country. What happens is the emergency department nursing staff provide nursing care on an ongoing basis for that patient until a bed becomes available, which clearly then impacts on their ability to be available then to see new arrivals.

"We see about 130 to 140 patients a day, so you can imagine that we need staff available to provide for those patients, and they can be everything from a patient who has collapsed because of having an overwhelming infection, to a heart attack, to a stroke, to a patient with major internal bleeding," he said.


Overwhelmed staff are also having to deal with minor complaints like sprains as well. However, like many departments, they tend to stream minor injury work to a separate area within the department, he says, so that work tends to happen without the crowding being affected by it.

"The crowding really does affect the critical care end of our care and the care of those patients who need admission," says Dr Gilligan.

"So it is not unusual at all for me to come into work and to see a person sitting on a chair who I have seen the day before on the ambulance trolley, who I have taken a history from, performed a physical examination, instituted initial treatment whether that be fluids, antibiotics, oxygen, and referred them onto the relevant team if admission is relevant for them.

"To come in the following day to find them sitting on a chair still waiting for that bed is clearly distressing for them, because essentially it means that I, as a doctor, said to them: 'you're too sick to go home,' and yet the best we as a health care service are currently able to offer them is a chair sitting in a hugely overcrowded emergency department," Dr Gilligan says.

"We have had the experience of managing a patient very recently in fact, a patient who came into us on their ambulance trolley in what we call septic shock, which is basically where their blood pressure is extremely low and their heart rate is very high, their oxygen saturations are low, they are very, very sick and require a lot of initial management.

"All of that initial management was performed for that patient on their ambulance trolley because I had no available trolley on which to put the patient, and the patient moved from our resuscitation room, having been resuscitated, to the operating theatre whilst on their ambulance trolley the entire time because we had no available trolley."

He said that it's not unusual for them to have to delay a treatment for a patient because they don't have a trolley.

"In other words, we might have a patient where we are querying the possibility of meningitis but we can't perform a lumbar puncture because we don't have a trolley on which to place the patient to perform the lumbar puncture. They have to lie flat for us to do it and for a period of time afterwards.

"So you know that is just one example of how crowding does affect the timeliness of care. But there is research now internationally that shows the impact of crowding with regard to increased mortality.


"So if you arrive to an emergency department that is already overcrowded, your outcome will be worse than if you come to a department that isn't suffering with crowding and that just makes logical sense.

"It's difficult for the patient, it's very difficult for their relatives to see, you know, their relative who is unwell being managed in an environment that is less than we would wish it to be from the point of view of the actual space available."

In Beaumont, it has previously emerged that patients sitting on a plastic chair while waiting for a bed can actually be concerned that if they get up to got to the toilet their chair will be taken.

"That is clearly very distressing for people to have to almost bags a seat in the place," Dr Gilligan added.

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