Analysis: The nurses' dispute has highlighted the problem of 'inappropriate' patients, writes Dr Muiris Houston, Medical Correspondent.
The expected overrun of Accident and Emergency departments over the bank holiday weekend did not materialise. While St Patrick's night had the usual quota of drink- and violence-related injuries, the rest of the weekend was remarkably quiet, according to doctors. .
One Dublin hospital has had about 20 to 25 per cent fewer attendances at Accident and Emergency since the nurses' action began. In another, the minor injury section has been significantly less busy and doctors have also noted less elderly sick patients attending over the weekend.
Junior hospital doctors have felt the brunt of the nurses' action. They say they are having to do ECGs, put on plaster casts and are having to leave patients to answer routine phone inquiries. According to one, this situation is unsustainable and has the potential "to go rapidly downhill". However, there has been no friction between health professionals.
In hospitals where it is the norm to have 20 to 30 people waiting on accident and emergency trolleys for beds to become available, typically only five patients were waiting, with every expectation that they would be accommodated within three to four hours. This reflects the greater availability of hospital beds due to the cancellation of routine admissions, rather than a decrease in the number of seriously ill people requiring hospital admission.
But an intriguing question is raised. Where have all the patients gone who clog up Accident and Emergency departments on a routine basis? It certainly raises the issue of inappropriate attendance in casualty departments by up to 25 per cent of those who make up the regular workload.
These are people with minor injuries more appropriately dealt with by general practitioners; patients with medical problems - not emergencies - who have chosen to attend Accident and Emergency rather than wait for an appointment with their family doctor; and those who use the Accident and Emergency service to obtain a second opinion following a consultation with their doctor.
An increasing number of inappropriate tenders are people with a diagnosed problem who have been referred to the hospital outpatient department for treatment but who are frustrated by delays of two years and more before their problem can be dealt with. Some attend because their symptoms have worsened and are seeking relief. Others see repeated attendance at Accident and Emergency as a means of being moved up the urgency ladder. So where have the patients gone? GPs who were on duty over the weekend reported business as usual. Deputising agencies, from where you call out a doctor at nights and at weekends, say they were as busy as they usually are over a bank holiday. Significantly, however, they were not swamped with calls.
It is hard not to conclude that at least one fifth of the usual Accident and Emergency tenders are inappropriate and that some effort should be made to exclude those attenders permanently.
The observation of the Accident and Emergency doctors of a reduction in sick elderly requiring treatment is a worrying one. They represent appropriate tenders who are not being seen; presumably they are receiving treatment in the community but they are a group of people who can become sick quite rapidly.
They are also the group most likely to heed calls not to attend because of the dispute; hopefully this desire not to bother the doctors and nurses does not have any serious repercussions.
Although the effect of the dispute has been less than predicted, the nurses' action is creating a new spiral within an overstretched system. The 60 patients a day in Dublin, and countless numbers elsewhere, whose planned admissions are being cancelled, will rapidly form a cohort of people who will become genuine emergencies by default. Nurses risk creating a new category of emergency patient the longer they continue this dispute.