Clarke report makes 17 recommendations for ED at UHL

The Clarke report into the death of Aoife Johnston makes 17 recommendations aimed at improving how patients are dealt with in the Emergency Department of UHL, in particular people presenting with sepsis.

It recommends that steps should be taken by the HSE to determine whether there are circumstances where "a GP, on identifying a risk of sepsis in a patient, takes the initial treatment steps required at that time, while also referring the patient to an ED for further assessment and additional treatment, if necessary".

The report says consideration should be given by the HSE to identifying if there are ways in which "patients who attend at the ED and who are potentially in need of urgent treatment, but who do not arrive by ambulance, can be assessed in triage more quickly, instead of having to wait in a queue system".

Reviews are also recommended to identify if there are ways in which more resources could be allocated to the triage system in the ED in UHL in circumstances where demand, in the shape of presenting patients and especially those referred with conditions requiring urgent intervention, require it and to identify if there are ways in which more resources could be allocated to the Emergency Medicine Early Warning System in the ED in UHL.

Electronic system

Other recommendations include improving the electronic system used in the Emergency Department, which notes if a patient is identified as query sepsis, to ensure it is flagged more clearly.

The report says the hospital should ensure "once a patient, presenting with symptoms that point to a serious condition like sepsis which requires prompt treatment, enters the hospital system, this is highlighted and immediately evident on the electronic system and all paper records, without a clinician or nurse having to open the individual detailed screen".

In the independent investigation, Mr Clarke also recommends that a review should take place to identify such other serious conditions, apart from sepsis, that require prompt treatment.

He says it could "ensure that measures are in place to minimise the risk of doctors and nurses in the ED being, in practice, unaware of the particular risk attaching to specific patients when the ED is particularly busy".

Administration of medication

In relation to the administration of medication, the Clarke report recommends that once a patient is seen and prescribed medication by a doctor, they should not be waiting over an hour, as happened in Aoife Johnston's case, for the medications to be administered.

To that end, a recommendation is made that a full review of the system in the ED in UHL for the administration of all prescribed medications should take place "in order to obviate the risks of delay once medication is prescribed".

It says a review should take place "to ascertain whether there are additional measures which could be adopted to ensure that the Resus area is, to the greatest extent possible, used only for patients whose clinical requirements necessitate their being in such an area in order to ensure proper patient management".

High number of presentations

The report calls for a detailed study to determine the reasons why the ED in UHL has a higher number of presentations, and a higher percentage of presentations resulting in admissions, than other Model 4 hospitals nationally.

It says the study could also be used to determine if systems could be put in place in the community to reduce the level of presentations, admissions and the consequent pressure on beds in the Dooradoyle site.

Other recommendations include a review of the communications systems in UHL and the wider hospital group aimed at ensuring when important decisions are made at Senior Management level, such as the operation of protocols, that they are effectively and clearly communicated to managers and staff on the ground.

A review of the coordination of the roles of doctors in the ED, in particular when the ED is busy and all doctors have many patients to attend to, is also recommended.

It says the roles and responsibilities of the Emergency Medicine Consultants-on-call should be reviewed and "clarity should be brought to the question of if, and if so when, it might be appropriate for the Consultant on-Call to attend, not for the purposes of providing an additional pair of hands when the ED is under pressure, and not where such a consultant is required to come in where their particular expertise is required for an individual patient, but where circumstances might warrant a Senior Clinician who is not dealing with individual patients being in a position to exercise an overall view on the situation in the Emergency Department".

Dooradoyle site limitations

There is also a recommendation that "research should urgently be carried out to identify whether the limitations on the Dooradoyle site are such that it cannot be expanded beyond a number of beds which is below the number likely to be required on even an optimistic scenario concerning admissions, patients stay and discharge".

The report says "it would appear that such an analysis, should it lead to the view that those limitations do create a long-term problem, might well inform decisions as to whether alternative measures need to be adopted to deal with ED demand in the Midwest region".

"If a conclusion is reached that Dooradoyle cannot, in the medium term, be expanded to a sufficient extent to accommodate admissions arising from ED, then alternative solutions must necessarily be found."

Mr Clarke also recommends that "the HSE should, if and when the Johnston family consider it appropriate, liaise with the family with a view to memorialising Aoife".