Comhairle na nOspidéal

1. Comhairle na nOspidéal Report of the Committee on Accident & Emergency Services Mr. Tommie Martin

2. Membership • Professor Gerald O’Sullivan, Consultant General Surgeon, Mercy Hospital, Cork. Chairman • Mr. Joseph Cregan, Principal Officer, Department of Health & Children • Dr. Deirdre Lohan, Consultant Anaesthetist, Navan/Drogheda • Mr. Colman O’Leary, Consultant in Emergency Medicine, Limerick • Dr. Donie Ormonde, Consultant Radiologist, Waterford • Dr. Sheelah Ryan, C.E.O., Western Health Board • Mr. Tommie Martin, Chief Officer, Comhairle na nOspidéal • Mr. Andrew Condon, HEO, Comhairle na nOspidéal (Secretary) • Ms. Mary-Jo Biggs, EO, Comhairle na nOspidéal (Assistant Secretary)

3. Terms of Reference “Arising from discussions with the Minister and Department of Health &Children, Comhairle na nOspidéal established a committee to undertake a review of the structure, operation & staffing of Accident & Emergency Services and Departments. The review will aim to: • Facilitate the development of a better quality service, with greater continuity in patient care, delivered twenty-four hours a day by appropriately trained doctors • Promote the development of regionalised A&E trauma services in line with national and international best practice in patient care • Provide for a substantial increase in on-site senior clinical decision making on a 24 hour basis • Define the future role of A&E consultants Simultaneous to the Comhairle review, it is envisaged that health authorities will consider how best to organise A&E services in their areas in conjunction with the Comhairle committee.”

4. Methodology • Committee met over thirty times • Extensive consultation process – met & received submissions from • Health boards & voluntary hospitals • Professional bodies • Training bodies • Other interested parties • Collected data on attendances in each hospital in the country • Reviewed national and international literature

5. Impact of Prolonged Waiting Times • Additional risk to patients outcome due to delays between presentation and assessment • Risks that delays may be further extended where triage not undertaken • Increased number of patients leaving department before treatment • Overcrowding • Restricted access to emergency services and delays in treatment of patients on arrival • Public perception of service

6. Main causes of delay in Emergency Department • The absence or partial implementation of formal triage process • Restricted access to inpatient beds • Restricted access to pathology and radiology services • The treatment and management of large number of patients with minor injuries and illness who could be treated elsewhere • Limited availability of senior clinical decision makers • The design of, and resources available to, the Emergency Department

7. Structure of Hospital Emergency Service PROPOSALS Regional Emergency Departments • Located in major regional hospitals • Serve catchment population of about 250,000 • Be major trauma receiving hospital for region • Provide a referral service for local general hospitals • Staffed by a number of consultants in emergency medicine • Multi-professional team • Department led by a Director

8. Hospital Emergency Departments with access to some specialist surgical and medical services on-site • Be linked to the Regional Emergency Department for trauma services, subspecialty services and certain diagnostic services • Able to manage most emergencies, including stabilisation & assisted ventilation • Staffed by 1-2 consultants in emergency medicine • Multi professional team • One consultant act as head of department

9. Hospital Emergency Departments with access to specialist services off-site • Consultant (Physician or Surgeon or other consultant) on hospital staff to function as lead clinician in, and have responsibility for, the organisation and of the Emergency Department • 24 hour access to medical staff on-site • Provide nurse led services for minor illness and injury • Access to consultants in emergency medicine in the regional department for support, development & training purposes

10. Staffing the Hospital Emergency ServicesProposals Regional Co-ordinator of Emergency Services • One per health board • Advise on operation, organisation of emergency services • Responsible for development and implementation of agreed protocols across region Director of the Regional Emergency Department • Post could rotate between the different consultants in emergency medicine in department or filled from a competitive process • Have overall clinical and administrative responsibility for department

11. Consultants in Emergency Medicine • Large majority of sessional commitment should be to clinical as distinct from administrative duties or legal work • Duties centre on the stabilisation of patients • Responsible for ensuring that patient is admitted to the most appropriate service to further explore problem if required. • Depending on the number of consultant posts in emergency medicine in a service, different rosters and cover arrangements will apply • At least one of the consultants in emergency medicine in the regional emergency department should have a special interest in paediatic emergency medicine

12. Increase in consultant posts • Designed to be implemented on a phased basis • At present 21 posts of consultant in emergency medicine • First stage - increase to 55 posts • Final stage recommend increase to 74 posts • Allows sufficent time for changes in organisation & service delivery • Training & recruitment of additional consultants • Achievement of a contractural environment which allows on-site rostering of consultant staff to cover busy periods in A&E

13. Staffing Issues • 75% of patients attend A&E between the hours of 8 a.m. and 8 p.m. • Committee aims to put in place structures which facilitate the on-site presence of Consultants in Emergency Medicine in Regional Emergency Departments between the hours of 8 a.m. and 8 p.m., 7 days a week, 365 days a year

14. Re-organisation of Hospital-Based Emergency Care • The aim of hospital services • right care • right time • right place • right people • System-wide problems - System wide solutions • Emergency services be reformed & restructured in conjunction with the rest of hospital

15. The organisation of hospital services - • emergency care, • in-patient elective care, • day & outpatient care • Distinct management structure for the hospital emergency services • Hospital emergency service committee • chaired by consultant in charge of emergency services • supported by administrative structure including Hospital Emergency Service Manager • Comprise acute surgical, acute medical, paediatrics, psychiatric, radiology & pathology staff, nursing, anaesthetic, GP’s etc..

16. Further measures • Introduction and use of common triage systems • Better interaction with primary care • Timely transfer of patients to appropriate treatment location within hospital or other facility • Greater role for nurses • Minor injury and illness areas • Observation wards • Dedicated and accessible diagnostic facilities • Better access to and management of inpatient beds