The Irish Association for Emergency Medicine is a Registered Charity and is the expert representative
body for the Medical Specialty of Emergency Medicine. It seeks to ensure that the best possible
emergency care is delivered in Emergency Departments (EDs) across Ireland and its members are
doctors working in Ireland’s EDs.
The current situation
EDs across Ireland are operating well beyond their capacity. ED attendances are rising year-on-
year* and although properly functioning EDs generally discharge approximately 70-75% of the
patients that they see, the number of admissions is inexorably rising. Ireland’s inadequate acute bed
capacity means that an increasing proportion of patients that require admission to a hospital bed
from an ED remain in that ED. This causes increased clinical risk for these and other patients but also
means that the ED is significantly compromised in its ability to see the next group of patients safely
and efficiently. This effect is compounded by inadequate community facilities which mean that on
any given day approximately 600-700 patients whose acute hospital care is finished (sometimes
called “delayed discharges”) are not in a position to go to the community for the want of provision
of the necessary supports or resources. This contributes very significantly to the number of inpatient
boarders that EDs are forced to accommodate and along with the indisputable hospital bed
shortage, is at the heart of the “trolley problem”. Although the causes of ED crowding have been
known for over 15 years, it is unfortunately true that there has been no sustained attempt made to
address the capacity constraints in the hospital or community, resulting in clearly proven clinical risks
for patients and staff alike.
What a new Government needs to do?
As crowding in EDs is proven to cause the death of patients who wouldn’t otherwise die and inferior
medical outcomes for all ED patients, the first health priority for an incoming Government must be
the elimination of ED crowding. While individual political parties and the Dáil as a whole have
espoused Sláintecare as a model for future healthcare delivery, this laudable project will have no
impact unless the current hospital capacity problem is addressed. Although Primary and Community
Care will have a long term impact on the numbers of patients with chronic medical conditions
requiring acute care, the patients who languish on trolleys are those deemed to require acute in-
patient hospital care and need hospital beds.
Any political party that aspires to be in government after the General Election must:
1. Commit to an accelerated plan to create an additional 2,000 acute hospital beds within 3
years and a further 500 beds within the following 2 years;.
2. Immediately address the issue of delayed discharges to ensure that the current number of
approximately 700 per day is reduced to no more than 100 patients at any given time;
3. Provide sufficient diagnostics to ensure that patients presenting urgently are not admitted to
hospital to facilitate a diagnostic workup that could be done while in the ED (or, even worse
with less urgent need where it is thought that “admission is the only way to access scans”).
Diagnostics should be front loaded in such a way as to ensure that an appropriate clinical
decision can be made as to the necessity for admission for treatment;
4. Resource EDs with the necessary staff and space to allow timely and safe care.
Implications of allowing the status quo to continue
It has been known for many years that detaining patients in an ED beyond the time of the decision
that they require hospital admission is dangerous and some patients die as a result. Evidence
emerging from a study of over 4,000,000 ED attendances in NHS England strongly suggests that 1 in
83 patients who remain in an ED awaiting admission to a hospital bed for more than 6 hours and 1 in
31 patients who remain in the ED for more than 11 hours will die as a direct result of the failure to
provide a hospital bed in an appropriate timeframe.
Currently, many of the patients that require admission from an ED wait excessive periods of time;
therefore the implication of these statistics for Ireland is truly frightening. No other public health issue
in Irish medicine currently has such profound and devastating implications for patients as ED
crowding does. Clearly, the option of avoiding dealing with the root causes of ED crowding is no
*2.7% increase in ED attendances between October 2018 and October 2019 with a 3.1% increase in
patients over the age of 75.
25th January 2020