Health Commissioner finds accident and emergency at Mater Dei in deleterious state

The newly-appointed health ombudsman Charles Messina has called for the introduction of a rapid assessment and treatment area inside Mater Dei's accident and emergency department, after finding limited space for the high turnover of patients presenting themselves at the A&E department.

Messina's own-initiative report, carried out in October 2012 and endorsed by Ombudsman Joseph Said Pullicino, said many patients were being left long hours, if not days, on stretchers awaiting admission in a restrictive space "devoid of privacy, dignity, general hygiene", increasing the risk of hospital infection.

Messina said many patients occupying most of the A&E floors waiting for a hospital bed, creating confusion that interfere with the concentration and service delivery of all staff.

The inquiry found that there were just 18 cubicles for the examination and treatment of some 300 patients admitted daily throughout 2012. 31% of patients were defined as very urgent, priority 1 patients; 21% were priority as urgent priority 2 patients while 17% were not urgent, priority 3 patients. The remaining 31% were referred to other departments.

Of these cubicles, 13 were reserved for priority 1 patients who are very sick and in some cases need prolonged medical management, while five cubicles are used for priority 2 patients. Since Area 2 was now being used as a holding bay for priority 1 patients awaiting a hospital bed, priority 2 patients had to be seen in Area 3 together with priority 3 patients.

Priority 3 patients however were deemed that they should not go to hospital in the first instance, and instead should be managed in a primary healthcare setting.

Messina found shortcomings in various areas of A&E:

• repetition of work where junior doctors (housemen) have to wait for senior doctors to discharge patients, but not enough senior emergency doctors are on call so patients end up waiting longer for a high level assessment: "There were instances when patients were told they were fit to be discharged but had to wait for more than 24 hours for the doctor to go to the ward for his final decision."
• long waits for ultrasound and CT scans;
• the acute medical and surgical admission wards are being used as regular medical wards, instead of serving to decant A&E patients;
• long waiting lists for patients needing a consultant at the outpatients department with the result that some patients go to A&E with the hope of having investigations done urgently.

Possible solutions

Messina said that since Mater Dei is an acute hospital, more beds are needed for patients requiring convalescence, rehab or admission to a home for the elderly. He said that consultants need to see their patients get discarged after the acute phase if over, but this meant that they should have their mind at rest that any after care needed is also being well taken care of.

He also said that surgical and medical acute admissions wards at the A&E had to be made available as they were originally intended, that is, to receive all daily acute admissions from A&E after a primary medical management plan.

Apart from better manned 24/7 health centres, Messina said that junior doctors should be replaced by basic or higher specialist trainees from medicine, surgery and orthopaedics and deployed routinely at A&E after their morning ward work. "They should be the doctors seeing the patients for the first time and they will be assisted by junior doctors, avoiding repetition of work and long waits for senior medical management."

The inquiry also demanded the setting-up of another triage room, increase cubicles and monitored beds, and re-establishing a short-term, high turnover Emergency Observation Ward manned by A&E specialists.

In a reply to the inquiry, health minister Godfrey Farrugia said he recognised A&E issues as a national healthcare priority, and that Messina's observations had also been highlighted by A&E staff and management.

"The ministry views this report as a constructive and positive feedback and proof of the great challenge it has inherited from the previous administration."