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Reconfiguration of Services in the Mid West. Future Role of the Local Hospital. History. FitzGerald Report Outline of the future hospital system: report of the Consultative Council on the General Hospital Services Dublin: Stationery Office, 1968. A Changing Ireland!. Patient expectation - PowerPoint PPT Presentation
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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!