Proposal for the future of acute services at South Tipperary General Hospital

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Limerick 1970s
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Limerick 1950s
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Limerick 2010
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Our Lady of Lourdes
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South Tipperary General Hospital
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RTE Newsflash
.. recent reports that the ongoing violence has
moved off the streets of Limerick, and spread
elsewhere in the country, are apparently true.
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Reconfiguration in South East
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Reconfiguration in South East
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Dept of General
Surgery, STGH
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D.I.Y. 2010
National Surgical Reconfiguration Project
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Reconfiguration of Acute Hospital Care
just what is it all about anyway ?
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Reconfiguration Modernisation
? Improvement of Services ? Altering the
Role ? Gaining Control ?
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Where is the evidence that the patient benefits
?
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or, is it just about downgrading !
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History of Successful Reconfiguration in Irish
Health Services - FEDERATED HOSPITALS -
MANCH - JERVIS St / RICHMOND - SOUTH
DUBLIN
- CORK - WRH
So whats the common theme ?
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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
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Motorway Major Road Network 2010
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Has there been successful reconfiguration of
acute Services in Smaller hospitals ? .
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What defines a smaller Hospital ? ..

• - Bed numbers
• - Activity
• - Complexity of work
• - Budget
• Geography
• Hospitals now well flagged

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Independently Resourced Hospitals Blackroc
k Clinic MPH Beacon Bons Secours Hospital
Group Hermitage Clinic Whitfield Mount Carmel
Hospital Group Galway Clinic .. and others
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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
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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
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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
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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
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Getting the balance correct
Necessary Reconfiguration vs
Unnecessary Reconfiguration vs Unsafe
Reconfiguration
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Stranger things happen ! ...
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So what have we done ? ..
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South Tipperary General Hospital
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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

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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

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National Statistics
In-patient Discharges
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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

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Services

• Surgery General
• Surgery Urology
• Obstetrics Gynaecology
• Paediatrics Neonatology
• Acute Psychiatry
• E.D.
• Imaging including 24 hour CT
• Laboratory

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Services

• General Medicine
• Cardiology
• Diabetes/Endocrinology
• Gerontology
• Acute Stroke Unit
• Gastroenterology
• Rheumatology
• MAU

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E D Workstation
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ED Minor Injuries Adult resus
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Emergency Department Activity

• 2007 2008 2009
  change
• New Atts 25,943 29,116 31,832
• Return 2,692 2,830 3,079
• Total 28,185 31,946 34,911 9

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National Statistics
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1 of 4 New Theatres
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Surgery
2007 2008 2009 Change
Admissions 2,744 2,732 3,006 10
Average Length of Stay 4.58
Day Cases 2,341 2,459 2,527 5
Operations
Major 832 792 981 23
Minor 1,538 1,393 1,694 21
Endoscopies 1,774 2,336 2,281 - 2
Out-Patients
New Attendances 2,363
Return 4,166
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Surgical Department South East Comparative
Statistics Jan-Nov 2008
Waterford Wexford Kilkenny Clonmel
Inpatient Discharges 2552 2982 3426 3006
Daycases 2317 1985 2305 2322 (25272009)
A.L.O.S. (Days) 6.41 4.9 4.37 4.58
Surgical Daycases of Total 2007 31 18 30 34 (452009)
Surgical Admissions with no procedure 31 36 38 20
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Day Ward Endoscopy
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1 of five new inpatient wards
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Medical Department
2007 2008 2009 Change
Admissions 4,996 5,331 4,864 - 10
Average Length of Stay 6.29 6.25
Day Cases (inc MIC) 2,348 2,680 2,861 7
Medical Oncology NA NA 2,336
Day Cases Total 5,197
Out-Patients
New Attendances 2,295
Return 7,900
TOTAL 10,195
Endoscopies 1,332 1,625 1,712 5
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Medical Departments S E Hospital
ComparisonsGeneral 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 (51972009)
Casemix Index .95 .86 .76 .96
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New Intensive Care Unit
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ICU Activity Snapshot
Patients Bed Days Used Occupancy ()
2006 42 695 48
2008 135 1627 84
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Anaesthetics Activity Snapshot
Surgical Anaesthetics Change Gynaecology Anaesthetics Change Obstetric Anaesthetics Change
2008 2185 1379 226 (06)
2009 2675 22 1594 16 521 130
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Obstetrics
2008 2009 change
Admissions 1,957 2052 5
Average Length of Stay Days 3.17 3.16
Births 1,178 1,365 15

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Gynaecology
Activity
2008 2009 change
Admissions 845 783 639 -13
Average Length of Stay 2.7 2.64
Number of Procedures 1379 1594 16
Day Cases 139 259 347 32
Total 984 1032 986
Outpatients
New 1,141
Return 2,085
Total 3,226
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Paediatric Party
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Paediatrics Activity
2007 2008 2009 Change
Admissions 1,381 1,742 1,492 - 15
Average Length of Stay 2.62 2.58
Day Cases 15 109 109 0
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Psychiatry Activity
2007 2008 2009
Acute Admissions 602 663 661

Out-Patients 845
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X Ray Dept
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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
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New Oncology Ward
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In Hospital Visiting Consultant Led Services

• Oncology
• Palliative Care
• Dermatology
• Haematology
• Microbiology
• Orthopaedics and Fracture Clinics

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New physio gym
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In Hospital Associate Specialties

• Cardiac Investigation
• Dietetic
• Laboratory
• Pharmacy
• Physiotherapy
• Occupational Therapy
• Speech and Language Therapy

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Library
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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

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Medical Unit Morbidity/Mortality Conference
26/03/10
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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

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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
OPD Attendance 114,087 52,369 48,241 45,241
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 (08) 2,608 2,414 2,201 1,365 (09)
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Projected Annual Activity of Regional Centre of
Excellence South East

• Elective Inpatients 12,290
• Non- Elective 48,700
• Total Inpatients 60,990
• Deliveries 8,900
• ED Attendance 127,000
• (Allowing for 50 reduction from peripheral
  hospitals)

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Estimated Requirement for Acute Day Local
Rehabilitation BedsRegional Centre of Excellence
SE

• Acute Inpatient Beds 900
• Day Beds 48
• Rehab 128
• Total 1076
• Current Total 572
• New Bed Requirement 496
• (Based on Horwath/Teamwork Report HSE Mid-West
  2008)

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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

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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
  pre-hospital hospital systems.

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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

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Thomond Park 2005
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Teamwork
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Leaders
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Backup !
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Catch ..
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Turn.
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Now , Do You want to be the player scoring the
goal, or the one throwing the
stick ? ..
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Unnecessary Reconfiguration in Ireland 2010
Doomed