Regionalisation in Emergency Medicine
(Sharing International Experience)

A conference on Regionalisation in Emergency Medicine was held on Wednesday 30th October 2002 at St Columcille's Hospital, Loughlinstown, Co. Dublin

Speakers with experience from a variety of health care systems gave a number of presentations. The meeting was chaired by Mr John Ryan, Consultant in Emergency Medicine, South East Dublin and was introduced by Mr Michael Lyons, CEO of the East Coast Area Health Board:

It is almost a truism to note that in the health services, resources are finite in the health services. The resources which are allocated us are therefore very precious indeed and it is imperative that we use them wisely since our ability to provide comprehensive, high quality services is determined not only by the level of resources available to us but also by the efficiency with which we use them. It is our very clear responsibility to gain the greatest possible benefit from our resources so that this in turn can benefit the people of our Area. In developing hospital services for example, because of the limited nature of resources, it would quite simply not be possible to develop a total comprehensive general hospital service on each acute hospital site. What we must do instead is to develop a network of hospitals which will operate as a co-ordinated, complementary grouping: this will mean a precise determination of the role of each acute hospital as part of that grouping.

This point was re-enforced in the recent Comhairle na nOspideal report on Accident and Emergency Services. The report envisages that each service should have a clear, designated role within the regional network commensurate with its ability to provide appropriate and timely care to patients presenting, and the clinical, diagnostic and other resources available to it.

Summing up the aim of hospital services, the report has really given us a definition of the quality which is at the heart of the new Health Strategy. It says that:

· The patient must receive the right care
· Care must be delivered at the right time
· Care must be delivered in the right place
· Care must be delivered by the right people

We should be unapologetic in our drive towards this high level of quality. People have a right to know that the service they are receiving from us is based on best-practice evidence and meets approved and certified standards. If we want to improve the quality of our health system, we must implement internationally recognised evidence-based guidelines and protocols. Not only do our patients deserve this, but we also have to recognise that health professionals now practice in a more demanding, transparent environment. An evidence-based approach forms an essential element of the quality agenda which is our objective and which is central to the recently launched Health Strategy Quality and Fairness : A Health System for You. The Strategy emphasises that all decisions must be based on evidence from research findings, statistical data and other documented trends. In future, all decisions must be supported by reference to this kind of evidence or to agreed standards, protocols or models of best practice.

Evidence based guidelines, tighter professional standards and patients' rights and expectations all add to these demands of the new environment. We welcome this greater accountability, but we must be certain that our systems are robust and in line with international best practice so that they will stand up to the most acute levels of scrutiny.

This is our Board's vision for a quality health service for the East Coast Area. A further aspect of that vision has been to make these services seamless and integrated with the services of other providers in our Area. For St Columcille's our aim is to which ensure it take its place and play an important role in the East Coast Area network of emergency medicine services. Other participants in that network include St Vincent's University Hospital and St Michael's Hospital, Dun Laoghaire. To that end, the three acute hospitals in the East Coast have been working together co-operatively and in a spirit of partnership. Since our Board was founded, we have shared a vision of an integrated network of acute hospital services in which each hospital would have a designated role and where a patient would not be seen as a patient of a particular institution, but as our patient - a patient of the East Coast Area. In bringing about this integrated network, our Board has found both of our sister hospitals to be open, flexible and willing to work co-operatively with us in the best interests of the patients of the East Coast Area.

One example of our joint working, was the collaboration of the three hospitals in the East Coast Area in making a joint submission to the Committee on Accident and Emergency Services established by Comhairle na nOspideal. In our submission, we proposed a Joint Department of Emergency Medicine with joint Consultant appointments, common training and shared protocols across the three sites in the East Coast Area. We were very pleased that our proposal was given recognition by Comhairle and the joint Department was established. Because of this, significant and crucial developments have taken place in St Columcille's including the appointment of:

· Two additional Consultants in Emergency Medicine
· An Emergency Clinician
· Three Registrars in Emergency Medicine
· Three SHOs in Emergency Medicine
· Five additional Clinical Nurse Managers
· Three Patient Liaison Officers

Along with this enhancement of human resources in the Department, important clinical developments have taken place including:

· Introduction of the Manchester Triage system
· Use of the Footman Walker computerised medical records system
· Enhanced nurse education and professional development
· Development of expanded nursing skills
· Protocol driven care - especially for cardiac events
· Introduction of clinical audit and research
· Provision of 24-hour senior nurse cover

A key part of working towards quality service provision in the East Coast has been the upgrading of services here in St Columcille's and much of our attention has been dedicated to that since our Board's inception. Funding of €6.5m has been allocated to our Board for developments in St Columcille's. This will allow for much-needed upgrading work on wards and other services to allow for better patient services and a better working environment for staff.

Most importantly, this funding will bring about developments to the configuration of the Emergency Medicine Department, a vital component of service delivery here. After full consultation with medical, nursing and ancillary staff a refurbishment plan has been approved to facilitate the process of rapid assessment and streaming of patients within the Department.

These developments will allow for patient care to take place more effectively and efficiently. But the investment in St Columcille's of €6.5m is a very clear signal from the Eastern Regional Health Authority and from our Board that St Columcille's is continuing to play a key role in the network of emergency medicine services in the East Coast Area and in the region as a whole. The precise nature of that role is being articulated and this may involve some change; for some, change may be threatening, but it's a process we cannot avoid and it can also be viewed as an opportunity to challenge which changing circumstances and demographics present.

Here in St Columcille's we may consider ourselves fortunate in many ways. We have the investment; partnership and trust developed in the network. We have a hard-working, dedicated staff group. We have a vision of quality and accountability and a commitment to change the way in which we work to bring about that quality and accountability.

Regionalisation in Emergency Medicine (The Comhairle Report)
Mr Tommie Martin (CEO Comhairle na nOspideal)

East Coast Area Emergency Medicine - The Way Ahead ?
Mr Robert McQuillan (Director, Emergency Medicine South East Dublin)

Regionalised Emergency Medicine - The Belfast Experience
Mr Laurence Rocke (Consultant in Emergency Medicine Royal Victoria Hospital, Belfast)

Regional Emergency Medicine - The American Experience
Mr Paul McQuaid (EMT-Paramedic NEHB)

Regionalised Emergency Medicine (Implications for Pre-hospital Care)
Professor Gerard Bury (Professor of General Practice UCD)

The Key Note Lecture was given by Dr Paul Gaudry, Director Emergency Services Stream, Western Sydney Area Health Service, NSW Australia. Dr Gaudry is the current secretary of the Australian College of Emergency Medicine. He is a world famous figure in Emergency Medicine and has published widely on all aspects of Emergency Care

Emergency Service Delivery in a Networked Environment
Dr Paul Gaudry