Reconfiguration of Services in Reconfiguration of Services in the Mid Westthe Mid West

Future Role of the Local HospitalFuture Role of the Local Hospital

FitzGerald ReportOutline of the future hospital system:

report of the Consultative Council on the General

Hospital ServicesDublin: Stationery Office, 1968

HistoryHistory

A Changing Ireland!A Changing Ireland!

Patient expectationPatient expectation

Cancer strategyCancer strategy

HIQAHIQA

Doctors ExpectationsDoctors Expectations

TEAMWORK - background risk issues !TEAMWORK - background risk issues !

1 inpatient elective case per day 1 inpatient elective case per day

105 surgical “emergencies” in one month 105 surgical “emergencies” in one month

(Full theatre on call in 3 local hospitals) (Full theatre on call in 3 local hospitals)

1 in 3 rota (78 rest days) half of all weekends covered by locum!1 in 3 rota (78 rest days) half of all weekends covered by locum!

A/E: Weak clinical governance in local hospitals! A/E: Weak clinical governance in local hospitals!

TEAMWORK Report TEAMWORK Report Mid WestMid West - 2009- 2009

Services are too fragmented !Services are too fragmented !

““Unable to sustain safe reliable levels of care on a Unable to sustain safe reliable levels of care on a continuous basiscontinuous basis in Trauma, Acute Surgery, and in Trauma, Acute Surgery, and

ICU/High Dependency”ICU/High Dependency”

SAFETY !SAFETY !

““These issues should be rectified These issues should be rectified immediately” !immediately” !

Limerick: Junction of Mid west !Limerick: Junction of Mid west !““Hub and Spoke” Hub and Spoke”

75% of population live within 25 miles of Limerick75% of population live within 25 miles of Limerick

ideal area for integrated health service !ideal area for integrated health service !

Project group set up to develop local plan!Project group set up to develop local plan!

Clinical Lead – ChairmanClinical Lead – ChairmanExecutive Lead – national profileExecutive Lead – national profileSenior Nurse – full time on projectSenior Nurse – full time on project

HSE Transformation office - Project Manager and Nursing HSE Transformation office - Project Manager and Nursing Development OfficerDevelopment Officer

Senior Nurse (2) Senior Nurse (2)

Set up a Set up a Project Board, Project Board, Project Team, thenProject Team, then “ “Workstreams” in A&E and Surgery.Workstreams” in A&E and Surgery.

Lots of meetings between Project Group and relevant stakeholdersLots of meetings between Project Group and relevant stakeholders

The Vision of the FutureThe Vision of the Future TeamworkTeamwork

Delivery of care is now being designed around what is best Delivery of care is now being designed around what is best for the patient, not what satisfies the requirements of the for the patient, not what satisfies the requirements of the service, or an organisation, or its staff.service, or an organisation, or its staff.

Non-acute care is delivered in local “centres of excellence”Non-acute care is delivered in local “centres of excellence”

ensuring easy access to a wide range of services for ensuring easy access to a wide range of services for management of most ‘routine’ conditions; management of most ‘routine’ conditions;

Acute care is delivered in a single, regional centre Acute care is delivered in a single, regional centre responsible for managing the more complex conditions.. responsible for managing the more complex conditions..

Selling the Vision!Selling the Vision!

Staff Public GP’sStaff Public GP’sMid West Regional hospitalMid West Regional hospital

Tertiary Care CentreTertiary Care Centre

Major Trauma UnitMajor Trauma Unit

Cancer CentreCancer Centre

Academic/University CentreAcademic/University Centre

Ennis / Nenagh/St JohnEnnis / Nenagh/St John

Advanced diagnosticsAdvanced diagnostics

Day SurgeryDay Surgery

Local Emergency CentreLocal Emergency Centre

Inpatient bedsInpatient beds

TherapiesTherapies

Primary Care TeamPrimary Care Team

Pre requisites for change Pre requisites for change Quick Wins ! Quick Wins !

Emergency TheatreEmergency Theatre

Capacity to centralise intensive CareCapacity to centralise intensive Care

Ambulance transport Ambulance transport

New services in local hospitals - orthopaedics, new endoscopy units New services in local hospitals - orthopaedics, new endoscopy units

Improved Access to Diagnostics (Nimis) Improved Access to Diagnostics (Nimis)

Trouble out West !Trouble out West !

HIQA Report on Ennis Hospital HIQA Report on Ennis Hospital (April’09)(April’09)

““define clear role for the smaller hospital !”define clear role for the smaller hospital !”

“ “need structured relationship between need structured relationship between hospitals”hospitals”

Outreach Day Surgical ServicesOutreach Day Surgical Services

““Select Basket of medical conditions” Select Basket of medical conditions”

HIQA Report – implications !HIQA Report – implications !

Regionalise A&E Services immediately !Regionalise A&E Services immediately !

No ventilated patients to be kept in Ennis !No ventilated patients to be kept in Ennis !

Local A&E Close at 8pm.Local A&E Close at 8pm.Clinical Governance Established !Clinical Governance Established !

More ambulances More ambulances

Advanced ParamedicsAdvanced Paramedics

Direct medical Direct medical admission access admission access

“ “Bypass Protocols” Bypass Protocols” Trauma, Obstetrics, Paediatrics Trauma, Obstetrics, Paediatrics

Local Public and GPs not happy !Local Public and GPs not happy !

Ambulance Activity and Response timeAmbulance Activity and Response time

Ambulance response to AS1 calls by county 2009: 8 minute target

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP

Month

% w

ith

in 8

min

ute

s

Target

LIMERICK

Clare

North Tipperary

Improvement in response times due to more Improvement in response times due to more ambulance availabilityambulance availability

Capacity:Capacity: New A&E attendancesNew A&E attendancesCumulative A&E attendances in Mid West HSE Hospitals

(2008 & 2009)

0

10000

20000

30000

40000

50000

60000

70000

Cum

ulat

ive

num

ber

of n

ew a

tten

danc

es

Total 2009

Total 2008

2009 RGH

2008 RGH

2009 nenagh

2008 Nenagh

2009 Ennis

2008 Ennis

Impact on Admissions from A&EImpact on Admissions from A&E

Numbers admitted to MWRH through A&E

0

50

100

150

200

250

300

350

400

Num

bers

adm

itted

2 extra patients requiring admission per day

Medical inpatient Activity Medical inpatient Activity June 2009 vs 2010 June 2009 vs 2010

Medical Inpatient ActivityJuly 08- June 09 V July 09 V June 10

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

ENN 08-09

Enn 09-10

Nen 08-09

Nen 09-10

Rhd 08-09

Rhd 09-10

St John's 08-09

St John's 09-10

Medical in-pat 3464 2887 2833 2568 9137 8706 1923 2282

ENN 08-09 Enn 09-10 Nen 08-09 Nen 09-10 Rhd 08-09 Rhd 09-10St John's 08-

09St John's 09-

10

Ennis and Nenagh and St Johns continue to Ennis and Nenagh and St Johns continue to provide significant medical inpatient serviceprovide significant medical inpatient service

All hands on Deck !

Reconfiguration of General SurgeryReconfiguration of General Surgery

Theatre ScheduleTheatre Schedule”All men are equal but some are-----------!!””All men are equal but some are-----------!!”

Hospitals in the Mid WestHospitals in the Mid West““changing the way we work” !changing the way we work” !

Emergency ServicesEmergency Services Regional A&E - clinical governance Regional A&E - clinical governance Acute surgery – centralised Trauma Centre – bypass protocolAcute surgery – centralised Trauma Centre – bypass protocol

Anaesthesia/ ICU: centralise and expand !Anaesthesia/ ICU: centralise and expand !

Regional Surgical ServiceRegional Surgical ServiceCancer Centre, Cancer Centre,

Elective and Day surgery in 3 local hospitalsElective and Day surgery in 3 local hospitals

Medical Model in Local Hospital : next challenge !Medical Model in Local Hospital : next challenge !

Critical Care / Medicine Critical Care / Medicine

Centralise Critical Care Centralise Critical Care

Anaesthetic ResourceAnaesthetic Resource

Impact on Local Hospital?Impact on Local Hospital?

Region wide Medical ModelRegion wide Medical Model

Can local hospitals remain in their current mode?Can local hospitals remain in their current mode?

Relationship of Medicine to Anaesthesia ?Relationship of Medicine to Anaesthesia ?

Bed Capacity for medical patients in RegionBed Capacity for medical patients in Region

Role of Acute Medical Assessment UnitRole of Acute Medical Assessment Unit

Medical inpatient Activity Medical inpatient Activity June 2009 vs 2010 June 2009 vs 2010

Medical Inpatient ActivityJuly 08- June 09 V July 09 V June 10

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

ENN 08-09

Enn 09-10

Nen 08-09

Nen 09-10

Rhd 08-09

Rhd 09-10

St John's 08-09

St John's 09-10

Medical in-pat 3464 2887 2833 2568 9137 8706 1923 2282

ENN 08-09 Enn 09-10 Nen 08-09 Nen 09-10 Rhd 08-09 Rhd 09-10St John's 08-

09St John's 09-

10

Ennis and Nenagh and St Johns continue to Ennis and Nenagh and St Johns continue to provide significant medical inpatient serviceprovide significant medical inpatient service

Shannondoc: 8PM to 8AMShannondoc: 8PM to 8AMShannondoc: Ennis 2009 Vs 2008

8PM to 8AM

0

20

40

60

80

100

120

140

160

180

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Week

Calls

2008 2009

Shannondoc: Nenagh 2008 Vs 20098PM to 8AM

0

20

40

60

80

100

120

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Week

Calls

2008 2009

Acute Medical Assessment UnitAcute Medical Assessment Unit

The AMAU will provide a rapid The AMAU will provide a rapid assessment for GP referrals requiring an assessment for GP referrals requiring an acute medical assessmentacute medical assessment

Can keep a significant number of patients Can keep a significant number of patients out of hospital !out of hospital !

JEN – The Model JEN – The Model Hospital

OPD Diagnostics Endoscopy Day Surgery

Inpatientsin

JEN rapid retrieval

NCHD

Training

Triage

Acute

MWRH

Sub-acute

Post

Major Surgery

Elderly

Rehab

LOS 21-28days

Up skill clinical staff

LOS < 5daysAmbulance

Service

Who will run? GP or

Community Geriatrician

rapid response team

Pre-AssessmentClinic

AMAU

Region WideRegion Wide DiagnosticsDiagnostics

National Integrated Medical Imaging System (NIMIS)National Integrated Medical Imaging System (NIMIS)

Unified imaging system across all Mid West: Unified imaging system across all Mid West:

Q3 2010Q3 2010 ???? ????

Recession vs. ReconfigurationRecession vs. Reconfiguration

Moratorium preventing the transfer of retired staff WTE !Moratorium preventing the transfer of retired staff WTE !

HSE being limited in its flexibility by Dept Of Finance !HSE being limited in its flexibility by Dept Of Finance !

Meaningful reconfiguration is threatened !Meaningful reconfiguration is threatened !

Progress !Progress !

““Changing the order and Changing the order and bringing order to change !”bringing order to change !”

The small hospital does have a The small hospital does have a vital role to play in a modern vital role to play in a modern

Irish health system!Irish health system!