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Preparing for the inevitable emergency

There is going to be a lot of emphasis on the pre-hospital care element of the patient journey

Pre-hospital emergency medical services are going to be increasingly important following the implementation of the proposed new trauma system, Lloyd Mudiwa flags.

An important three-part motion, discussed at the recent Irish Medical Organisation’s (IMO’s) AGM, which ran from April 5-8 in Killarney, Co Kerry, relating to paramedics and emergency medicine services in Ireland did not receive any press coverage, presumably because it does not directly impact doctors.

The motion proposed by Dr Michael Molloy, Consultant Emergency Physician and Disaster Medicine Specialist at Wexford General Hospital is particularly relevant now given all the new clinical care programme developments. And especially because of the recent publication of the A Trauma System for Ireland: Report of the Trauma Steering Group, which is proposing trauma bypass, there is going to be a lot of emphasis on the pre-hospital care element of the patient journey.

“So we will have to focus quite extensively on the additional skill-sets and training required for paramedics and advanced paramedics, and possibly even a new type of pre-hospital care practitioner in order to ensure that patients get the highest standard of care possible and that bypass doesn’t lead to worse outcomes than we currently have,” Dr Molloy told me at the AGM. The National Office of Clinical Audit (NOCA) Major Trauma Audit National Report 2016 has just revealed that Ireland has a fantastic 96 per cent survival from major trauma in Ireland. NOCA wants to improve that excellent rate even further, but there are pros and cons to developing the Irish trauma system.

Centralising some of the services means you get specialists who are very experienced and technically capable, but for some patients unfortunately trauma bypass increases the duration of their journey to the appropriate hospital. It also means, for those patients, that their families have to travel further to visit them in hospital.

Average ambulance journey times in Ireland currently range from 10-15 minutes in the cities rising up to one hour in some rural areas or even longer.

“With trauma bypass that could increase even further for a lot of people — up to an hour and a half to two hours. That is something health authorities will have to take into account in advance of any decision to immediately bypass some hospitals.

We can see from previous examples (none other than the Taoiseach himself Leo Varadkar recently admitted that the Government has come to the conclusion that expanding access to free general practitioner care to the recommended 500,000 per year would be too fast see ‘Expanding free GP care’) that it’s very easy to introduce — at the stroke of a pen — a new policy. A new policy such as one where ‘hospital x’ is bypassed, and ‘hospital y’ now takes up a significantly increased number of emergency attendances compared to previously, but without any extra capacity beds or even physical receiving space.

“We want to avoid those mistakes this time,” Dr Molloy explained the motivation for his two motion to me. A front-loading of the trauma system via the provision of a transitional fund – along the lines of the one proposed by the Director General of the Health Service Executive, Tony O’Brien, most recently also at the IMO AGM, ahead of the implementation of the Sláintecare plan — would be important specifically for the trauma system reconfiguration as well because Ireland currently has a hospital system where there is a very small number of intensive beds.

This is in comparison to jurisdictions generally considered to have the best trauma systems — such as Boston and Massachusetts in the US, New Zealand and Australia where the capacity for critical care of their hospitals can be as much as 25 per cent of their total bed complement. Whereas in Ireland it is less than 6 per cent in most hospitals. This critical care capacity certainly has to be enhanced and in the near future prior to undertaking any system reforms via a transitional fund.

A second part of the motion was for the appointment of a Chief Paramedic Officer in the Department of Health. “We have a Chief Medical Officer, we have a Chief Nursing Officer, and Chief Pharmaceutical Officer …,” Dr Molloy said.

“A Chief Paramedic Officer is essential when we are talking about reconfiguring the services because not everybody is acutely aware of what emergency medical services do or can do, and having that type of person in-house will enable them [Department of Health officials] to proactively redevelop and reconfigure, and avoid potential complications because somebody hasn’t thought of the Emergency Medical Services factor.” He added: “That single post is not going to break the bank and I would suggest that would be an incredibly worthwhile investment.”

A second part of the motion regarded producing primary legislation to strengthen the regulatory functions of the Pre-Hospital Emergency Care Council (PHECC), again recognising that with the significant amount of reconfiguration of emergency medical services and the impact this is going to have on the ambulance service, a stronger regulatory function is going to be required.

See ‘PHECC can’t strike off criminals ‘technically” which explains this motion better.

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