So What Actually Happened in Cork University Hospital in January 2018? Feb 13, 2018 -
The headline in the Irish Examiner on Friday 22nd December last read “Cork University Hospital Cancels Surgeries for Two Weeks” telling it’s readership that as part of the planning for the inevitable Winter challenges in its Emergency Department, the leadership in Cork University Hospital decided to defer the recommencement of planned surgical activity to January 8th allowing a period of one week to proactively manage the anticipated influx of emergency patients. Predictably the reaction lacked any real attempt to understand the dynamic at play or the complexities of aligning emergency and planned activity in a large acute hospital.
Two weeks later on the 4th January 2018, the headline in the Irish Times read “The Problem of Patients Waiting for Days on Trolleys in the State's Public Hospital Emergency Departments has yet to be Effectively Addressed” highlighting the pressure on Emergency Departments at the beginning of the busiest time of year for emergency admissions to hospitals.
So what actually happened in Cork University Hospital in respect of emergency and planned activity in January? Was the decision to defer planned activity for one week to January 8th the correct decision and how did the Hospital perform in January 2018 relative to 2017? The answer, as ever, lies in the data and in understanding the interplay between emergency and planned activity.
Emergency Department Activity
Remarkably, patterns of activity in Emergency Departments remain very predictable over time and in January 2018 5,456 patients presented in the Department compared with 4,817 in 2017 an increase of 13%. What does differ between both years is that Cork University Hospital is now over 6 months in to the implementation of a quality improvement programme called Project Flow ’17, for emergency care that has seen a 50% reduction in trolley numbers (at 8am each morning) since its commencement in mid-2017.
This change programme incorporates multiple new processes to improve patient flow but especially it reflects a commitment by leadership at all levels to improve the experience of patients attending ED. These changes have contributed to a significantly improved performance in the flow of patients through the ED and Figure 1 demonstrates the trend that led to 120 less trolleys in the ED in January 2018 a reduction of almost 16% over the 2017 performance.
Cumulative Trolley Numbers in the ED in Cork University Hospital 2017 / 2018
The decision to recommence planned surgical activity on January 8th was carefully considered and was based, in part, on the learning from the previous year when the Hospital experienced unprecedented demands on its ED service. Furthermore during 2017, the Hospital constructed a new Day Surgery Unit adjacent to the theatre complex to allow for an independent, autonomous elective entity that would not be compromised by demands on emergency care. This Unit opened on January 8th in tandem with a commitment from hospital leadership that except in extremis, there will be no cancellation of elective surgical admissions to the Hospital.
Two benchmarks may serve to represent what actually happened in January in respect of elective planned activity vis. (i) what was the relative level of day case activity in January of 2017 and 2018? and (ii) what was the relative level of cancellation of planned surgical admissions in both periods?
In respect of the levels of activity in both periods the evidence demonstrates that there was a similar number of surgical day patients admitted to the Hospital in January 2018 relative to 2017 notwithstanding that activity was concentrated in to a three week period in 2018.
In 2017, the Hospital experienced great difficulty in managing to continue to provide elective, planned surgical services because of demands on the Emergency Department and in January of that year 97 elective admissions were cancelled leading to patient dissatisfaction and to concern about the alignment of emergency and elective care. The opening of the Day Surgery Unit has changed this dynamic and has enabled the Hospital adopt a policy of non-cancellation of surgical admissions and Figure 2 demonstrates the numbers of such cancellations in January 2018 (zero) relative to 2017 (97).
Most public hospitals in Ireland operate at a level well in excess of 95% capacity which is considered to be the level beyond which inefficiencies and reduced performance occurs. Hospitals that have busy emergency and elective services struggle to achieve a mix between the two that enable sometimes conflicting goals to be achieved. What then was the leadership of Cork University Hospital to do when faced with the certainty that there would be an influx of emergency patients in the first weeks of January?
The leadership of the Hospital did what it needed to do and planned accordingly and the data clearly demonstrates that the decision to defer planned surgical activity by one week (in line with the opening of the Day Surgery Unit) was the correct decision.
Commentary on health issues is difficult and there are always inclinations in era of instant communications to publish and broadcast the latest soundbite even if this is at the cost of some reflection and consideration of other contextual factors. One can only hope that those commentators who do seek out the truth and who do seek to understand the nuances in such complex issues will be increasingly heard in future debates.
Chief Executive Officer