HIQA Finds UHL ED Was “Grossly Overcrowded”

HEALTH inspectors found the Emergency Department (ED) was “grossly overcrowded” with a total of 121 patients requiring care on February 21, a new report has revealed.

Patient experience times (PETs) and the time spent waiting for tests were raised by patients in the emergency department as areas of great frustration, according to a new report from the Health Information and Equality Authority (HIQA).

One patient described how they waited for four days for a magnetic resonance imaging (MRI) scan and seven days for an electroencephalogram (EEG).

When asked what could be improved about the healthcare services at UHL, patients described how the hospital environment was‘noisy’ and how‘the bright lights in the emergency department made it difficult to rest and sleep’.

Trolleys were described as “uncomfortable”. Patients described being accommodated on trolleys on the corridor as “not dignified or private”. Patients also reflected on how “there was not enough staff’” and “staff were overworked”.

The report warns the association between an increase in morbidity and mortality and overcrowding in emergency departments is well established.

Hospital management and the HSE recognise and acknowledge that a key causal factor of overcrowding of UHL’s emergency department is UHL’s inpatient bed capacity, which is insufficient to meet the growing demand in the Mid-West region.

On the first day of this inspection, inspectors found the emergency department was grossly overcrowded with a total of 121 patients registered in the department at 11.00am.

Documentation reviewed by inspectors showed that a total of 246 people attended UHL’s emergency department that day, marginally lower that the daily attendance of 290 people in March 2022.

The report’s findings emerged following an unannounced inspection of UHL on February 21 and 22 following a similar inspection in March 2022.

Th emergency department has experienced unprecedented levels of attendance since January 2022. The hospital has one of the highest rates of attendance year on year.

The recorded attendances to UHL’s emergency department in 2022 was 79,644, which was the second highest level of attendances of all the Model 4 hospitals in the country that year.

Furthermore, the occupancy rate of inpatient beds at UHL in 2022 was 105%. This occupancy rate has become the operational norm at UHL and is well above the maximum operating occupancy rate of 85% proposed by the Department of Health in the capacity review report of 2018.

On 15 March 2022, HIQA found significant non-compliance with the four national standards assessed and inspectors were not assured that the measures implemented by hospital management were adequate and sufficiently effective in managing the overcrowding of the emergency department and the risks to patient safety identified during that inspection.

On February 21, 2023, HIQA found the hospital to be partially compliant with three national standards and non-compliant with one national standard assessed on the days of inspection.

This represented some improvement on HIQA’s findings in 2022, where three of the four national standards assessed were found to be non-compliant, with the remainder found to be partially compliant. Recent findings indicating improvement included changes to local management arrangements at the hospital including the appointment of a senior manager assigned on site for the overall daily operational running of the hospital.

There was an improvement in the level of nurse staffing levels in the emergency department compared to 2022 findings, coupled with an enhancement in the number of consultants in emergency medicine and a change to consultant work practices to ensure greater levels of onsite availability over the working day and week.

The report cited improvements to the way services are organised and managed to enable more timely treatment and decision-making around patient care – these changes had begun to yield shorter treatment times and lengths of stay for patients in the emergency department.

Notwithstanding these findings, the emergency department remained very overcrowded with 72 patients on trolleys and chairs awaiting an inpatient bed.

This level of overcrowding continued to impact the privacy and dignity of patients, despite the best efforts of staff – albeit a number of the risk issues HIQA found in 2022 had been addressed.

Findings from the inspection for areas in the hospital other than the emergency department were more positive, with eight out of 11 national standards assessed found to be either compliant or substantially compliant.

In particular, the ability to provide care in a more private and dignified way was better enabled outside of the emergency department. Identified areas for required improvement included in hospital infrastructure, staffing levels, and better use of audit to drive improvement.

The hospital and wider HSE also fully acknowledged that improvement efforts to address ED overcrowding remain a work in progress. HIQA identified the following additional planned measures that are intended to further address continued overcrowding at the hospital’s emergency department.

These included that the hospital is in the process of building or planning the development of two additional 96-bed blocks to add significant extra inpatient bed capacity. The first of these blocks is intended to be opened in late 2024 or early 2025, with the second intended to open in 2027.

Efforts were planned to build on recent improvements to the way work was organised to enhance efficiency in the unit, allied to a commitment to further utilise initiatives to provide alternate care pathways for in particular some older patients who present to the emergency department.

Efforts are underway to enhance the approach to workforce planning and vacancy filling.

HIQA stressed it is imperative that these gains are built on and further efficiencies are achieved.

Following the inspection, HIQA sought further assurances that the hospital and wider region would be effectively supported to enact substantive measures to address capacity deficits, including in acute and community service configuration, capacity and resourcing implementation.

A need for a whole-region plan for the Mid-west region – to include acute, community and general practice – was further emphasised by HIQA to comprehensively address the continued overcrowding situation at UHL.

The hospital has submitted a follow-up compliance plan in response to the inspection findings, outlining its short, medium and long-term actions to address the non-compliances.

Dan Danaher