IAEM Responds to comments of General Practitioners
The Irish Association for Emergency Medicine categorically refutes the assertion made by Dr Conor McGee, President of the National Association of General Practitioners, that Emergency Departments (EDs) were sending patients home when they should be in hospital. There was an inference, with nothing but anecdote to support it, that this was systemic. Other delegates at the meeting made equally sweeping statements about the quality of care provided in Irish EDs which are at variance with the facts.
The reality is this: internationally, the threshold for hospital admission has risen over the past 10 years and Ireland is no exception. A significant number of conditions which were previously treated as an inpatient are now typically treated as an outpatient and this is better for patients, their families and the Health Service alike. This is a trend which will continue. Hospital admission is not without its own risks and unless there is a clear benefit to a patient being admitted to hospital then this shouldn’t happen just because it might be a more convenient solution for other healthcare professionals.
The public can be assured that the decision to discharge a patient home from ED is only made after careful medical assessment (often including a suite of investigations) to ensure that it is safe to do so. To suggest that patients are routinely sent home without adequate assessment is unfair and misleading to patients, their families and the public.
IAEM agrees that problems can arise in certain circumstances such as when patients are sent by their General Practitioner to an ED with a clinical problem for which the ED has no solution (e.g. long-term back pain), to facilitate an investigation or test to which access is not available or as a means of trying to access a service which should be accessed by a different route. In these cases the ED may have nothing further to offer the patient.
Furthermore, Dr McGee’s suggestion that patients with chronic conditions (citing diabetes, lung conditions and heart failure) need to be (automatically) admitted flies in the face of modern medical thinking. This thinking sees merit in avoiding the need for such patients to be admitted to hospital by improving community outreach services for them and ensuring that when inpatient care is needed that it be facilitated through this outreach service rather than admission through an ED. The Association fully accepts that where a patient has had their emergency care completed and a decision has been made that hospital admission is required, such patients should be transferred expeditiously to a hospital bed and not remain on a trolley in the ED. The presence of inpatient boarders severely limits the capacity of an ED to function optimally and is associated with increased mortality and morbidity for patients. The Association has advocated very strongly for the past decade that this high risk situation must end thus allowing EDs to function as intended, rather than to act both as an Emergency Department and an inpatient ward. Ironically, if Dr McGee’s demands were met, there would be more inpatient boarders in EDs. The Association also accepts that there is a severe capacity constraint in the Irish Healthcare System with a serious shortage of both hospital and community beds, a situation that is getting worse over time. This situation is exacerbated by the large number of patients (currently in excess of 700) whose acute medical care has been completed but remain in acute hospital beds pending transfer to an appropriate lower acuity setting. This is a matter that the HSE and Department of Health must prioritise to improve the chances of a patient who requires acute inpatient care being actually admitted to a hospital bed in a timely fashion. While our Association also agrees that there is a need for a greater number of decision makers in EDs around the country (Ireland has less than a third of the Consultant in Emergency Medicine posts it should have compared with other comparable Healthcare Systems), this is likely to lead to fewer rather than more patients being admitted to hospital. It is clear that our General Practitioner colleagues share many of our concerns regarding care of our mutual patients. It is also clear that while EDs work hard to manage increasing numbers of attendances, resources need to be directed to enable General Practitioners to fulfil their role in caring for their patients in the community. A more considered approach by our colleagues in General Practice to resolve these issues may ultimately prove more successful than providing media sound bites sniping at Emergency Medicine.