The National System-Wide Escalation Framework governs how our hospitals manage and respond to surges in in-patient and Emergency Department activity.
The Framework seeks to achieve this, at least in theory, by providing a ‘tiered and incremental’ series of responses that will enable a hospital to respond in a systematic and controlled way when these unexpected increases in activity occur, or when such increases threaten to exceed hospital capacity and diminish quality of patient care.
It is specifically designed to mitigate the risk of further escalation and return the system to safer levels of occupancy or use or to what is also referred to as ‘Steady State’ status.
A Steady State exists in hospitals when:
“demand and capacity for acute in-patient care, both current and predicted unscheduled and scheduled care is being managed such that there is timely access to emergency (unscheduled) care and treatment within national agreed key performance indicators (95% less than 6 hour wait and no waits greater than 9 hours).
Only as an absolute last resort should a hospital implement what is known as the Full Capacity Protocol.
This includes “the admission of patients to “extra” beds on inpatient units and their environs”, i.e trolleys on corridors. It can also include the option of time limited ambulance diversion to provide protection to the hospital from new demand.”
That’s the theory.
The reality is a different animal altogether.
Indeed, data from the HSE’s Special Delivery Unit, which records the volume of Full Capacity Protocol alerts across hospital groups, makes it clear that for the 2016-2018 period alone, the Protocol was ‘deployed’ an astonishing 9,669 times.
Unsurprisingly perhaps, University Hospital Limerick is recorded as having deployed the Full Capacity Protocol the highest number of times-a staggering 336 in 2018. In 2016 the number for UHL was 322 and in 2017 it was 294.
Similar numbers are applicable to South Tipperary General, University Hospital Waterford, Galway University Hospital, Tallaght Hospital and St Luke’s Hospital Kilkenny.
What this means in practice is that hospitals rarely if ever have the opportunity to ‘de-escalate’ down from Full Capacity status.
Indeed, when the FCP was introduced in 2015, it was done so in the teeth of fierce opposition from the Irish Nurses and Midwives Organisation.
The INMO argued that it was being drawn up “at the behest of a government faced with a continuing barrage of bad publicity relating to their emergency departments.”
Speaking at the time, Dave Hughes, then deputy general secretary of the INMO and joint chair of the Accident and Emergency Forum, said that “the sanction to use full capacity protocol, based on past experience, was likely to be abused and that the evidence to date is that it would become the first rather than the last option.”
Mr Hughes also made it clear that although the HSE instructions clearly indicated the FCP should be implemented after all other measures have been exhausted, “the record shows that, both in Ireland and in England, this policy becomes the only policy once it is allowed happen at all.”
To put it more bluntly, one of the major concerns of the INMO and others was that in deploying the Full Capacity Protocol a hospital would essentially be allowed to close for business.
This in turn reduces or indeed eliminates the possibility of the hospital being able to accurately reflect the true level of need. If the doors are ‘closed’ then trolley numbers can be kept artificially low, for example.
Nothing to do with healthcare.
A lot to do with decreasing political pressure from a dysfunctional health system.
Nothing in the intervening years from 2015 onwards, when the FCP was first introduced, has disproven this original assessment or prediction.