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Acc ID ENTS a R e No t ra N do m e V e n t s T h e y are Pre D Ic tA Ble t h E y C AN B E P re VE N Ted

Acc ID ENTS a R e No t ra N do m e V e n t s T h e y are Pre D Ic tA Ble t h E y C AN B E P re VE N Ted. East Coast Area Emergency Medicine – The Way Ahead ?. Robert McQuillan Director of Emergency Medicine South East Dublin. ?. Documents for Consideration. Comhairle Report.

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Acc ID ENTS a R e No t ra N do m e V e n t s T h e y are Pre D Ic tA Ble t h E y C AN B E P re VE N Ted

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  1. AccIDENTSaReNot raNdomeVents TheyarePreDIctABle thEyCANBE PreVENTed

  2. East Coast Area Emergency Medicine – The Way Ahead ? Robert McQuillan Director of Emergency Medicine South East Dublin

  3. ?

  4. Documents for Consideration

  5. Comhairle Report Tommie Martin

  6. Five Principles for future structure of emergency services • Patients transferred to the hospital most capable of providing appropriate care • Integrate management of emergency health needs - primary care, pre-hospital care, transport and hospital services • Manage emergency hospital care as a single integrated service unit with pathways of care • The health board area should network all resources for emergency patient care • Staff guided by agreed protocols with data systems for planning audit and evaluation

  7. Health Strategy • Patient at the centre of care • Increased A&E consultants • Triage • Nurse practitioners

  8. HIGHEST STANDARD OF PRE-HOSPITAL EMERGENCY CARE • ongoing upgrading of the ambulance fleet • 24 hour on-duty staffing for all ambulance stations • crewing of all ambulances with emergency medical technicians • strengthening of IT links between ambulances and A and E departments • augmentation of current response capability • introduction of first responder schemes, involving generalpractitioners and voluntary personnel • development of a dedicated emergency ambulance service through the separation, where appropriate, of emergency and routine work • strengthening of the performance management function, with an emphasis on audit and monitoring of response times • ongoing training in the use of defibrillators. Quality and Fairness 2000, p 84

  9. Primary Care • “Primary care is the appropriate setting to meet 90-95% of all health and personal social services needs” • Liaison between primary and secondary care will be improved”

  10. Acute Hospitals -Problems • high attendance rates;ED- 22%  since 1988 OPD - 37%  since 1980 • long delays for treatment and/or admission; • insufficient acute hospital beds to facilitateadmission to hospital; • increasing proportions of hospital beds occupied by patients admitted through A&E; • cancellation of elective admissions andprocedures; • long waiting lists for elective procedures; • acute hospital beds occupied by persons no longer in need of acute care; • unacceptably high bed occupancy levels in major acute hospitals. Acute Hospital Bed Capacity 2002

  11. Convenience Vs Experience • Service arrangements should be such that patients are not unduly burdened with traveling long distances….. • A key issue in maintaining the skills of highly trained specialist clinical staff is the number of cases dealt with on an ongoing basis……….. • Resuscitation, assessment and treatment of acute illness and injury on a 24-hour basis in patients of all ages by appropriately trained and experienced staff prior to discharge home is a prerequisite

  12. Regionalisation and a National System • The response team at the site of accidents should have communication with a “base” hospital so that access to medical expertise is available from the point of touch down at the site. A regional patient retrieval and transfer system linked to the national system should be put in place without delay. Helicopter transport should be considered as part of the transport arrangements.

  13. Cost of EM department • Pay 3.5m • Non pay 0.5m • Resources 1.0m • Total 5.0m

  14. Regionalisation of Emergency Services • Appropriate utilisation of hospitals • Staffing levels and numbers • Integration and networking of services • Establishing protocols and standards to allow pathways of care prioritised for acuity • Establishing data systems to allow planning audit and evaluation

  15. Appropriate Utilisation of Hospitals • St. Vincent’s, St. Michael’s, St Columcille's • Eye and Ear • Hume St • Holles St • St John of God’s • Blackrock clinic • Others

  16. Beds E.M. attendance % return E.M. admissions St Vincent’s 471 37,500 8 8400 St Columcille’s 150 25,300 11 4040 St Michael’s 104 24,900 36 2200 TOTAL 725 87,711 7 14640 Basic statistics for the 3 general hospitals

  17. Regionalise How to utilise the 3 general hospitals to provide the most appropriate care? • 1 major unit and close 2 departments • 1 major and 1 or 2 minor units • 1 major and 1 comprehensive unit and close the third • 1 major and 1 comprehensive and a role for the third department

  18. Solution? • Regional Unit – St. Vincent’s University Hospital • Comprehensive Unit – St. Columcille’s Hospital • Minor Unit and Clinical decision unit – St Michael’s Hospital

  19. Staffing - Advantages of Consultants and Senior Medical Cover • Improvement in the quality of care • Expeditious and improved patient throughput • Reduction in the number of errors attributable to inexperience • Reduction in the number of unnecessary investigations, admissions, waiting times, treatment times and review attendances • Improvements in teaching, training and supervision of medical staff A&E Services 2002, p 96

  20. Advantages (cont.) • Reduction in costs associated with inefficient useof medical staff • Improvement in the community’s perception of, and confidence • Improved quality assurance and risk management • Reduction in the number of complaints • Improvement in the reputation among other medical groups • Improved use of new technology. A&E Services 2002, p 96

  21. Consultants Columcille’s Vincent’s Michael’s

  22. What is Senior Cover ? • Consultants • Emergency Physicians • Specialist Registrars • Clinical Fellows • Registrars • Senior House Officers • Interns

  23. Supreme Court Judgement “A SHO in A&E …could refuse admission, he could not admit a patient without a second opinion” “It seems to me that any system which gives absolutely authority to a junior doctor is inadvisable. By its very nature the position of a senior house officer is one where the holder is learning his profession. He must meet from time to time cases with which he is not familiar and in which he would welcome the opinion of a senior.”

  24. Emergency Physicians “If Ireland did not embrace the introduction of assistant grades, the nation’s problems would be much greater than those in other countries where the assistant grades played a significant part in the health services workload”

  25. St . Vincent’s manpower • No overall change in staff numbers other than consultants • Grade of senior staff increased with appointment of 2 emergency physicians • Approval to appoint specialist registrars • Grade of registrars increased with appointment of clinical fellows • All SHO posts on rotations and new SHO rotation in EM started • Significant increase in numbers of clinical nurse managers

  26. St. Vincent’s - Organisation • No significant structural changes as yet, chest pain unit and clinical decision units are “virtual” • Rapid Assessment Team • Trauma Team • Chest pain, radiology and respiratory protocols • Point of care testing • Academic department – attendance, staff numbers, types of hospitals, - transferable • Computerisation

  27. St.Columcille’s manpower • Consultant • Emergency Physician • Medical registrar • 4 registrars • 5 SHOs • CNM2 • 5 CNM1s • 3 public liaison officers

  28. St. Columcille’s structure • Significant structural changes have been approved and funded with areas for • Major (9), minor (6), resuscitation (2), paediatric waiting and treatment, triage, offices, staff room, kitchen, relatives and viewing, stores, point of care, decontamination.

  29. St. Columcille’s organisation • Teaching • Protocols • Computerisation • Rotations • Regular feedback

  30. St. Michael’s • No structural changes some internal reorganisation • Emergency physician • 2 SHO/Registrars • 1 Clinical Fellow • Regional protocols • Excellent nurses • 8am to 8pm

  31. PRE-HOSPITAL Primary care – regional concept Ambulance service Alternatives IN-HOSPITAL Pathways of care based on specialty and acuity Network

  32. Madsen Cooperation and Competition

  33. Comments of 7 year olds • “Impossible to get a marble” • “I could get a marble if I could play on my own”

  34. Questions • Are the hospitals utilised correctly? • What is the best pathway of care for seriously injured patients? • Who should provide the care? • How should paediatric emergencies be handled? • How do we supply a service to the south of the region? • How do we integrate more closely with pre-hospital care?

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