Meeting the Challenge of Patient FlowDec 4, 2018 -
Mr. J. A. McNamara
The challenge to the health system posed by An Taoiseach Leo Varadkar to look differently at how it plans for the post-Christmas period is both timely and appropriate. The public and political system deserve to know what we are doing to plan for the post-Christmas period, including the contingencies for which we are making provision. In this regard, the health system has undergone significant change in terms of work practices, technology and skill mix over the past decade and will continue to do so as healthcare changes.
In planning for Winter, we must, as ever, reflect on what has happened in previous years and while circumstances differ from year to year, patient activity in our Emergency Departments remains remarkably consistent throughout the year, even if the profile of patients attending changes. In addition, the numbers of patients requiring admission from our Emergency Departments remains very stable at typically 30% of attendees throughout the year.
As an example, Cork University Hospital has 200 patient attendances in the Emergency Department each day, of which 60 will require admission – a difficult daily challenge that commences at 6.30 each morning with the identification of patients who can be discharged to create capacity for other patients. This process is managed with the highest level of intensity throughout the day and in this endeavour, difficult choices frequently have to be made to balance ethical and medical considerations regarding patients for discharge.
However, the uniqueness of the post-Christmas period, with a combination of increased use of Emergency Departments and difficulties in placing patients in community services, requires additional interventions both internally in the hospital and in community services. It is critically important in planning for this period, that we are mindful of the very many patients who will still require our services for the myriad of other conditions such as cancer care and debilitating medical conditions and who will not come through our Emergency Departments. Every hospital will be different in that respect.
There are a number of themes in planning for this period in Cork University Hospital;
- Staffing – rosters will be flexed to ensure that the maximum number of appropriate staff are on duty and at a sufficiently high level of seniority to maximise patient flow during this period;
- Outpatient and Diagnostic Services – in order to ensure access to clinics or to diagnostic services to avoid presentation at ED, or to facilitate early discharge, provision will be made for such appointments and bookings will be flexed accordingly;
- Internal patient flow – it was clear previously, that when the medical assessment unit (providing rapid access for General Practitioners) functioned on a 24/7 basis, the result was improved patient flow and staff will be rostered as a priority to provide for this during this period. In addition, changes in the interplay between the various parts of the acute medical services will be implemented to improve flow;
- Scheduling of elective surgery – priority will be given to emergency surgical services during this period and planned surgery will cease on December 21st and will recommence on January 7th. Much elective surgery is now performed on a day basis and the impact of cancelling surgical procedures on emergency flow has been demonstrated to be minimal and is disproportionately traumatic for patients;
- Internal escalation processes – key executive, medical and nursing leaders in the hospital will be meeting over the pre and post-Christmas period to monitor the situation with the authority to make whatever interventions are necessary to manage situations that may emerge such as the need for additional theatres for Orthopaedic services as were required previously;
- Purchase of private beds – if necessary, as previously, beds will be purchased for appropriate patients, in the private hospital setting to maintain capacity in the hospital and to support patient flow;
- Access to community services – in order to support patient discharge from the hospital, provision will need to be made to ensure that patients can be transferred to community hospitals, convalescent beds, transitional care beds or home with necessary home supports. The challenge of maintaining patient flow will not be met simply by focussing on internal processes in our hospitals to the exclusion of our community partners. There is an immense resource embedded in our hospitals and community services and the public and the political system rightly expect that this should be optimised while, for example, bed capacity and staffing are increased over time in line with government policy.
Similar interventions should be made throughout hospital and community services in the health service nationally if we are to collectively manage patient flow throughout this period (and indeed all year round).
I realise, that in presenting this plan, we will be open to criticism when there are trolleys in our Emergency Department (as inevitably there will) during this period, but I believe the public and our political masters deserve the assurance that in so far as is possible, everything that can be done is being done to prospectively manage a challenging situation.
At one time the perception was that the difficulties in our Emergency Departments were resolvable by changing practices therein. Thinking evolved to a point whereby the issue of patient flow was seen to be a hospital-wide problem requiring flexing of planned and emergency activity. It is now apparent that the challenge is in fact a system-wide one that requires the collective efforts of the hospital and community systems to support patient flow.
We have an opportunity with these insights and with the expertise we have in our hospital and community services to make this post-Christmas period one in which we can demonstrate to the public and to the political system that we can prospectively manage patient flow while ensuring that patients get the best service possible.
Tony McNamara is CEO of the Cork University Group of Hospitals