An unannounced inspection of the emergency department (ED) in University Hospital Limerick (UHL) last March found that one patient had been left waiting on a trolley for in excess of 116 hours, which is almost five days.

A second patient had been waiting on a trolley for 85 hours, which is three-and-a-half days.

The inspection was carried out by the Heath Information and Quality Authority (HIQA) on March 15, 2022. As part of this, the inspectors spoke with staff and management. They also observed care being delivered and interacted with people who were attending the ED.

While the midwest region has three local injury units, UHL has the only ED in the region providing a 24/7 service for a catchment area of over 385,000 people. In recent years, the hospital has experienced consistent overcrowding. It usually tops the Irish Nurses and Midwives Organisation’s (INMO) daily Trolley Watch figures.

On the day of the inspection, inspectors found that the ED was “grossly overcrowded”. Extra patients were placed on trolleys in corridors “with very little free space between them”. By 11.30am, there were 50 extra patients accommodated on trolleys, double the capacity of the ED.

“In addition, all 25 beds in the Acute Medical Unit (AMU) were occupied. An additional four patients were accommodated on trolleys on the corridor of the AMU. In effect, the AMU was acting, like many other areas of the hospital, as an overflow ward for non Covid-19 patients from the ED, and was not functioning as designed, as an alternate flow pathway for patients in order to take pressure from the ED.

“This indicated to HIQA that the normal means of facilitating patient flow were simply not working at the hospital at the time of inspection,” the inspectors said.

They spoke to a number of patients in the ED. While all were complimentary about the staff and acknowledged that they were “doing their best”, most pointed out that there were simply not enough staff, remarking that those who were there were “run off their feet”. Some expressed concern about how overcrowding in the ED impacted on their safety.

Patents also commented about the lack of space and the lack of privacy and confidentiality. They also highlighted the waiting times. One patient said they had waited 90 minutes to be triaged and “were waiting in a wheelchair for 14 hours while awaiting a trolley”.

The inspectors noted that among all the patients in the ED at 11.30am on the day of the inspection, 43% “were boarding in the department while awaiting an inpatient bed”. The majority of these were “being accommodated on trolleys in corridors with very limited space between each trolley, which impacted on patients’ privacy and confidentiality”.

In fact, the inspectors noted that clinical consultations and assessments were carried out “wherever the person was located”.

“For patients on a trolley, this was usually on a corridor. In this setting, it was not possible to maintain privacy and confidentiality when communicating and interacting with patients. There was a significant risk that others (patients, visitors and staff) could overhear patient-clinician conversations and personal information exchanged between patients, medical and nursing staff.

“Overheard conversations and disclosures adversely affect patients’ trust and can lead to a breakdown in the relationship between them and their caregivers, and is not in line with a human rights-based approach to healthcare promoted and supported by HIQA,” they said.

The inspectors also found that on March 15, nurse staffing levels in the ED were

insufficient to meet the needs of patients. On that day, it had a shortfall of 17% in the agreed number of nurses rostered on duty for the department.

“This significantly impacted on the delivery of safe, quality care and on the timely triage and assessment of attendees to the department,” the inspectors said.

Furthermore, nursing rosters provided to HIQA for a four-week period showed that, on average, the ED was short in the range of four to eight nurses per shift (day and night shift), which represented a nursing staff deficit of 17%-33% per shift.

HIQA said it was not satisfied that the hospital was adequately planning, organising and managing its nursing workforce in the ED to ensure high-quality, safe and reliable healthcare in the department.

“Although no deficiencies in medical resourcing of the department were identified, the nursing staff levels were insufficient to meet the needs of the volume of patients receiving care in the ED on the day of inspection.

“Hospital managers need to ensure that there are sufficient staff available at the right time, with the right skills to deliver safe, high-quality care in the ED and that there are contingencies in place to ensure that the service can meet increases in demand such as that caused by the increased numbers of patient presentations,” the inspectors said.

They emphasised that at the time of writing this report, “it remained unclear to HIQA what was intended through formally agreed and funded plans for the hospital and the wider midwest region in order to increase capacity in the medium to long-term, and as aligned to the Sláintecare plan”.

“Consequently, after the inspection HIQA wrote to the chief operating officer of the HSE to seek clarity as to what is planned to address these accepted structural deficits at hospital and wider midwest region levels.

“While risk issues identified by HIQA through this inspection need to be sustainably addressed in the short-term following this inspection, it is also of critical importance that a formally agreed and fully funded longer-term plan for the midwest region is implemented in relation to service configuration, capacity and resourcing,” the inspectors added.

On the day the HIQA report was published (June 17), according to the INMO’s Trolley Watch figures, UHL had the highest number of patients on trolleys in the country (78).

HIQA’s inspection report of UHL can be viewed here.