Biting UHL review finds beds placed “any time anywhere”

A SITE visit of University Hospital Limerick (UHL) found permissive boarding with beds placed “anytime, anywhere, even and including mixed gender” five months before the onset of the Covid-19 pandemic, a new unpublished report has revealed.

Serious questions about the model of care being adopted in UHL were highlighted in a draft report – “Review of Unscheduled Care Performance” concerning nine public hospitals, which has been released by the Irish Patients’ Association.

Chaired by Prof Tom Keane, former President of the RCSI and joint National Lead Clinical Programme in Surgery, the review team, included external clinical and management expertise from NHS Scotland, the Scottish Government and NHS England.

They visited nine public acute hospitals including UHL and Galway University Hospitals from August 16, 2019 to November 18, 2019.

Overcrowding continues to be a problem in UHL, with 95 patients on trolleys in the hospital on Wednesday, April 6, which once again was the highest in the country. UHL had 36 more patients on trolleys than Cork University Hospital, which was the second most overcrowded public hospital with 59 patients on trolleys.

In fact, overcrowding in UHL increased this week from 72 on Monday to 97 on Tuesday before falling slightly by two on Wednesday to 95.

Even though patients were moved to trolley spaces on in-patient wards, the review team found waiting times for admission of up to 65 hours.

One of the review team’s recommendations called for the medical model in UHL to be re-examined.

“There was widespread permissive boarding – any bed anytime, anywhere, even and including mixed gender.

“This does not create extra capacity but increases length of stay and risk, especially in the medical specialities. There is an urgent need for better cohorting and early speciality rounding.

“Patients were waiting in corridors in the main ED areas and the hospital routinely employs additional staff with a senior nurse to try to provide safe care and attend to the patient care needs.

“The corridor patients had no privacy. Corridor nursing in ED is unsatisfactory because of poor visibility and ED consultants are often unaware of who is waiting in corridors nominally under the care of the admitting specialist consultant.”

“The non-admitted stream also had long PET times with patients that are not yet seen as a priority. There is a need to target this stream to help overcrowding.”

UHL has 438 inpatient beds, 76 day case spaces and 48 Psychiatry beds. In order to improve daily operational management, the Review Team feel that a hospital-wide, multidisciplinary morning huddle should be put in place to start the ‘rhythm of the day’ and to ensure that the whole site is aware of front door pressures and their role in resolving this.

The team proposed bed management meetings should be restructured to be inclusive, action-orientated and decision making meetings rather than simple situation reports (SITREP).

There is a need for much clearer senior roles with hospital-wide responsibilities for managing flow and an executive chair should drive the bed management meetings on a daily basis especially regarding discharges.

When the review team were there, there was no on-call executive present. Discharge numbers before midday were poor with limited implementation of the SAFER bundle.

This also requires consultant ownership but the review team sensed that medical consultant engagement/ownership across the system appeared to be an issue. This needs further discussion regarding roles and responsibilities

The non-admitted stream had long Average Patient Experience Times (PET) times with patients that are not yet seen as a priority, continuing to overcrowd.

The surgical service would benefit from a pathway to convert some emergency surgical attendances such as abscesses to planned urgent care, which would free up surgical bed capacity and improve patient experience.

The review team stated seven day diagnostics are needed to ensure discharge numbers are maintained throughout the week

They were concerned that there was either none or inadequate ward based therapy teams/social workers and this needs a workforce review.

“There is no criteria led discharge, which would improve early discharges and patient experience of discharge

“The Discharge Lounge had plenty of space but was underutilised, processing on average 15 patients per day pulled from wards, mostly surgical.

“The Review Team had concerns about infection control issues related to the types of patients being admitted without restriction, notably on Ward 3A.”

The team noted opportunistic ‘out-of-hours’ admissions are common in the Acute Medical Unit, which is open seven days per week but is intended to operate as an acute medical unit for extended days, Monday to Friday. The area is not protected or prioritised, which means it cannot fulfil its role as a rapid assessment and treatment area.

Irish Nurses and Midwives’ Organisation assistant director of industrial relations, Mary Fogarty described the report’s findings as “very stark but not surprising”.

“This is a very honest review about systems in the hospital, which nurses believe could be improved in terms of patient flow.”

Ms Fogarty called on the national HSE to commission the review team to return to UHL and complete a report on how many of their recommendations were implemented.

She explained this is the only way to establish if there has been an improvement in the system.

The UL Hospitals’ Group was asked how many of the recommendations in the draft report have been implemented in the hospital.

The group stated the aim of the review at the time was to provide expert insight and recommendations that could help hospitals improve processes and procedures in delivering patient care.

“The arrival of the Covid-19 pandemic in March 2020 required the HSE to respond to the extraordinary challenges posed and in doing so resulted in the implementation of structures and initiatives to address many of the issues and recommendations that were identified in the draft report.

“The review as undertaken in 2019 has limited if any material benefit to be considered today as a basis for implementation, particularly given the action plans in place to address our current and future challenges.

“In this context the draft report is outdated as a result of the pandemic and the significant investment that has taken place in our hospitals during that time.

“The report has remained in draft format since January 2020 and close-out of the review process, to include factual accuracy checks and response from the nine sites reviewed, was never completed.”

The group outlined significant progress has been made in enhancing capacity in both acute and community services to facilitate patient flow within its acute hospital system and egress.

However, the Department of Health has stated: “There are a number of issues of concern in the review for the Department and it would not agree with the assessment above.

“There is no evidence that the changes necessitated by Covid-19 have brought about the type of permanent, long term structural, operational, or organisational changes recommended in the review or improved the leadership and management, which was found wanting in the review.”

“Despite the significant drop in numbers attending ED since March 2020, there remains significant use of trolleys to provide care for long periods, especially in some hospitals and PET targets are not met in many cases.”