Trolley Gar - Let's Change The Debate
Aug 16, 2016 -
Author: Tony McNamara, CEO, Cork University Hospital Group
Over recent years the Irish Health system has intensified the use of metrics to improve performance and has been successful in helping to embed a culture of decision making on the basis of data rather than on intuition or precedent.
One of the metrics used is the three times daily count of trolley numbers in our acute hospitals called “Trolley Gar” which reflects the count of patient numbers on trolleys at 8 am, 2 pm and 8 pm daily. Unfortunately these data and specifically the trolley count at 8am, has become the touchstone for the health service and is often used opportunistically by various stakeholders to criticize the Minister, the HSE and various other leaders responsible for the delivery of the health system.
The use of this data at 8 am for the purpose of making a judgment on the hospital or health service performance is flawed for a number of reasons including the fact that at 8 am, hospitals are at their most vulnerable having had only emergency diagnostic services available in the previous twelve hours and minimal access to resources required to transfer patients to beds.
In reality, high numbers of patients on trolleys is a stimulus for hospitals to take various escalation measures including additional ward rounds, cancellation of elective admissions and other initiatives most of which are set out in the Workplace Relations Commission recommendations of December 2015. The reality is that these processes should be embedded in the routines of all acute hospitals and are only moderately successful when employed in a reactive manner.
There is however another perspective on the all-pervasive focus on the daily 8 am trolley count and in my view the following issues are worth noting;
- The trolley count at 8 am, when diagnostic and other critical services hospitals have not been functioning at the level required to progress patients through the pathway (either for admission [33%] or for discharge [67%]), is not a fair representation of the performance of hospitals;
- Importantly, low trolley numbers at the 8 am count do not necessarily reflect lower attendances but rather better processes over a 24 hour period and as an example week ending July 29th (2016) reflects an 8 am count of 9 on average with 175 average ED attendances at Cork University Hospital which is the normal ED activity for the Hospital;
- It is also important to note that in some hospitals, good internal processes rapidly reduce the number of patients waiting a bed in the hours following the 8 am count and in CUH the average 8 am count of 19 patients per day (year to end of July 2016) was reduced by over 50% by 2 pm each day to 9 patients;
- The unfair representation of the 8 am trolley count as a measure of critical deficits in the hospital and the health system is overly simplistic and doesn’t reflect the nuances of the multi-various factors that should be part of the discussion on the efficiency of patient flow processes;
- It is clearly in the interest of some stakeholders such as staff representative groups, opposition politicians and private providers to use this data opportunistically to criticize the Minister, the HSE and individual hospitals in support of increased resource allocation;
- It might be observed that indeed it is not in the interest of some stakeholders to see a resolution to the “ED crisis” or to optimize patient flow since that will only serve to reduce the leverage that might otherwise be exerted to secure more staffing (e.g. Workplace Relations Commission 2015 recommendations on ED) and resources for the placement of delayed discharges (€75m in 2015) etc.;
- Whatever the motivation for the use of the 8 am trolley count as a proxy for performance, the abuse of this singular metric serves to damage the reputation of individual hospitals and by extension, of the health system generally;
- This metric is a singular measure of the number of patients awaiting admission in our Emergency Departments. As such it is not a measure of the patient experience time (PET) nor is it a measure of the efficiency of patient flow in our hospitals.
Overall the conclusion might be that a much more nuanced approach is needed to create a more informed debate on the efficiency of the patient pathway and the all-important patient experience in our hospitals. The challenge is for health care providers to create that dialogue through the advocacy of National Care Programmes, by informing the public that these are much more complex issues than are usually portrayed and by encouraging informed debate in the media on these issues.
A measure of the complexity of this issue is that in the case of Cork University Hospital, where c. 70,000 patients attend the ED each year and 33% require admission, there have been almost 130 different changes in the pathway for emergency patients (www.cuh.hse.ie/About-Us/Patient-Quality-Safety/The-Change-Programme-2013-2016/Unscheduled-Care-Patient-Pathway/)
Notwithstanding this substantial change programme much work remains to be done following the reconfiguration of services that has resulted in 2 Emergency Departments serving Cork city and county where a short few years ago there were 5.
Our focus in CUH is moving towards demonstrably improving the experience of each individual patient who attends our ED and we are specifically focused on ensuring that no patient waits over 24 hours and no patient aged over 75 years will wait over 9 hours for a bed.
We intend reducing these targets further later this year in the belief that this is in the interest of quality patient care even if this results in a higher number of patients at times in ED at the 8 am count. If there are resultant increases in trolley numbers while the hospital’s processes rapidly place those patients in beds and this generates discussion on the inadequacies of the 8 am count that will be a very welcome secondary outcome.
Your comments are welcome below. Thank you.