Following inspections of seven Emergency Departments, HIQA found that during 2022, the Irish health system was under unprecedented strain as it continued to see an increasing number of patients presenting to emergency departments which was significantly higher than in previous years.
HIQA identified four key areas for both immediate and longer-term attention to address safety issues in our emergency departments. These were:
- The need to continue to urgently build additional capacity within the whole healthcare system, both acute and community, through implementation of the recommendations from the Department of Health’s ‘Health Service Capacity Review’, which was published in 2018. In particular, it said there was a need to assess capacity requirements at a regional basis as recommended in the capacity review and the prioritisation of investment to be informed by the outputs from such assessment. This would also require associated investment in additional supports to aid infrastructural capacity, inclusive of diagnostic services.
- More responsive leadership, governance and management were needed at local, regional and national level, which acted to address performance issues when identified. Such an approach needed to recognise that – notwithstanding contextual challenges – some hospitals coped better than others with the demands placed upon them and this was often driven by better local operational management. Such an approach should also not only be confined to just acute services. A collective approach to ownership of this problem across both acute and community services in a region, with seamless planning and a shared approach to escalation in the event of overcrowding was needed. In short, emergency department overcrowding needed to be recognised as a whole health system problem, and the normalisation of comparatively poor performance should not be tolerated.
- A need to advance a more effective approach to strategic workforce planning at local, regional and national level that enabled effective anticipation and management of manpower shortages. This acknowledged that recent developments to benchmark and enhance nursing and medical consultant staffing levels in our emergency departments represented an important initial step along this road to improvement.
- More effective identification, monitoring and management of patient safety risks associated with overcrowding in emergency departments, with timely escalation and response to risk within hospitals should they occur. Particular areas for focus should aim to address short-term staffing deficits relative to demand, timely responsiveness to surges in presentation, and close attention to treatment times inclusive of triage times and times to medical assessment.
HIQA said the progression of some measures within hospital services was encouraging. These included work to promote and resource safer staffing models and increase bed capacity.
“Emergency department overcrowding and insufficient access to acute and primary services will continue to occur unless a system-wide approach is taken to address major structural challenges. There is also a need to develop operational and leadership capability to support more effective management of patient flow and processes within hospitals and between hospitals and community services and respond to, rather than continuing to tolerate or normalise, this problem.”
It said it was clear that emergency department overcrowding would likely be a feature of our health service in the short term as the key areas that required ongoing attention, such as increased capacity and appropriately resourced and trained workforce, were progressed. Indeed, as we emerged from the COVID-19 pandemic, current pressures on the health system indicated emergency department overcrowding might get worse before it has the potential to get better. To sustain efforts in the interim, the health service would need to continue to work in difficult circumstances to ensure the safe and effective care of each patient that sought care over the pending winter season. Better understanding of the drivers of demand among an older and more ailing population post-pandemic, coupled with better planning around capacity across the entire healthcare system, were needed to strengthen operational grip on unscheduled care, facilitate elective capacity and support patient-focused service planning. The implementation of the Sláintecare plan also needed to progress at pace. Crucial to the effective implementation of such reforms were efforts to strengthen and sustain the healthcare workforce at a time when there was a shortage of global healthcare workers. This would require a timely and effective response from a health system that adapted to the daily pressures on emergency departments, while at the same time working to tackle the underlying contributory factors that also need to be addressed.