Limerick 1970’s Limerick 1950’s Limerick 2010 Our Lady of Lourdes South Tipperary General Hospital RTE Newsflash: ….. recent reports that the ongoing violence has moved off the streets of Limerick, and spread elsewhere in the country, are apparently true…. Reconfiguration in South East Reconfiguration in South East Dept of General Surgery, STGH National Surgical Reconfiguration Project D.I.Y. 2010 Reconfiguration of Acute Hospital Care: just what is it all about anyway ? … Reconfiguration: Modernisation ? Improvement of Services ? Altering the Role ? Gaining Control ? Where is the evidence that the patient benefits ? … or, is it just about downgrading… ! History of Successful Reconfiguration in Irish Health Services - FEDERATED HOSPITALS - MANCH - JERVIS St / RICHMOND - SOUTH DUBLIN - CORK - WRH So what’s the common theme ? Reconfiguration of Acute Services Evidence of benefit Urban vs Rural Road Network 2000 vs Motorway Network 2010 Celtic Tiger 2000 era vs Anglo world 2010 Motorway & Major Road Network 2010 Has there been successful reconfiguration of acute Services in Smaller hospitals ? …. What defines a ‘smaller’ Hospital ? .. - Bed numbers - Activity - Complexity of work - Budget -Geography -Hospitals now well flagged Independently Resourced Hospitals Blackrock Clinic MPH Beacon Bons Secours Hospital Group Hermitage Clinic Whitfield Mount Carmel Hospital Group Galway Clinic ….. and others The real question is can we or should we reconfigure Acute core services in the Intermediate-sized Hospitals -Kilkenny -Portlaoise -Portiuncula -Tullamore -South Tipperary ( Reconfiguration 2007) -Kerry -Wexford -North Western group -Naas -Mullingar Drivers of Reconfiguration ‘The Claims’ Critical Mass Outcomes Government Policy / Transformation Programme Safety / Licensing Specialism Working Time Restrictions Diminishing pool of Doctors / Professionals Costs Training ‘Drivers’ of Reconfiguration ‘The Counter Claims’ - Critical Mass Differs hugely in every western country - Outcomes No Evidence for vast majority of acute conditions - Safety Read the papers - Specialism Recognized ceilings - Working Time Restrictions Mostly being achieved - Diminishing pool of Doctors / Professionals Fault is one of policy / manpower embargo - Costs No Savings - Training Ask the trainees Reconfiguration should be about : What services are working well vs What services would work better in central located hopsital vs What financial benefits are accrued from reconfiguration Getting the balance correct Necessary Reconfiguration vs Unnecessary Reconfiguration vs Unsafe Reconfiguration Stranger things happen ! ... So what have we done ? ….. South Tipperary General Hospital S.T.G.H. 1940 Surgical Hospital Cashel 1952 Medical/Maternity Hospital in Clonmel 1969 Acute Psychiatric Unit integrated in Clonmel 1996 High Court agreement to reconfigure all acute care 2007 Reconfiguration finally happens 2008 May: Official opening STGH by Minister Mary Harney Demographics STGH Population Served Med/surg/mat/gynae/paeds: 110,000 Psychiatry: 150,000 (planned 88,000) Pop.Profile: Mixed urban/rural (70% rural) Major manufacturing farming equine centre Geographic Area: Approx 1,000 sq miles National Statistics In-patient Discharges 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 Wexford Mater St. Luke's St. Vincents Kerry Cavan South Portiuncula Midland Midland Mercy Connolly South Naas General Our Lady's St. Michaels Merlin Park Roscommon Louth Ennis General Nenagh St. Mallow St. John's Monaghan Bantry 0 Overview Statistics 2009 STGH Discharges 12,794 + 3% Day Cases 8,430 + 46% Radiology Procedures 74,557 + 20% E D Attendances 34,911 + 6% Deliveries 1,365 + 15% (+36%/3 years) OPD Attendances 47,045 + 6% G I Endoscopies 3,993 + 1% Services Surgery General Surgery Urology Obstetrics & Gynaecology Paediatrics & Neonatology Acute Psychiatry E.D. Imaging including 24 hour CT Laboratory Services General Medicine Cardiology Diabetes/Endocrinology Gerontology Acute Stroke Unit Gastroenterology Rheumatology MAU E D Workstation ED Minor Injuries Adult resus Emergency Department Activity 2007 2008 2009 % change New Atts 25,943 29,116 31,832 Return Total 2,692 2,830 3,079 28,185 31,946 34,911 +9 National Statistics ED Attendances 2007 Longford/Westmeath Wexford General Sligo General Kerry General St. Luke's Hospital, Connolly Hospital Letterkenny General Midland Regional Mayo General South Tipperary Naas General Cavan General Mercy Hospital, St. Columcilles South Infirmary Portiuncula Hospital, Our Lady's General Ennis General St. John's Hospital, Louth County Nenagh General St. Michaels Roscommon County 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 1 of 4 New Theatres Surgery Admissions 2007 2008 2009 % Change 2,744 2,732 3,006 + 10 Average Length of Stay Day Cases 4.58 2,341 2,459 2,527 +5 Major 832 792 981 + 23 Minor 1,538 1,393 1,694 + 21 Endoscopies 1,774 2,336 2,281 -2 Operations Out-Patients New Attendances 2,363 Return 4,166 Surgical Department South East Comparative Statistics Jan-Nov 2008 Waterford Wexford Kilkenny Clonmel Inpatient Discharges 2552 2982 3426 3006 Daycases 2317 1985 2305 2322 (2527:2009) A.L.O.S. (Days) 6.41 4.9 4.37 4.58 % Surgical Daycases of Total 2007 31% 18% 30% 34% (45%:2009) % Surgical Admission s with no procedure 31% 36% 38% 20% Day Ward Endoscopy 1 of five new inpatient wards Medical Department Admissions 2007 2008 2009 % Change 4,996 5,331 4,864 - 10 6.29 6.25 Average Length of Stay Day Cases (inc MIC*) 2,348 2,680 2,861 Medical Oncology NA NA 2,336 +7 5,197 Day Cases Total Out-Patients New Attendances 2,295 Return 7,900 TOTAL 10,195 Endoscopies 1,332 1,625 1,712 +5 Medical Departments S E Hospital Comparisons General Medical Jan-Nov ‘08 Waterford Wexford Kilkenny Clonmel Admissions 4686 6856 5667 5331 ALOS (Days) 9.0 6.45 5.81 6.29 Daycases 2534 1403 1447 2464 (5197:2009) Casemix Index .95 .86 .76 .96 New Intensive Care Unit ICU Activity Snapshot Patients Bed Days Used Occupancy (%) 2006 42 695 48 2008 135 1627 84 Anaesthetics Activity Snapshot Surgical Anaesthetics % Change 2008 2185 2009 2675 Gynaecology Anaesthetics % Change 1594 % Change 226 (’06) 1379 22 Obstetric Anaesthetics 16 521 130 Obstetrics 2008 2009 % change Admissions 1,957 2052 +5 Average Length of Stay Days 3.17 3.16 Births 1,178 1,365 +15 Gynaecology Activity 2008 2009 % change Admissions 845 783 639 Average Length of Stay 2.7 2.64 Number of Procedures 1379 1594 16 +32 Day Cases 139 259 347 Total 984 1032 986 Outpatients 1,141 New Return 2,085 Total 3,226 -13 Paediatric Party Paediatrics Activity 2007 2008 2009 % Chan ge Admissions 1,381 Average Length of Stay Day Cases 15 1,742 1,492 2.62 2.58 109 109 - 15 0 Psychiatry Activity Acute Admissions Out-Patients 2007 2008 2009 602 663 661 845 X – Ray Dept Imaging Activity 2008 2009 % Change X-Rays 46,517 53,541 +15 CT Scans 3,846 5,990 +59 Ultrasounds 10,752 13,651 +30 Dexa Scans 1,003 1,375 +37 Total 62,550 74,557 +20 New Oncology Ward In Hospital Visiting Consultant Led Services Oncology Palliative Care Dermatology Haematology Microbiology Orthopaedics and Fracture Clinics New physio gym In Hospital Associate Specialties: Cardiac Investigation Dietetic Laboratory Pharmacy Physiotherapy Occupational Therapy Speech and Language Therapy Library Academic Links UCC Integral Teaching Hospital U.Lim Integral Teaching Hospital 1st Aug 2010 UCD Paediatrics Medical School U.Lim Midwifery Training Placements U.Lim Physiotherapy Placements WIT General Nurse Training Placements WIT Strategy Development WIT Research/Service Evaluation Training DIT Cardiac Technician Placements Medical Unit Morbidity/Mortality Conference 26/03/10 Innovations STGH 1969 One of the first acute mental health inpatient units integrated into general hospital 1985 First County Hospital fully developed diabetes/endocrine service 1986 First rheumatology service S. E. 1986 1987 First dietetic service S. E. 1992 First open access GI endoscopy service Ireland 1992 First multi disciplinary infertility clinic outside Dublin 1994 First colposcopy service S.E. 2001 First pulmonary rehab service outside Dublin 2002 First joint inflammatory bowel disease clinic Ireland 2007 Syncope assessment service 2009 Acute stroke unit with thrombolysis 2009 First fracture liaison service in non-orthopaedic centre S E Hospitals Comparison 2009 Waterford Wexford Kilkenny Clonmel Beds 572 283 330 276 Occupancy % 85.16 93.44 83.73 94.59 ALOS 5.7 4.3 4.8 5.6 Inpatients Discharged 21,281 14,347 15,788 12,794 Day cases Discharged 18,721 6,589 9,281 6,680 52,369 48,241 45,241 OPD Attendance 114,087 New OPD Attendance 23,580 12,201 15,972 12,594 Return OPD Attendance 90,507 40,168 32,269 32,677 Number of Deliveries 2,608 2,414 2,201 1,365 (’09) Projected Annual Activity of Regional Centre of Excellence South East Elective Inpatients Non- Elective Total Inpatients Deliveries ED Attendance 12,290 48,700 60,990 8,900 127,000 (Allowing for 50% reduction from peripheral hospitals) Estimated Requirement for Acute Day & Local Rehabilitation Beds Regional Centre of Excellence SE Acute Inpatient Beds Day Beds Rehab Total Current Total 900 48 128 1076 572 New Bed Requirement 496 (Based on Horwath/Teamwork Report HSE Mid-West 2008) Conditions for Reconfiguration SE Hospitals Acute Services 1 No acute service withdrawn until regional centre resourced & ready to deliver service 2 The PCCC resourced, developed & working to international best practice standards in & out of hours. 3 Ambulance service has fully developed mobile response capabilities by training advanced paramedics and deploying them to all areas of SE Conditions for Reconfiguration 4 Helicopter medical emergency service is fully integrated into emergency care system SE. 5 Advanced nurse practitioner & clinical nurse specialist workforce in place – network of local nurse led urgent care centres. 6 Effective partnership across all elements of prehospital & hospital systems. Conclusions Thriving 3 year old hospital with outstanding ethos of service & innovation Ever expanding local & outreach work Vital part of infrastructure of a major population & industrial centre Impossible to provide adequate alternative services without very major expenditure Thomond Park 2005 Teamwork Leaders Backup ! Catch ….. Turn…. Now , Do You want to be the player scoring the goal, or the one throwing the stick ? ….. Unnecessary Reconfiguration in Ireland 2010 Doomed