Transcript East Coast Area Emergency Medicine – The Way Ahead

AccIDENTS
aRe Not
raNdom
eVents
They are PreDIctABle
thEy CAN BE
PreVENTed
East Coast Area Emergency
Medicine – The Way Ahead ?
Robert McQuillan
Director of Emergency Medicine
South East Dublin
?
Documents for Consideration
Comhairle Report
Tommie Martin
Five Principles for future
structure of emergency services
• Patients transferred to the hospital most capable of
providing appropriate care
• Integrate management of emergency health needs primary care, pre-hospital care, transport and
hospital services
• Manage emergency hospital care as a single
integrated service unit with pathways of care
• The health board area should network all resources
for emergency patient care
• Staff guided by agreed protocols with data systems
for planning audit and evaluation
Health Strategy
•
•
•
•
Patient at the centre of care
Increased A&E consultants
Triage
Nurse practitioners
HIGHEST STANDARD OF PRE-HOSPITAL EMERGENCY CARE
• ongoing upgrading of the ambulance fleet
• 24 hour on-duty staffing for all ambulance stations
• crewing of all ambulances with emergency medical technicians
• strengthening of IT links between ambulances and A and E
departments
• augmentation of current response capability
• introduction of first responder schemes, involving general
practitioners and voluntary personnel
• development of a dedicated emergency ambulance service
through the separation, where appropriate, of emergency and
routine work
• strengthening of the performance management function, with an
emphasis on audit and monitoring of response times
• ongoing training in the use of defibrillators.
Quality and Fairness 2000, p 84
Primary Care
• “Primary care is the
appropriate setting to
meet 90-95% of all
health and personal
social services needs”
• Liaison between primary
and secondary care will
be improved”
Acute Hospitals -Problems
• high attendance rates; ED - 22%  since 1988
OPD - 37%  since 1980
• long delays for treatment and/or admission;
• insufficient acute hospital beds to facilitate admission to
hospital;
• increasing proportions of hospital beds occupied by
patients admitted through A&E;
• cancellation of elective admissions and procedures;
• long waiting lists for elective procedures;
• acute hospital beds occupied by persons no longer in need
of acute care;
• unacceptably high bed occupancy levels in major acute
hospitals.
Acute Hospital Bed Capacity 2002
Convenience Vs Experience
• Service arrangements should be such that
patients are not unduly burdened with
traveling long distances…..
• A key issue in maintaining the skills of highly
trained specialist clinical staff is the number
of cases dealt with on an ongoing
basis………..
• Resuscitation, assessment and treatment of
acute illness and injury on a 24-hour basis in
patients of all ages by appropriately trained
and experienced staff prior to discharge home
is a prerequisite
Regionalisation and a National
System
• The response team at the site of accidents
should have communication with a “base”
hospital so that access to medical expertise
is available from the point of touch down
at the site. A regional patient retrieval and
transfer system linked to the national
system should be put in place without
delay. Helicopter transport should be
considered as part of the transport
arrangements.
Cost of EM department
• Pay
3.5m
• Non pay
0.5m
• Resources 1.0m
• Total
5.0m
Regionalisation of Emergency
Services
•
•
•
•
Appropriate utilisation of hospitals
Staffing levels and numbers
Integration and networking of services
Establishing protocols and standards to allow pathways
of care prioritised for acuity
• Establishing data systems to allow planning audit and
evaluation
Appropriate Utilisation of
Hospitals
•
•
•
•
•
•
•
St. Vincent’s, St. Michael’s, St Columcille's
Eye and Ear
Hume St
Holles St
St John of God’s
Blackrock clinic
Others
Basic statistics for the 3 general
hospitals
% return
Beds
E.M.
attendance
E.M.
admissions
St Vincent’s
471
37,500
8
8400
St Columcille’s
150
25,300
11
4040
St Michael’s
104
24,900
36
2200
TOTAL
725
87,711
7
14640
Regionalise
How to utilise the 3 general hospitals to provide the most
appropriate care?
•
•
•
•
1 major unit and close 2 departments
1 major and 1 or 2 minor units
1 major and 1 comprehensive unit and close the third
1 major and 1 comprehensive and a role for the third
department
Solution?
• Regional Unit – St. Vincent’s University Hospital
• Comprehensive Unit – St. Columcille’s Hospital
• Minor Unit and Clinical decision unit – St Michael’s
Hospital
Staffing - Advantages of Consultants
and Senior Medical Cover
• Improvement in the quality of care
• Expeditious and improved patient throughput
• Reduction in the number of errors attributable to
inexperience
• Reduction in the number of unnecessary investigations,
admissions, waiting times, treatment times and review
attendances
• Improvements in teaching, training and supervision of
medical staff
A&E Services 2002, p 96
Advantages (cont.)
• Reduction in costs associated with inefficient use of
medical staff
• Improvement in the community’s perception of, and
confidence
• Improved quality assurance and risk management
• Reduction in the number of complaints
• Improvement in the reputation among other medical
groups
• Improved use of new technology.
A&E Services 2002, p 96
Consultants
Columcille’s
Vincent’s
Michael’s
What is Senior Cover ?
•
•
•
•
•
•
•
Consultants
Emergency Physicians
Specialist Registrars
Clinical Fellows
Registrars
Senior House Officers
Interns
Supreme Court Judgement
“A SHO in A&E …could refuse admission,
he could not admit a patient without a
second opinion”
“It seems to me that any system which
gives absolutely authority to a junior
doctor is inadvisable. By its very nature
the position of a senior house officer is
one where the holder is learning his
profession. He must meet from time to
time cases with which he is not familiar
and in which he would welcome the
opinion of a senior.”
Emergency Physicians
“If Ireland did not embrace
the introduction of assistant
grades, the nation’s
problems would be much
greater than those in other
countries where the
assistant grades played a
significant part in the
health services workload”
St . Vincent’s manpower
• No overall change in staff numbers other than
consultants
• Grade of senior staff increased with appointment of 2
emergency physicians
• Approval to appoint specialist registrars
• Grade of registrars increased with appointment of
clinical fellows
• All SHO posts on rotations and new SHO rotation in
EM started
• Significant increase in numbers of clinical nurse
managers
St. Vincent’s - Organisation
• No significant structural changes as yet, chest pain unit
and clinical decision units are “virtual”
• Rapid Assessment Team
• Trauma Team
• Chest pain, radiology and respiratory protocols
• Point of care testing
• Academic department – attendance, staff numbers,
types of hospitals, - transferable
• Computerisation
St.Columcille’s manpower
•
•
•
•
•
•
•
•
Consultant
Emergency Physician
Medical registrar
4 registrars
5 SHOs
CNM2
5 CNM1s
3 public liaison officers
St. Columcille’s structure
• Significant structural changes have been approved and
funded with areas for
• Major (9), minor (6), resuscitation (2), paediatric
waiting and treatment, triage, offices, staff room,
kitchen, relatives and viewing, stores, point of care,
decontamination.
St. Columcille’s organisation
•
•
•
•
•
Teaching
Protocols
Computerisation
Rotations
Regular feedback
St. Michael’s
•
•
•
•
•
•
•
No structural changes some internal reorganisation
Emergency physician
2 SHO/Registrars
1 Clinical Fellow
Regional protocols
Excellent nurses
8am to 8pm
Network
PRE-HOSPITAL
• Primary care –
regional concept
• Ambulance service
• Alternatives
IN-HOSPITAL
• Pathways of care
based on specialty and
acuity
Madsen Cooperation and
Competition
Comments of 7 year olds
• “Impossible to get a marble”
• “I could get a marble if I could play on my
own”
Questions
• Are the hospitals utilised correctly?
• What is the best pathway of care for seriously
injured patients?
• Who should provide the care?
• How should paediatric emergencies be handled?
• How do we supply a service to the south of the
region?
• How do we integrate more closely with prehospital care?