Emergency department overcrowding: ‘People get left behind because there’s nobody at home’

The numbers written on the wall of a small office in St Luke’s Hospital in Kilkenny tells the story of why this hospital, and so many others across Ireland, is so busy these days.

The line begins 89, 84, 75, 87, 75, 73, 60, 88 and continues in similar vein for every patient in the hospital. On another wall of “The Hub”, the operations room of the hospital, there’s another column for patients in the emergency department, starting with 78, 72, 75, 87, 74, 70, 92…

The numbers, in case you haven’t guessed, refer to the ages of those currently being treated. A 100-year-old, a 98-year-old and several patients aged over 90 are among those in beds in St Luke’s; 70 per cent of patients are aged over 65.

“What we call the emergency department crisis is really an internal medicine crisis of older people placed in the ED,” St Luke’s clinical director, Prof Garry Courtney, explains, standing in the middle of the department last Monday, while staff hurry about him from patient to patient.

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Emergency department overcrowding: ‘People get left behind because there’s nobody at home’

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As more patients pour in, they are put up in the Acute Medical Assessment Unit (AMAU) – ultimately eight out of these 10 beds have to be sequestered for ED patients, making them unavailable today for other patients

The day we visit turns out to be one of the hospital’s busiest yet. There are patients everywhere – 61 more than St Luke’s is funded for – and they have to go somewhere.

The first overflow patients are housed in a surge ward, part of the original hospital buildings from the 1940s, that was tarted up for the Covid-19 pandemic and is now staffed with agency workers. As more patients pour in, they are put up in the Acute Medical Assessment Unit (AMAU) – ultimately eight out of these 10 beds have to be sequestered for ED patients, making them unavailable today for other patients.

Next, the day service unit is raided to house the wave of incoming ED patients, leading to the cancellation of planned surgeries.

“We are putting patients in the wrong places,” Courtney says in frustration, but still they come. Trolleys are parked on narrow, brightly lit corridors here and there with screens around them providing a modicum of privacy.

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“We’re completely overcrowded – and this is completely normal,” says Dr Rory McGovern, a stroke specialist who is working his way through the list of patients who streamed in the hospital’s doors over the weekend.

There are 40 patients from the weekend on McGovern’s list but only 13 treatment rooms. Already this morning, he has had two new patients arriving in with strokes, who needed urgent treatment with clot-busting drugs.

Among the patients still waiting are a woman with long-term headache and back-pain, another woman brought in from a nursing home with agitation, and a person with a rash.

“They’re on the corridor, they’re not emergencies but there’s no in-between services in the community. My first half an hour was spent seeing people because of this lack of resilience in the community. Services are very good between nine and five, but afterwards…”

Seven or eight of Sunday’s cases involved home falls. “You can’t stop people, if they fall, ringing an ambulance and coming in,” McGovern says. “Diagnosis is done quickly along with the recognition of their frailty. But the negotiations to try to get someone home once they’re in the hospital are often very difficult.”

“It’s not good for the person to be here, but the family will say they’re not keen on having them home at the moment and that they need more care.”

“Sometimes,” he observes, “it’s a symptom of this wonderful thing of everyone working. People get left behind because there’s nobody at home.”

I last visited St Luke’s seven years ago, as its new emergency block was about to open. The changes since then show how much has been achieved, and how much more needs to be done.

Back in 2016, about 30 patients a day were coming to the dilapidated old ED housed in the hospital’s former laundry. The current average is 144 during the week and 105 at weekends; last Monday, there were 165 attendances.

The waiting-room of the ED is as busy as you would expect for a Monday morning. To my unmedical eyes, people look unhappy more than unwell

Since then, a new emergency block has opened, as has a stroke unit and the repurposed surge ward. The modern parts of the hospital are bright and airy, there is quality art everywhere on the walls and equipment is to a high spec. Showers and 1,000 lockers were installed for staff as part of the investment dividend from Covid-19.

The hospital has long been regarded as a hub of innovation. It was the first to open an AMAU to take some of the pressure off the emergency department, and the first to turn local GPs into decision-makers.

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By empowering GPs to make referrals, St Luke’s tries to break up the monolithic queue of patients heading for the emergency department. “We try to move the queue; instead of it going out to the grass, we split it up – there’s one for the ED, the AMAU, surgery, children, etc,” Courtney explains. “Because we take the old, frail, 90-year-olds out there (in the AMAU), they can fly through their work here in ED.”

The waiting-room of the ED is as busy as you would expect for a Monday morning. To my unmedical eyes, people look unhappy more than unwell.

“Quite a lot of people shouldn’t be here, but we’re not in charge of that and they’ll have to wait,” Courtney whispers.

The people on the plastic seats are waiting to see the triage nurse in her small office. But other patients have a fast-pass to the AMAU based on their level of sickness or frailty. “You walk in here” – Courtney gestures to the door of the AMAU – “if you have the secret sauce. With the letter from the GP, you’re through everything”.

Bright ideas only go so far when attendances are surging and patients are getting older and frailer. “We are the basket – if anything in your life happens, we take you – but there needs to be more resilience in the community,” McGovern tells me. “An understanding they should try to keep people out of hospital.”

A small minority of staff are wearing masks as we tour the hospital. Four patients have Covid-19 and another four are being tested. A more immediate concern is RSV (respiratory syncytial virus), which staff say is “everywhere”. Their fears are borne out by the arrival of two infants with severe breathing difficulties, who are loaded in ambulances for transport to Dublin for treatment.

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With another flu wave expected over winter, low vaccination rates among staff are a worry. Barely half have taken the flu shot this winter, compared to 73 per cent last year.

Managing the flow of patients is what the 11am daily meetings in The Hub are about. Senior managers and nurses, almost all women, provide updates on the latest incoming cases and the never-ending efforts to make space by discharging well patients.

The list of patients on the walls is coded green for “discharge”, red for “unfit for discharge” with variations in between. “It gives us a visual view of every patient in the hospital – who has left or is ready to leave, who is waiting on long-term care and how full critical care is,” explains flow manager Bríd Crennan.

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Most of the local nursing homes are privately run; staff say they “pick and choose” which older patients they will accept. Higher dependency patients are usually most difficult to place.

“We have a good relationship with the nursing homes but dementia beds in particular are very hard to source,” Crennan says.

Physios are in short supply, as are porters. In the community, potential home helps have been lured away to work in supermarkets with easier working conditions

“We definitely need more beds, there’s no way round it,” says Eleanor Moore, deputy manager. “If we had more, our turnovers would be fantastic.”

More hospital beds means more staff, and they were in short supply even before the HSE was forced to pause recruitment recently. Though smaller Model 3 hospitals like St Luke’s are the workhorse of our health system, they struggle to compete against the big Model 4 hospitals in the cities.

Physios are in short supply, as are porters. In the community, potential home helps have been lured away to work in supermarkets with easier working conditions, Courtney observes.

To make itself more attractive to potential staff, Kilkenny has beefed up the training it provides for doctors – hundreds of RCSI and University of Limerick medical students come here each year. Compared to more remote hospitals, it benefits from relative proximity to Dublin, as well as affordable housing and an attractive location.

Yet it’s a small hospital with “one of everything”, as Courtney puts it. McGovern says he works one night in nine in ED, and one in two when on stroke duty. His equivalent in Dublin might have to work one night in 30.

A similar hospital in England would have two or three full-time stroke consultants, he says. “There’s absolutely no way in the National Health Service that I would be doing the job of three to four people.”

“I’m okay with it because I grew up with this. But here’s nobody like him or me coming up,” he adds, referring to Courtney, who has worked in St Luke’s for 27 years and plans to continue doing so after retirement age. “People do not want to work as hard as we work. The multitasking I’m doing now is not acceptable to many people. This is an issue.”

Difficulties accessing Child and Adolescent Mental Health Services (Camhs) are a major concern. The previous week, staff tell me, four young patients waited six days for access to Camhs, including a number of teenagers with suicidal ideation. On the day we visit, several rooms are occupied by mental health patients with parents, awaiting referrals.

“It’s just not a suitable place for a young person to be stuck in for so long,” Crennan says.

Our visit to St Luke’s was suggested by the HSE with the aim of showing the pressures hospitals are likely to face this winter. Last Monday showed how busy many already are. It certainly looked busy, but there was no sense of crisis or of staff being under unbearable pressure. The work environment was bustling and collegiate; the building itself well-lit and maintained.

“There’s actually great joy in working in a hospital,” McGovern, a 20-year frontline veteran, observes. “It’s really lovely being with patients but I think the new generation coming up are more worried about everything. We always have great fun working in hospital and we try to generate fun in the midst of the chaos.”

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