Explainer: January trolley crisis is predictable but seems impossible to prevent

It’s now a case of hospital A&E departments enduring a year-round eternal winter, reaching breaking point in January and for many weeks beyond. So if it so predictable, then why has it not been fixed?

Rise in older and sicker patients

Hospital A&Es are seeing an increase in patient attendances, but crucially it is the growing number of people over 75 who are piling on even more pressure.

Older patients have more complex needs and can have several illnesses. Once admitted to a ward, they have a longer stay. As an example, on November 26 last A&Es saw 2,950 patients in this age group, compared to 1,701 a year previously.

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The vast majority should be discharged or given a bed in a ward within nine hours, but the evidence is that this winter it is proving more of a struggle to meet this target.

Blockages versus flow

The key to reducing trolley gridlock is to speed up patient flow. Once a patient is brought into the treatment section of the emergency department, they should be seen by a doctor as quickly has possible and undergo diagnosis.

The current problems arise because of overstretched services which can cause delays in the patient receiving medical attention. There is a lack of senior decision makers in A&Es – experienced doctors who are more confident in deciding to discharge a patient. A junior doctor may take a more cautious approach and decide to admit the patient. The patient can spend hours on a trolley which may be compounded by waiting for a diagnosis. This is because of work practices which can reduce access to diagnostic machines out of hours.

Lack of beds

Everyone agrees more hospital beds are needed and although more have been opened in recent years, they cannot keep pace with demand.

It means after a doctor has decided a patient be admitted to a ward, the hospital may have run out of available beds.

Another 190 beds are due to be opened in the first three months of 2020, including a number in blackspots such as South Tipperary Hospital. But these beds need staff if they are to come on stream.

A growing problem this winter is the high number of patients who no longer need to be in hospital but cannot leave due to lack of proper step-down care, such as homecare packages or a nursing home place. At the end of last month some 546 beds were occupied by these patients.

Patient services outside of hospital

The care available to a patient outside hospital can make or break a week’s trolley traffic in a particular hospital.

Patients with long-term illness, particularly older people, need regular monitoring and medical attention to reduce their chances of a serious health setback, which leaves them with no option but attend A&E. Busy GP practices, which no longer can provide same-day appointments, may not have the time to give them this kind of care.

For patients who are ready for discharge from hospital, there may be delays in securing acceptance under the Fair Deal nursing home scheme as they fill out necessary paperwork. Others who are returning to their own homes may be living alone and need to secure homecare.

Priority is given to patients in hospital when it comes to delivering home help and homecare packages – but demand outstrips supply, and also a shortage of carers.

Flu and other infections

This year’s winter flu arrived early, fuelling overcrowding.

Traditionally patients who may be feeling unwell over Christmas and the new year hold out at home, but then flood A&Es in early January.

This combination of pent-up demand and flu means this week will be particularly bad.

The Government’s €26m “winter initiative” plan has been in place since November and is inadequate to meet this week’s emergency, although it does reduce the impact. The reality is, January 2021 is unlikely to be any different.

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