Put simply, the Drogheda emergency department is too small for its 37,000 patients, writes Martin Wall.
Up until a few years ago Our Lady of Lourdes hospital in Drogheda was a regional centre providing services for patients in the northeast of the country.
However, healthcare, just like transport and educational services, has come under pressure as a result of the sudden expansion of populations in the counties surrounding Dublin.
The new consultants' report on emergency services says Drogheda and many other towns in the hospital's catchment area in Meath and Louth have become part of the commuter belt.
It also maintains that there has been a surge in the number of people from north Co Dublin attending Our Lady of Lourdes to avoid queues in city centre hospitals.
The report points out that Our Lady of Lourdes does not have the worst A&E problem in the country, and that waiting times for patients on trolleys are not as long as elsewhere.
However, it makes it clear that the infrastructure at the hospital as well as facilities and work practices are in some cases lagging behind what are needed to cater for the growing demands.
Quite simply, it says that the current emergency department is too small for the 37,000 patients who attend annually.
It also maintains that there can be up to 20 people on trolleys, and that the unit is ill- equipped to deal with those waiting.
While it says that ideally a new facility should be provided, it acknowledges that the HSE's plans for the reconfiguration of services in the northeast could take years to complete. In the interim it proposes reforms to improve the flow of patients.
It calls, for example, for the emergency department to have greater access to diagnostics. At present there is no dedicated X-ray facility in the department which is reliant on the main radiology unit. This operates from 9am to 5pm, with an on-call system outside these hours.
The report also says that the nurse-led triage scheme in the department is unable to operate on a 24-hour basis due to staff shortages. It proposes that this should run until 10pm at least. It maintains that the hospital is unable to provide a "see-and-treat" scheme at busy periods because of the number of consultants in the department and their shared responsibilities with other hospitals.
It also says that the department has no dedicated input from physiotherapists, and that there is no occupational therapy service in the hospital as a whole "which severely impedes early assessment, treatment and rehabilitation".
It says the hospital's work as a regional fracture centre considerably impacts on waiting times early in the week. It says the hospital has been largely unable to change the times of fracture clinics to avoid peak time in A&E due to other commitments of consultants.
It also highlights the impact of limited after-hours primary care services, and says that 72 per cent of those attending the A&E had not seen their GP. It suggested that up to 39 per cent of those attending could be treated in other settings, if available, in the community.
The report says in many ways the emergency department was operating as "a community safety net" in the absence of other choices.
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Hospital has 339 beds and around 37,000 A&E attendances annually.
Although GPs did not refer patients inappropriately, it was clear that the emergency department was operating as a community safety net in the absence of other choices.
72 per cent of patients attending the emergency department were self referred and had not been to their GP first.
The hospital needs a larger specifically- designed emergency department.
HSE needs to review the future of the hospital as a whole in terms of alteration and/or re-provision.
Medical and nursing rosters should be reviewed to ensure staffing matches peak activity.
Triage service should be developed at least until 10pm.
Priority should be given to increasing direct access to basic diagnostics.
Hospital should look at development of acute medical unit.
Hospital should consider keeping open the 5-day ward at weekends to accommodate elective patients who have surgery later in the week.
There should be more consistency in discharge processes and the introduction of discharge lounges should be considered.