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Portiuncula Hospital moved Emergency Dept patients ‘off the books’

One patient was accommodated on a trolley in the isolation room of the Emergency Department of Portiuncula Hospital for more than 60 hours due to lack of appropriate inpatient isolation facilities, an inspection has revealed.

The announced inspection by the Health Information and Quality Authority (HIQA) of Portiuncula Hospital last May focused on infection prevention and control, medication safety, patients with conditions such as sepsis that could cause them to rapidly deteriorate and transitions of care.

The Emergency Department (ED) was busy during the two-day visit by inspectors, with 31 patients in the emergency department, which had 18 cubicles opened across two areas.

Patients waited between three and 61 hours for an inpatient bed. Ten of the admitted patients were in the department over nine hours and two admitted patients were in the department over 24 hours. Eight patients were on trolleys along corridor of the ED.

Average of 80 patients per day

Figures from 2022 showed there was an average of 80 patients attending every day – 12% increase since 2019 before the pandemic.

“The daily attendance rate to the ED was steadily increasing and on the days of inspection there had been between 104 and 116 daily attendees to the ED,” the inspectors noted.

Inspectors were critical of the hospital’s method of recording patient numbers in the ED.

Their records showed that 67% of patients who attended the department between January and September 2022 were discharged or admitted within six hours, 88% within 9 hours and 99.8% within 24 hours.

However, inspectors highlighted the fact that admitted patients accommodated in the ED were transferred to an ‘ED virtual ward’ once they were approved for admission, so they were no longer registered on the hospital’s electronic system as being in the ED even though they were physically there.

“As the admitted patients accommodated in the ED had not physically left the ED, they should be included in this metric. This should be reviewed by the hospital as a priority following this inspection to ensure the accuracy of the hospital’s reporting.”

While there were higher lengths of stay for medical patients compared to the national average, management attributed this to the increase in the number of patients aged 75 years with complex medical needs and delays in transfer to step-down facilities.

There were five patients in the hospital who were experiencing a delay in the transfers of care, inspectors found.

‘Operating effectively’

Overall, HIQA found Portiuncula was operating effectively with a range of measures implemented on a daily basis to improve the patient flow through the ED and throughout the hospital.

It also said it was satisfied with the governance and oversight of infection prevention and control, antimicrobial stewardship and infection outbreaks at the hospital.

“The hospital was challenged with capacity issues and lack of isolation facilities resulting in poor patient flow from the ED. The mismatch between the demand for inpatient beds, especially isolation facilities, and the hospital’s overall capacity resulted in admitted patients being accommodated in the ED awaiting an inpatient bed.”

The hospital had 13 single rooms, many without ensuite facilities, which was far below what was needed to meet capacity.

“On the day of inspection one patient was accommodated on a trolley in the isolation room in the ED for over 60 hours due to lack of appropriate inpatient isolation facilities.”

Management said this would be addressed by the opening of the new 12-bed Dunlo Ward which opened in September, the completion of a replacement block with additional isolation facilities expected to be opened by August next year and a proposed new larger ED modular build sent to the HSE for capital funding approval.

The report found there was a shortfall in rostered nurses and pharmacists, which the hospital was trying recruit.

There were five newly approved pharmacists’ posts under recruitment but despite recent recruitment drives the hospital had been unable to fill these posts.

Portiuncula performed well in the 2022 National Inpatient Experience Survey 2022, with patients scoring 9.3 when asked if they were treated with respect and dignity in the ED, higher than the national average of 8.7.

Response from Saolta University Health Care Group:

The Saolta University Health Care Group – which operates Portiuncula – said significant work has been carried out by the hospital in all areas where compliance issues were highlighted by HIQA.

In a statement, Saolta said: “The HIQA report notes that at the time of inspection, Portiuncula was challenged by outdated infrastructure in particular in the distinct lack of single rooms and ensuite facilities in the hospital. It is deeply regrettable that the hospital was found to be non-compliant with Standard 2.7 (‘Healthcare is provided in a physical environment which supports the delivery of high quality, safe, reliable care and protects the health and welfare of service users’), however, significant progress has been made in this area since the inspection took place.

“In September 2023 a major infrastructure project was completed in Portiuncula with the opening of the Dunlo Ward.

“The 50 bedded replacement ward block will further alleviate our infrastructure and capacity challenges at the hospital, this build is progressing with an expected completion date of August 2024. The new unit will provide single room accommodation with ensuites and will have two compliant negative pressure rooms on each floor, which has been raised by HIQA as a risk.

Patient dignity

“In Portiuncula, we make every effort to promote and maintain patient’s dignity and respect and we deeply regret the need to accommodate patients on trolleys on the ED corridor. We acknowledge that this measure negatively impacts on our patient’s dignity and privacy and we apologise for the distress this causes to our patients and their families.

“As a solution to the sustained pressure on the ED, the hospital is in the process of appointing a design team for a modular expansion build to the Emergency Department. Capital funding has been sanctioned for this expansion. This development will improve the toilet facilities, which was reported as a risk by HIQA, and will have a direct impact on safeguarding patient care while offering service users’ dignity, privacy and autonomy.

“The hospital is also taking steps to address staffing levels in the ED which were raised within the HIQA report.

“A submission has been approved at Group level for a for a Consultant in Emergency medicine. The application process is in process.

“On the day of inspection there were five nursing vacancies at the hospital, we are engaged in an on-going recruitment campaign to fill all outstanding vacant nursing post in the Emergency Department and across the wider hospital.

“The hospital has been approved to hire a Clinical Pharmacist to provide services to new 12 bedded Dunlo Ward and to the Emergency Department.

“At the time of the inspection the security detail were providing cover from 8-8pm. This has been extended to 24-hour cover since June 2023,” the statement read.

James Keane, Hospital Manager at Portiuncula, said: “As a hospital team we work very hard to ensure that good governance structures and monitoring systems are in place so we can identify and act on opportunities for improvement.

“I want to acknowledge the incredible commitment and dedication of our staff in providing a patient centred approach and we will work together to build on the good practice highlighted in this report.”

For more, read this week’s Connacht Tribune:

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