Waiting times of up to 90 hours for emergency department beds ‘not uncommon’, Hiqa says

Patients in hospital emergency departments (EDs) often have to wait 80 to 90 hours to get a bed, according to the State’s health watchdog.

Overcrowding in EDs continues to “compromise the dignity and respect of patients, and poses a risk to the health and safety of patients,” the Health Information and Quality Authority (Hiqa) warns in the report published on Wednesday.

Improved leadership and governance within hospitals, greater investment in resources and more effective workforce planning are recommended in the report, which summarises the findings of the first seven inspections carried out by Hiqa since April.

“Emergency department overcrowding needs to be recognised as a whole health system problem, and the normalisation of comparatively poor performance should not be tolerated,” it says.

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Hiqa says the health system is under unprecedented strain due to record ED attendances, an ageing population, the after-effects of Covid-19 restrictions and a shortage of GPs in the community.

“Consequently, issues such as reduced access to community services, limited acute and community bed capacity, ineffective patient flow, and insufficient staffing levels, continue to cause overcrowding in Irish emergency departments.”

Overcrowding in emergency departments continues to “compromise the dignity and respect of patients, and poses a risk to the health and safety of patients,” the report states.

University Hospital Limerick and Mayo University Hospital were found to be non-compliant with three of the four standards assessed, while Cork University Hospital and Sligo University Hospital were non-compliant with one standard. St Vincent’s University Hospital in Dublin was fully compliant with all four standards, and Cavan Hospital and St Michael’s Hospital were partially compliant with three standards.

In five of the seven EDs Hiqa was not satisfied there were effective management arrangements for delivering safe services. Some hospitals were operating at double capacity on the day when they were inspected.

Six hospitals were short of nurses, and in one the shortfall was 34 per cent. Two hospitals used consultants who were not on the specialist register.

Target times missed

Due to overcrowding six EDs failed to maintain patients’ right to privacy and failed to meet performance targets on wait times. Up to half of all patients were not dealt with within the target time in some hospitals, and up to one-fifth were in the ED for more than 24 hours.

The report says it is “not uncommon” to find patients in EDs who have been waiting 80 to 90 hours for a bed, with a patient waiting 116 hours in once case.

Inspectors identified areas for improvement around patient dignity and privacy, ensuring sufficient workforce numbers and “the protection of patients from harm associated with the design of service delivery”.

“Furthermore, improvements were needed to ensure that there is a balanced approach to the daily operational management of patient flow, capacity and appropriate staffing, which is clearly linked to patient safety and activity.”

The report warns that ED overcrowding and access issues will continue to occur unless a system-wide approach is taken to address major structural challenges.

“There is also a need to develop operational and leadership capability to support more effective management of patient flow and processes within hospitals and between hospitals and community services and respond to, rather than continuing to tolerate or normalise, this problem.”

Hiqa notes some “encouraging” measures within hospitals including the resourcing of safer staffing models and increases in bed capacity.

To address safety issues, it recommends the urgent addition of capacity within the whole healthcare systems - in hospitals and the community. Capacity requirements at a regional level should be assessed and there should be investment in diagnostics and other infrastructure.

Hiqa also says more responsive leadership, governance and management is needed at local, regional and national level “which acts to address performance issues when identified”.

“Such an approach needs to recognise that – notwithstanding contextual challenges – some hospitals cope better than others with the demands placed upon them and that this is often driven by better local operational management.”

The report also recommends a more effective approach to strategic workforce planning to anticipate manpower shortages and more effective identification, monitoring and management of patient safety risks.

‘Significant risks’

Sean Egan, HIQA director of healthcare regulation, says the inspections conducted at the more crowded emergency departments over the last nine to twelve months have identified significant risks to patients in terms of safety, privacy and dignity.

Speaking to the News at One on RTÉ Radio 1, Mr Egan said there is a “fundamental mismatch” between available capacity within the health system, both in the acute and community setting, which is manifesting itself in overcrowding in emergency departments.

Mr Egan said one of their key findings involves staffing deficits.

“We have seen deficits in terms of nursing staffing and also medical staffing. That coupled with unprecedented levels to emergency departments....sheer volumes of patients presenting which have reached levels that we have never really seen before in emergency departments. It is contributing to a system where capacity outstrips demand and ability to provide timely services.”

Mr Egan said there are variances in the way the issues is managed across various hospitals.

“I think one of the interesting findings from the sample of inspections we conducted is that we have identified that it is not a homogeneous problem across all hospitals.

“Some hospitals cope better than others, and what we are really talking about there are a more rigorous and more efficient application of a number of the measures that we know improve flow for patients through the emergency department, and in to inpatient beds and equally in to a more appropriate setting which is often in the community.”