Special Report 70: Emergency Departments   Summary of Findings

Summary of Findings

There are 50 acute public hospitals in the State. The examination reviewed emergency departments in 33 of those hospitals. In 2008, the emergency departments examined had over one million attendances. Approximately 25% of emergency cases were admitted to hospital following assessment while the remainder were treated and discharged. While the direct cost of emergency departments before taking account of overheads is estimated at ?196 million, ultimately in the hospitals examined, care for those patients who had to be admitted cost an additional ?1.5 billion in 2008.

The objective of the examination was to review service performance and assess the steps that the Health Service Executive (HSE) has taken to address key findings from a range of reviews conducted during the period 2002 ? 2007. The following broad areas were examined

  • the extent to which measures to improve care within emergency departments have been implemented and the scope for further improvement
  • the impact of wider hospital organisation on the effectiveness of emergency departments
  • the scope for further measures to divert cases currently handled by emergency departments to a more appropriate care setting.

Service Performance

There are significant variations in resources devoted to attendances at emergency departments. The number of patients handled by medical staff ranged from 8.15 to 30.57 per day across the different emergency departments. This pattern was mirrored in a wide divergence in the cost of treating persons who present at emergency departments, ranging from ?85 to ?281 per attendance.

The examination found that the provision of appropriate care in all types of emergency cases within a reasonable timeframe is adversely affected by the restricted availability of key resources.

  • 23 of the 33 emergency departments had delays in accessing senior decision makers.
  • Access to consultations from specialities within the wider hospital was rated as unsatisfactory in most cases.
  • In most cases, there was considerable scope to improve the timeliness of diagnostic support and four departments had unsatisfactory access to those services.
  • The waiting time for bed accommodation following decisions to hospitalise emergency patients was unsatisfactorily long in most cases.

Care in Emergency Departments

Fundamental prerequisites to the care of patients in emergency situations include on-site availability of senior clinical decision makers and prompt access to other specialist consultants. The recently negotiated contract with medical consultants which provides for increased working hours should extend the time decision makers are available and reduce patient waiting times. However, the HSE will need to put procedures in place to confirm that the service gain envisaged under the new arrangements is achieved.

A factor that will fall to be addressed in attempting to improve access to diagnostic services is the restricted working arrangements in the diagnostic disciplines. Current arrangements limit access to services at night and at weekends. Standards and norms in the provision of diagnostic services and the organisation of work in diagnostic disciplines need to be developed.

The two performance measures consistently used in emergency departments are the count of total attendances and the measurement of time between decisions to admit and the provision of a bed for the patient. In October 2007, a maximum twelve-hour target was introduced by the HSE and in January 2009, a total waiting time target of 6 hours was set from the registration of the patient in the emergency department to admission or discharge. A comparison of the average waiting time for admission from emergency departments in the period January to May 2008 with the same period in 2009 indicated that there had been an increase in the number of patients waiting 12 hours or more. 46% of patients were waiting 12 hours or more in early 2009.

Overall, the introduction of a comprehensive set of performance measures that are applicable to all emergency departments would help to drive performance and allow for comparability across hospitals. The Health Information and Quality Authority is developing such a suite of indicators including quality of care indicators. A pilot project is proposed for early 2010. When developed, the feedback should help emergency departments and the HSE to better manage the emergency services.

From an operational viewpoint, the streaming of emergency cases and the routing of appropriate cases through special clinics has the potential to improve emergency department efficiency and effectiveness. In addition, it would be worth evaluating the contribution of rapid access initiatives which hold the prospect of allowing quicker access to diagnostics and treatment.

Impact of Hospital Organisation

Emergency departments cannot operate in isolation from the wider hospital. Consequently, their effectiveness is tied into the way that the overall hospital in which they function is organised.

The examination noted some potential to improve emergency department effectiveness through

  • better planning of discharges and finding alternative lower cost accommodation for patients whose acute care needs have been dealt with
  • improving hospital capacity through a combination of day care, same day admission and, where necessary, increased bed numbers.

The examination concluded that the length of stay of patients could be better managed through

  • a wider use of early discharge planning based on standard targets for each condition
  • more even discharging across the week
  • discharge of patients earlier in the day which could favourably impact on bed availability since attendance in emergency departments tends to increase in the afternoon.

A dedicated bed management function operating on the basis of norms established in an evidence-based way could provide coordination of these functions.

As the cost of step-down beds is considerably lower than the cost of acute beds there may be scope for cost efficiencies through development of a strategy to provide more beds in the community.

Many hospitals have begun initiatives to improve patient flows and establish patient pathways through the hospital and some good practice opportunities were identified during the course of the examination. However, a systematic mechanism to provide for the sharing of these good practice initiatives is needed to facilitate replication on a wider basis.

Community Care Initiatives

The provision of alternatives to acute hospital care through strengthening primary and community care services could reduce reliance on the acute hospital services and demand on emergency departments.

Community intervention teams provide a rapid response to patients who are deemed medically suitable for treatment in the home. Four teams are in operation two of which are in Dublin and one each in Cork and Limerick. These services have the potential to generate significant efficiency savings relative to hospital care as well as better patient care.

In November 2006, a rapid access clinic in the community was opened in Smithfield in Dublin to provide care for older people with urgent but non-emergency care on the basis of referrals by their GPs or by emergency departments. A review of the clinic by the HSE found that 42% of new patients had avoided hospital admission through an emergency department. It is likely that the clinic has provided significant savings by comparison with the cost of acute hospital care.

The inadequate and fragmented arrangements for the management of chronic illnesses has been recognised for some time and both the Department of Health and Children and the HSE have been working to re-orient the related services towards a primary care setting and bring about a more integrated approach between hospital and primary care services. Bringing this re-orientation to completion will require the development of a robust change management programme, the setting of standards of care and clinical guidelines, as well as developing a framework for implementation at local level.

The HSE has developed a number of hospital avoidance measures such as home help and home care packages for older people who might otherwise occupy an acute hospital bed. An evaluation of home care packages is being finalised by consultants on behalf of the Department.

In 2008, there were nearly one million attendances at out-of-hours GP services which are provided to 90% of the population. This service should be evaluated to assess its cost effectiveness and whether it has the potential to impact on reducing demand in emergency departments. In addition, in order to assess the scope for savings from the further development of community intervention teams and community based rapid access clinics, a full overall costing exercise taking account of all overheads should be completed.

Overall Conclusions

The examination found that there were considerable differences in emergency department capacity and that cost per attendance also varied significantly across the service.

Some of the pressure on emergency departments could be ameliorated by more streamlined hospital processes particularly in managing discharges and increasing the volume of work completed on a day case basis.

Community initiatives need to be evaluated to determine their relative cost effectiveness and, to the extent that they are found to be more economic and effective, integrated into the primary care team model. This could also help reduce recourse to the emergency services.

As part of its Transformation Programme the HSE plans to reconfigure its acute services and concentrate emergency, urgent and complex acute care into regional centres with skilled clinicians. The intention is that regional centres will be supported by a network of minor injury units in outlying facilities. The report findings suggest that considerable work remains to be done to bring about change consistent with these objectives and align current service provision with the objectives of the desired reconfiguration.