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The solution is ‘beds, beds, beds’

12 Jan 2017

Dara Gantly

Dara Gantly on why we don’t need another bed capacity review to tell us how to solve the crisis in our Emergency Departments

Believe it or not, it is an old radio advert from New Zealand that is one of the first things that pops into my head when thinking about the Emergency Department trolley crisis.

This particular ‘earworm’, which has stuck with me for nearly a decade, was for a popular furniture store selling beds. Although being New Zealand, the ‘e’ sound in any word is switched to an ‘i’, so the word ‘bed’ will be more like ‘bid’. Think of the phase “he may be dead” sounding more like “he maybe did”. To make things even more confusing, the ‘i’ sound in a New Zealand accent is more like an ‘e’, which certainly made things like reports on the Six Nations Rugby quite jolting.

But ‘bids, bids, bids’ [sic] is what it’s all about, Minister Harris. The announcement of so-called “enhanced measures as part of the existing Winter Initiative Plan” last week is to be welcomed, but that welcome has been a half-hearted one for many.

Yes, 63 acute hospital beds is not to be sneezed at (literally, given the dominant influenza A (H3N2) virus that is circulating — but if you do, use your armpit or burn the tissue, says the HSE), as are an extra 60 transitional care beds over the next number of weeks for those awaiting a nurse home place. But this is far from radical surgery. What we need are thousands?

Exactly how many, we seemingly still don’t know. The HSE’s National Director with Responsibility for Emergency Management and the Winter Initiative Damien McCallion was brave (is that not his job?) to appear on RTÉ’s Prime Time last week (Jan 5, see here), particularly after some of the horrendous testimonies given by family members of patients and the biting commentary by Tallaght ED Consultant Dr Jim Gray, who unlike Minister Harris, believed the situation was “entirely predictable”. In fact, should we predict now another record-breaking trolley count for the first Tuesday in January 2018?

But the HSE’s Director for Emergency Planning did not particularly shine when pressed on how many additional beds would be needed to make the system safe. Tacitly agreeing that it was between the 63 provided by the HSE and the 9,000 suggested by UCC Health Economist Dr Brian Turner earlier that day on the News at One — a massive number needed to bring our bed capacity up to OECD averages (from 2.8 to 4.8 beds per 1,000 population) — is not very helpful for anyone. “Trying to guess [the number of beds required] is not a sensible approach,” McCallion noted, in reference to the ongoing bed capacity review being undertaken to determine what kind of beds are required and how many.

But we don’t need another one-off bed capacity review, which will go out of date just like all the previous reports. IMO President Dr John Duddy agrees there is no need for another bed review; rather the 1,600 beds lost in recent years need to be put back into the system. He also went further by describing the proposed increase in bed numbers of 63 as an “insult” given the hundreds of patients currently on trolleys.

Best practice would suggest that the HSE should have all this information at its fingertips and have a reasonable bed occupancy target to aim for. The NHS publishes bed availability and occupancy reports on a quarterly basis, complete with the total number of available bed days and the total number of occupied bed days by consultant main specialty. And this is not new: the data for this collection is available back to 2000-01. (By the way, the average daily number of beds open overnight was 129,458 in Quarter 2 2016/17, and the average occupancy rate was 87.5%).

We already know that bed occupancy rates of higher than 85 per cent can increase the risk of harm to patients, including hospital-acquired infections like MRSA and Clostridium difficile. Research as far back as 1999 (BMJ 1999;319:155–8) argued that any occupancy rate over this risked bed shortages and periodic bed crises.

It has been years since we have had a safe bed occupancy rate. Twenty-three hospitals were found in 2000 to have occupancy levels of greater than the above internationally recognised measure and among these, the average occupancy level was 95 per cent, but the range was from 85 per cent to 123 per cent. This high figure has remained and is higher than every other OECD country, except Israel. So clearly, we have no capacity to cope with unexpected surges in demand or major emergencies. Or even ‘expected’ surges in the first week of each January.

In 2000, the number of acute public hospital beds was 11,832 — approximately 6,000 lower than the number in 1980 (17,665). By 2012 (the latest statistics on the Department of Health’s website), this was down again to 10,492.

How many should we have? The Codd report (‘Acute Hospital Bed Capacity: A National Review’, 2002) indicated that 4,335 gross additional inpatient beds were required, but that if one built in maximum efficiencies into day of surgery admission, maximising day case procedures, additional community support services and facilities to allow for timely discharge of patients etc, you could bring the requirement down to an extra 3,000. Not 63!

But the HSE still seems to be clinging instead to the PA Consulting report of 2007 (‘Acute Hospital Bed Capacity Review: A Preferred Health System in Ireland to 2020’), whereby under its imagined ‘Preferred Health System’, in which more patients would be cared for in the community or at home with support, the current reliance on hospitals would be diminished. Having 612 patients on trolleys was not part of that preferred system.

Under such a model, the PA Consulting report believed Ireland would require 5,202 fewer hospital beds than were in place at that time to meet existing demand — or just 6,458. It just seems bizarre to me that we went from needing 3,000 more to 5,000 fewer beds in five years! But then political agendas can also come and go many times in a shorter period. I wonder what side of the bed the 2017 capacity review will fall out of this time?

But our annual winter trolley crisis does seem to take every new Minister for Health by surprise, each year. If you recall, on January 6, 2015, there were 601 patients on trolleys across the country, which prompted the INMO back then to call for an immediate meeting of the Emergency Department Taskforce to consider, and agree, measures to alleviate the crisis.

That breaching of the 600 mark had been the highest number of patients on trolleys ever recorded since the INMO began its trolley watch initiative in 2004. We had 612 last week — the highest ever, again — and 602 the following day. And the flu outbreak is still weeks away from reaching its peak.

Just compare Leo Varadkar’s response first time around in 2015, when he was caught abroad on holiday (‘Who’s in charge of this mess? Health Minister suns himself in Miami as trolley crisis worsens’ was how one tabloid unfairly put it), to last year when he — along with HSE DG Tony O’Brien — toured six of the country’s busiest EDs to inspect trolley levels.

I’m sure Harris will have learned a lot this winter.

The post The solution is ‘beds, beds, beds’ appeared first on Irish Medical Times.

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