HIQA: Limerick hospital emergency department 'not fit for purpose'

The Authority’s Report found a clear willingness to change and improve services for the public, but also found that the absence of a statutory governance framework is hindering the development of strong governance and patient safety functions.

HIQA’s director of regulation, Phelim Quinn, said: "Since the findings in 2009 of HIQA’s investigation into the quality and safety of hospital services in Ennis Hospital, there has been an extensive and positive journey of reconfiguration and reorganisation in the catchment area covered by UL Hospitals.

"Substantial governance and operational changes have occurred and these have the potential to improve services for patients.

"If such reorganisation can be supported and safely sustained, it would reflect the governance and accountability approaches previously recommended by the Authority and as advocated in the move to set up independent hospital trusts in Ireland."

The governance review is part of HIQA’s proactive programme of work seeking assurance on the quality and safety of services against the National Standards for Safer Better Healthcare.

It was conducted with the cooperation of staff from the six hospitals in the hospital group, and focused on risks previously identified by HIQA as part of its interaction with the hospital group.

The single most significant risk identified by the HIQA review was the serious delays and risks for patients and staff due to persistent overcrowding in the Emergency Department of University Hospital Limerick in Dooradoyle (previously known as the Mid-Western Regional Hospital, Limerick), the only site within the hospital group that was providing emergency department and critical care services.

Phelim Quinn went on to say: "HIQA believes the conditions experienced by patients attending the Emergency Department in University Hospital Limerick are unacceptable.

"The Department was overcrowded and not fit for purpose; this resulted in significant compromises in maintaining adequate levels of environmental cleanliness, and increased risk of Healthcare Associated Infections, impeded access to patients for care and observation, and severely reduced patients’ privacy and dignity.

"Other risks identified within the Emergency Department were delays in the admission of children to wards, while being accommodated in adult surroundings.

"This was despite the fact that a new children’s area had been developed but remained unopened. At the same time, staff in all the region’s local injuries units reported under-utilisation of their services. During the review, HIQA raised these risk issues at local and national HSE level."

The Authority also noted that there were delays in transferring patients from the Emergency Department to the Intensive Care Unit and or High Dependency Unit and that the absence of a single clinical governance structure for the management of the Intensive Care and High Dependency Units contributed to this.

The Authority recognised and acknowledged the change process that has been undertaken and the commitment of staff.

"UL Hospitals staff who were met by HIQA are committed to providing good safe care and to improving the services," said Quinn.

"The momentum witnessed locally must now continue and be supported by the HSE nationally in order to ensure patients in the region continue to receive safer, better care."

The hospital later issued a statement in response to the report.

Hospital statement in full

UL Limerick has an extensive capital project underway with a budget of €20m to build a new Emergency Department.

The construction of the new ED is underway and will be completed in 2016 and will provide the most modern ED services in Ireland when it opens.

UL Hospitals welcomes the HIQA review and acknowledges the opportunity to review and reflect on the work of the UL Hospitals Group. The report highlights some major changes and also points to issues in relation to patient safety particularly around the Emergency Department in University Hospital Limerick. It has been publicly acknowledged by UL Hospitals that the Emergency Department (ED) in UL Hospitals Dooradoyle is in need of a major redevelopment. UL has been successful in getting approval for the current capital project to build a new ED. The new ED will meet the needs of the local population in a modern, purpose built facility that will provide quality emergency services 365 days a year.

In the interim period, whilst the new ED is being built, the Executive Management Team in UL Hospitals has undertaken a number of measures to alleviate the pressure on the current ED and to address the overcrowding. These measures include:

* A 17 bedded short stay unit opened on 25 April (after the HIQA visit) and is being managed by the acute medicine physicians. The unit admits patients who are short stay and can be discharged within 48 hours of admission. It is anticipated that this unit will expand into an existing ward in the future increasing the capacity of the unit to 49 beds.

* The Acute Medical Unit (AMU) is open and takes direct referrals from GPs and referrals from the Emergency Department. There is a Consultant on duty in the AMU each day, ensuring patients are assessed by a senior decision maker in a timely fashion with regard to decision to admit or discharge. This unit takes patients who would otherwise be seen in the ED.

* The Surgical Assessment Unit is open and works in a similar fashion to the AMU, but for surgical patients.

* Twice daily formal bed meetings are attended by bed management and ward managers to review potential discharges as well as allocating beds to patients waiting in the ED, Acute Medical Unit (AMU), Surgical Assessment Unit (SAU) and elective admissions. The patient flow managers also liaise with diagnostics regarding patients who need investigations, thus preventing unnecessary delays.

* A navigational hub has been developed. Potential delays are identified at an early stage and addressed, as well as identification of diagnostics which, if carried out, will enable early discharge.

* Consultants are informed of the numbers waiting beds each day in the ED at 8am; several ward rounds are undertaken by the medical staff.

* The Assistant Bed Manager takes responsibility for coordinating discharge plans for patients requiring long term care via Fair Deal as well as other patients with complex discharges. The Assistant Bed Manager liaises with colleagues in Primary, Community and Continuing Care (PCCC) with regard to these discharges.

* A weekly complex discharge meeting has been set up and is chaired by the Chief Clinical Director to discuss patients who have been in the Hospital for greater than 30 days. This is attended by a member of PCCC.

* The Assistant Bed Manager also liaises with the rehabilitation units in the Mid West regarding the transfer of patients waiting rehabilitation.

* A daily teleconference is chaired by a member of the executive team. All hospitals within the group participate in the teleconference and the bed situation in all the hospitals is reviewed.

* Three patient flow nurse managers have been appointed since July 2013. They are responsible for coordinating the transfer of patients from UHL to Ennis, Nenagh and St John's Hospital as appropriate.

* There is a protocol for the management of ventilated patients while in ED and Anaesthetic cover is always available.

With the availability of three other Local Injury Units and Medical Assessment Units in the region (Ennis, Nenagh and St. John's) GPs and the public have an alternative treatment centre for unplanned injuries and suitable medical conditions.

On a daily basis patients present to the emergency department in University Hospital Limerick who could be more appropriately treated and managed in either the LIU / Medical Assessment Unit. Ongoing information campaign has been undertaken with GPs to highlight the swift responses available in the LIUs in Ennis, Nenagh and St. John's. Public information campaigns on the LIUs have been undertaken; a further campaign will take place this summer.

A separate Paediatric emergency area is now fully open since the review visit and provides a child friendly, separate area for children who require an emergency response. This new area has an isolation facility and its own toilets.

The report refers to the age limit of 14 for the paediatrics department; the age of 14 was set by the Department of Health some time ago. Currently the Paediatric Clinical Care Programme is in the advanced stages of developing a National Model of Care. One of the key recommendations is that the age cut of for paediatrics will be 16 years of age.

UL Hospitals is fully committed to implementing the National Model of Care once it has been adapted.

A new state of the art €35 million Critical Care Unit at the University Hospital, Limerick, was opened recently. The opening of the unit is a major step forward in the development of acute hospital services across the region and follows on radical improvements in the provision of critical care.

The unit has been future proofed by having the space to allow up to 12 ICU beds.

Currently the unit is seeking to increase the beds numbers from the current seven to 10 ICU beds.

The ICU department has a governance structure in place managed by a consultant anesthetist.

Ann Doherty CEO UL Hospitals said: "I welcome this extremely important HIQA report of the governance arrangements; the first such review in Ireland. I am delighted that HIQA acknowledged the commitment that our staff have to "providing good safe care and to improving the services.

"Staff have been exceptional in their drive to make our hospitals as the best they can be. I am very aware that the emergency department is not acceptable for our patients or staff and I have acknowledged that for some time.

"However we are in the middle of the construction of our new emergency department which is being built to 21st century standards and will be a vast improvement on our current ED. The new ED is opening in 2016 and will be a modern, patient focused facility."

"In the interim we have put in place a wide range of initiatives (listed above) to offset the current limitations of the old ED.

"Since January 2013 we have put in place many new initiatives including the appointment of a Board and a new management structure across all of the sites.

"We work closely with our colleagues in community services as patient care requires an integrated approach.

"The building blocks for a sustainable quality focused organisation are now in place as acknowledged by HIQA and we will use our Quality Improvement Plan to further progress improvement for our patients."