Picture this: you’re in an emergency department. You never expected to be here, but you have pneumonia or maybe a severe asthma attack. What a relief to discover that a trolley is just a hard, narrow bed – not a supermarket trolley!
You lie there, surrounded by crowds of patients, and worry about delays. If only more people would go to their GP, like you did, the staff could focus on those in need.
But they could tell you about people they know who were all referred by GPs: head injury, blocked intestine, heart rhythm problems, a badly broken arm, seizures and stroke are hospital cases. They all spent time on trolleys, mainly in Dublin. Most of them had health insurance too, like you.
A stream of busy health professionals come to ask questions, examine you, make notes, take blood samples and X-rays, and start you on treatment. It’s all very efficient.
As the nurse starts your drip, you comment sadly: “I’m one of those trolley statistics now.” To your surprise, he says no, you’re not.
The number on the news only includes “admitted” patients. You’d have to be assessed by the ward specialist doctors, and accepted as a hospital admission. If they can’t find a ward bed, then and only then, you’ll be a trolley patient. He says lots of people will be treated here overnight, but won’t be in the count.
Just being on a trolley doesn’t make you a trolley patient.
Too ill to follow all this, you hope you won’t be there overnight.
Assesses your case
Later, a doctor from the wards assesses your case, and decides you should be “admitted”. Unfortunately, she says, the hospital is full; you’ll be in A&E overnight.
Congratulations! Nothing has changed, there’s no special sign over your head but you are now one of the “trolley admissions”.
Wearily, you ask why there isn’t a bed for you. After all, Dublin has plenty of hospitals.
Some of the staff pause briefly to mull it over.
A doctor says Ireland used to have 18,000 beds for three million people, but closing wards has been fashionable since the 1980s. The HSE has been reducing beds ever since. Ten years ago, a report recommended cutting back to 9,000 beds.
A nurse explains that big Dublin hospitals, like Beaumont and Tallaght, actually opened with fewer beds than the hospitals they replaced. She says even the new national children’s hospital will have fewer overnight beds than the three current hospitals.
Another nurse says wards outside Dublin closed through reconfiguration.
She was a student when services centralised into Limerick. There was a surge of patients, far more than anyone expected, but no extra wards were provided. Instead, a beautiful new emergency department opened last year. Of course it filled up with trolley admissions, as there was nowhere else for the patients to go.
It’s mad stuff, she said. If a hotel needed extra rooms for guests you wouldn’t spend millions on a bigger foyer and put up camp-beds. There simply aren’t enough hospital beds.
She can list other failed solutions to the trolley crisis.
Prevent admissions
Kilkenny got a magnificent assessment unit, supposedly to prevent admissions. Think about it – you can’t be a “trolley admission” unless you’ve been assessed, so they have more trolleys than ever. Beds for elderly “bed-blocker” patients were opened, and that turns out to be a separate problem. The latest answer is primary care and GPs even though these patients have all been judged to need hospital care.
It’s just too much to take in.
You lie there under the bright lights and the noise, trying to doze. The nursing staff kindly push your trolley bed into a quiet corner, but it’s still an uncomfortable night.
Next morning, you feel much improved. You watch the consultant and ward doctors searching for “admitted” patients among the trolleys. They discharge you to continue treatment at home.
You comment “At least the HSE can learn from my case”.
The consultant sighs: “If only!” She explains that details of diagnosis and treatment are gathered on each patient – it’s called HIPE (hospital in-patient enquiry) data. But there’s a rule: because you didn’t physically leave the emergency department and move to a ward, your case is ignored. Your data will fall into a big black hole.
As for you and all the other trolley patients, the HSE knows only that you were in an emergency department, and you waited. That’s all. People who are on trolleys leave no data trail.
You’re puzzled: how can the HSE expect to solve the trolley crisis if they know nothing about the patients? Good question, the consultant says, moving on to the next trolley. Maybe that’s why they keep getting it wrong.
Dr Christine O’Malley is a consultant geriatrician and former president of the Irish Medical Organisation