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August 22, 2014

A capacity crowd

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Dr Mick Molloy

With years of experience in Emergency Departments under his belt, Dr Mick Molloy believes our ‘trolley problem’ can only be solved by increasing bed capacity.

A number of years ago, five to be precise, former Minister for Health Mary Harney labelled the fact that having 495 patients waiting significant periods on trolleys in Emergency Departments (EDs) was a “national emergency”.

Recently it has gotten even worse, as the trolley crisis has now become a ‘chair crisis’, with large numbers of admitted patients in a number of our EDs not even able to get a trolley, but forced to sleep on stackable plastic chairs. A bed on a ward is now considered a luxury for a patient admitted through the emergency department; trolleys are the norm, but chairs are becoming commonplace.

I guess lying on the floors cannot be too far away, as hospitals will surely soon run out of chairs when they have surges in admission on days when there have been large volumes of elective surgical procedures.

A spokesperson for one large hospital said recently that accommodating admitted patients on chairs in their ED was not a new phenomenon and that not all admitted patients needed a trolley.

That I find to be an incredible statement by anyone who has any knowledge of what lying on a trolley is like, let alone having to live on a stackable plastic chair for up to 48 hours.

Dose of reality
This particular hospital spokesperson requires a dose of reality and some ‘sensitivity training’ and should in fact be asked, as part of their own duty, to spend 48 hours in an ED trying to sleep on one of these chairs. Maybe this spokesperson should do their job and inform each of these patients why they don’t need a trolley and won’t get a bed for some time.

Up until now, it has been the nurses, doctors, porters, reception, security and catering staff employed in our EDs who have been doing all the apologising on behalf of the hospital, which is not part of their job descriptions.

To get back to trolleys, the Minister did go further at one point and explain that trolleys were quite comfortable, as an acquaintance had related to her. I would have to agree with her on that point.

Trolleys are actually comfortable, having spent some time on them myself as a patient, but only as a short-term station and not for anyone at risk of developing pressure areas, such as the elderly. They are certainly not where one would want to spend a few days.

If they were that comfortable, they would be used ‘up the house’ in wards as a space-saving measure, as they are smaller than the typical inpatient ward beds.

Being on the physical trolley, however, is only one part of the equation. The major issue is the environment. An ED that is designed to have 10 to 14 major (sick) patients being examined at any one time in its curtained cubicles is physically too small to accommodate up to 45 admitted patents on trolleys.

Most of these admitted pat-ients will require feeding as well, which can be another logistical nightmare for catering staff. I have heard in one hospital that the number of meals was limited at one point for patients on trolleys to a total of 10, as that was the maximum number of admitted patients that should be on trolleys — except that the additional 20 or 30 patients were not aware of this arrangement and obviously would have objected, had they known.

When there are 30, 40 or 45 admitted patients present on the floor in an ED, privacy also goes out the door. The most intimate details of a person’s life are being discussed as they lie within three feet of around four other patients’ earshots.

If one can get over all of the above, there then are the personal hygiene issues. A maximum of four toilets, if even that, available for that number of pat-ients means there can at times be queues for the facilities when there are patients admitted for whom diarrhoea is but one of their symptoms. Having a dedicated toilet per person is obviously a non-runner, as it would put too much pressure on the remaining single-sex toilets.

Showering, shaving and even a simple face wash are altogether other issues.

When visiting time does come around for those departments that do enforce visiting hours, if each of the 30, 40 or 45 admitted patients and 12 to 20 other patients under active treatment all have an average of two visitors, then space to move around can now be a significant problem, as there may be well over 100 people in the small space.

Fire safety issue
This must be a fire safety issue. Yet who will enforce fire safety when the ultimate end point will be to close the particular ED until the crowding has been solved?

That would just move the problem to the next ED, which now must be closed temporarily to solve the overcrowding, etc etc. Soon we will be moving patients from Dublin to Kerry or Letterkenny to be admitted — if, of course, they don’t already have trolleys of their own, which inevitably they do.

When will the message finally get through that capacity is the biggest issue facing us at present? Until we increase capacity by opening closed beds, commissioning new beds or opening up additional capacity for patients who have finished their acute phase of care, then there will be no solution to the ‘trolley problem’.

It’s as simple as that.