limerick 1970’s. limerick 1950’s limerick 2010 our lady of lourdes

Limerick 1970’s

Limerick 1950’s

Limerick 2010

Our Lady of Lourdes

South Tipperary General HospitalSouth Tipperary General Hospital

….. recent reports that the ongoing violence has moved off the streetsof Limerick, and spread elsewhere in the country, are apparently true….

RTE Newsflash:

Reconfiguration in South East

Reconfiguration in South East

Dept of General Surgery, STGH Dept of General Surgery, STGH

D.I.Y. 2010

National Surgical Reconfiguration Project

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

Urban vs Rural

Road Network 2000 vs Motorway Network 2010

Celtic Tiger 2000 era vs Anglo world 2010

Evidence of benefit

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

-Kilkenny

-Portlaoise

-Portiuncula

-Tullamore

-South Tipperary ( Reconfiguration 2007)

-Kerry

-Wexford

-North Western group

-Naas

-Mullingar

The real question is can we or should we reconfigureAcute core services in the Intermediate-sized Hospitals

Drivers of Reconfiguration

Critical Mass

Outcomes

Government Policy / Transformation Programme

Safety / Licensing

Specialism

Working Time Restrictions

Diminishing pool of Doctors / Professionals

Costs

Training

‘The Claims’

‘Drivers’ of Reconfiguration

- 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

‘The Counter Claims’

What services are working well

vs

What services would work better in central located hopsital

vs

What financial benefits are accrued from reconfiguration

Reconfiguration should be about :

Necessary Reconfiguration

vs

Unnecessary Reconfiguration

vs

Unsafe Reconfiguration

Getting the balance correct

Stranger things happen ! ...

So what have we done ? …..

South Tipperary General South Tipperary General HospitalHospital

S.T.G.H.S.T.G.H.

1940 Surgical Hospital Cashel1940 Surgical Hospital Cashel 1952 Medical/Maternity Hospital in Clonmel1952 Medical/Maternity Hospital in Clonmel 1969 Acute Psychiatric Unit integrated in 1969 Acute Psychiatric Unit integrated in

ClonmelClonmel 1996 High Court agreement to reconfigure all 1996 High Court agreement to reconfigure all

acute careacute care 2007 Reconfiguration finally happens2007 Reconfiguration finally happens 2008 May: Official opening STGH by Minister 2008 May: Official opening STGH by Minister

Mary Harney Mary Harney

Demographics STGHDemographics STGH

Population ServedPopulation Served

Med/surg/mat/gynae/paeds: 110,000Med/surg/mat/gynae/paeds: 110,000

Psychiatry: 150,000 (planned 88,000)Psychiatry: 150,000 (planned 88,000)

Pop.Profile: Mixed urban/rural (70% Pop.Profile: Mixed urban/rural (70% rural)rural)

Major manufacturing farming equine Major manufacturing farming equine centrecentre

Geographic Area: Approx 1,000 sq miles Geographic Area: Approx 1,000 sq miles

National Statistics National Statistics

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Bantry

Monaghan

St. John's

Mallow

St.

Nenagh

Ennis G

eneral

Louth

Roscom

mon

Merlin Park

St. Michaels

Our L

ady's

Naas G

eneral

South

Connolly

Mercy

Midland

Midland

Portiuncula

South

Cavan

Kerry

St. Vincents

St. Luke's

Mater

Wexford

In-patient Discharges

Overview Statistics 2009 STGHOverview Statistics 2009 STGH

Discharges 12,794 + 3%Discharges 12,794 + 3% Day Cases 8,430 + 46%Day Cases 8,430 + 46% Radiology Procedures 74,557 + 20% Radiology Procedures 74,557 + 20%

E D Attendances 34,911 + 6%E D Attendances 34,911 + 6% Deliveries 1,365 + 15% (+36%/3 years)Deliveries 1,365 + 15% (+36%/3 years) OPD Attendances 47,045 + 6% OPD Attendances 47,045 + 6% G I Endoscopies 3,993 + 1% G I Endoscopies 3,993 + 1%

ServicesServices

Surgery GeneralSurgery General Surgery UrologySurgery Urology Obstetrics & GynaecologyObstetrics & Gynaecology Paediatrics & NeonatologyPaediatrics & Neonatology Acute PsychiatryAcute Psychiatry E.D.E.D. Imaging including 24 hour CTImaging including 24 hour CT Laboratory Laboratory

ServicesServices

General Medicine General Medicine

CardiologyCardiologyDiabetes/EndocrinologyDiabetes/EndocrinologyGerontologyGerontologyAcute Stroke UnitAcute Stroke UnitGastroenterologyGastroenterologyRheumatologyRheumatologyMAUMAU

E D WorkstationE D Workstation

ED Minor Injuries ED Minor Injuries Adult resus Adult resus

Emergency Department Emergency Department ActivityActivity

2007 2008 2009 % 2007 2008 2009 % changechange

New Atts 25,943 29,116 31,832 New Atts 25,943 29,116 31,832

Return 2,692 2,830 3,079Return 2,692 2,830 3,079

Total 28,185 31,946 34,911 +9 Total 28,185 31,946 34,911 +9

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Rosco

mm

on C

ounty

St. M

ichaels

Nen

agh G

eneral

Louth

County

St. Jo

hn's H

osp

ital,

Ennis G

eneral

Our L

ady's G

eneral

Portiu

ncu

la Hosp

ital,

South

Infirm

ary

St. C

olu

mcilles

Mercy

Hosp

ital,

Cav

an G

eneral

Naas G

eneral

South

Tip

perary

May

o G

eneral

Mid

land R

egio

nal

Letterk

enny G

eneral

Connolly

Hosp

ital

St. L

uke's H

osp

ital,

Kerry

Gen

eral

Slig

o G

eneral

Wex

ford

Gen

eral

Longfo

rd/W

estmeath

ED Attendances 2007

National Statistics National Statistics

1 of 4 New Theatres1 of 4 New Theatres

SurgerySurgery20072007 20082008 20092009 % Change% Change

AdmissionsAdmissions 2,7442,744 2,7322,732 3,0063,006 + 10+ 10

Average Length of StayAverage Length of Stay 4.584.58

Day Cases Day Cases 2,3412,341 2,4592,459 2,5272,527 + 5+ 5

OperationsOperations

MajorMajor 832832 792792 981981 + 23+ 23

MinorMinor 1,5381,538 1,3931,393 1,6941,694 + 21+ 21

EndoscopiesEndoscopies 1,7741,774 2,3362,336 2,2812,281 - 2- 2

Out-PatientsOut-Patients

New AttendancesNew Attendances 2,3632,363

ReturnReturn 4,1664,166

Surgical Department South East Surgical Department South East Comparative Statistics Jan-Nov 2008Comparative Statistics Jan-Nov 2008

WaterfordWaterford Wexford Wexford KilkennyKilkenny ClonmelClonmel

Inpatient Inpatient DischargesDischarges

25522552 29822982 34263426 30063006

DaycasesDaycases 23172317 19851985 23052305 23222322(2527:2009)(2527:2009)

A.L.O.S. A.L.O.S. (Days)(Days)

6.416.41 4.94.9 4.374.37 4.584.58

% Surgical % Surgical Daycases Daycases of Total of Total 20072007

31%31% 18%18% 30%30% 34%34%(45%:2009)(45%:2009)

% Surgical % Surgical AdmissionAdmissions with no s with no procedure procedure

31%31% 36%36% 38%38% 20%20%

Day Ward EndoscopyDay Ward Endoscopy

1 of five new inpatient 1 of five new inpatient wardswards

Medical DepartmentMedical Department20072007 20082008 20092009 % Change% Change

AdmissionsAdmissions 4,9964,996 5,3315,331 4,8644,864 - 10- 10

Average Length of StayAverage Length of Stay 6.296.29 6.256.25

Day Cases (inc MIC*)Day Cases (inc MIC*) 2,3482,348 2,6802,680 2,8612,861 + 7+ 7

Medical OncologyMedical Oncology NANA NANA 2,3362,336

Day Cases TotalDay Cases Total 5,1975,197

Out-PatientsOut-Patients

New AttendancesNew Attendances 2,2952,295

ReturnReturn 7,9007,900

TOTALTOTAL 10,19510,195

EndoscopiesEndoscopies 1,3321,332 1,6251,625 1,7121,712 + 5+ 5

Medical Departments S E Hospital ComparisonsMedical Departments S E Hospital ComparisonsGeneral Medical Jan-Nov ‘08General Medical Jan-Nov ‘08

WaterfordWaterford Wexford Wexford KilkennyKilkenny ClonmelClonmel

AdmissionsAdmissions 46864686 68566856 56675667 53315331

ALOS ALOS (Days)(Days)

9.09.0 6.456.45 5.815.81 6.296.29

DaycasesDaycases 25342534 14031403 14471447 24642464 (5197:2009)(5197:2009)

Casemix Casemix IndexIndex

.95.95 .86.86 .76.76 .96.96

New Intensive Care UnitNew Intensive Care Unit

ICU Activity SnapshotICU Activity Snapshot

PatientsPatients Bed Days UsedBed Days Used Occupancy (%)Occupancy (%)

20062006 4242 695695 4848

20082008 135135 16271627 8484

Anaesthetics Activity SnapshotAnaesthetics Activity Snapshot

SurgicalSurgicalAnaestheticsAnaesthetics % % ChangeChange

GynaecologyGynaecologyAnaestheticsAnaesthetics % % ChangeChange

ObstetricObstetricAnaestheticsAnaesthetics % Change% Change

20082008 21852185 13791379 226 (’06)226 (’06)

20092009 26752675 2222 15941594 1616 521521 130130

ObstetricsObstetrics

20082008 20092009 % change% change

AdmissionsAdmissions 1,9571,957 20522052 +5+5

Average Length Average Length of Stay Daysof Stay Days

3.173.17 3.163.16

BirthsBirths 1,1781,178 1,3651,365 +15+15

GynaecologyGynaecology

Activity

20082008 20092009% change% change

AdmissionsAdmissions 845845 783783 639639 -13-13

Average Length Average Length of Stayof Stay

2.72.7 2.642.64

Number of Number of Procedures Procedures

13791379 15941594 1616

Day CasesDay Cases 139139 259259 347347 +32+32

TotalTotal 984984 10321032 986986Outpatients

NewNew1,1411,141

ReturnReturn 2,0852,085

TotalTotal 3,2263,226

Paediatric PartyPaediatric Party

Paediatrics ActivityPaediatrics Activity

20072007 20082008 20092009 % % ChanChangege

AdmissionsAdmissions 1,3811,381 1,7421,742 1,4921,492 - 15- 15

Average Length of Average Length of StayStay

2.622.62 2.582.58

Day CasesDay Cases 1515 109109 109109 00

Psychiatry ActivityPsychiatry Activity

20072007 20082008 20092009

Acute Acute AdmissionsAdmissions

602602 663663 661661

Out-PatientsOut-Patients 845845

X – Ray DeptX – Ray Dept

Imaging ActivityImaging Activity

20082008 20092009 % Change% Change

X-RaysX-Rays 46,51746,517 53,54153,541 +15+15

CT ScansCT Scans 3,8463,846 5,9905,990 +59+59

UltrasoundsUltrasounds 10,75210,752 13,65113,651 +30+30

Dexa ScansDexa Scans 1,0031,003 1,3751,375 +37+37

TotalTotal 62,55062,550 74,55774,557 +20+20

New Oncology WardNew Oncology Ward

In Hospital Visiting Consultant In Hospital Visiting Consultant Led ServicesLed Services

OncologyOncology Palliative CarePalliative Care DermatologyDermatology HaematologyHaematology MicrobiologyMicrobiology Orthopaedics and Fracture ClinicsOrthopaedics and Fracture Clinics

New physio gymNew physio gym

In Hospital Associate In Hospital Associate Specialties:Specialties:

Cardiac InvestigationCardiac Investigation DieteticDietetic LaboratoryLaboratory PharmacyPharmacy PhysiotherapyPhysiotherapy Occupational TherapyOccupational Therapy Speech and Language TherapySpeech and Language Therapy

Library

Academic LinksAcademic Links

UCC UCC Integral Teaching HospitalIntegral Teaching Hospital

U.Lim U.Lim Integral Teaching Hospital 1 Integral Teaching Hospital 1stst Aug 2010 Aug 2010 UCD UCD Paediatrics Medical SchoolPaediatrics Medical School

U.Lim U.Lim Midwifery Training PlacementsMidwifery Training Placements

U.LimU.Lim Physiotherapy PlacementsPhysiotherapy Placements

WIT WIT General Nurse Training Placements General Nurse Training Placements

WIT WIT Strategy Development Strategy Development

WIT WIT Research/Service Evaluation TrainingResearch/Service Evaluation Training

DITDIT Cardiac Technician PlacementsCardiac Technician Placements

Medical Unit Medical Unit Morbidity/Mortality Morbidity/Mortality Conference 26/03/10Conference 26/03/10

Innovations STGHInnovations STGH

1969 One of the first acute mental health inpatient units 1969 One of the first acute mental health inpatient units integrated into general hospitalintegrated into general hospital 19851985 First County Hospital fully developed First County Hospital fully developed

diabetes/endocrine diabetes/endocrine service service 1986 First rheumatology service S. E. 19861986 First rheumatology service S. E. 1986 19871987 First dietetic service S. E. First dietetic service S. E. 19921992 First open access GI endoscopy service Ireland First open access GI endoscopy service Ireland 1992 First multi disciplinary infertility clinic outside 1992 First multi disciplinary infertility clinic outside

DublinDublin 1994 First colposcopy service S.E. 1994 First colposcopy service S.E. 20012001 First pulmonary rehab service outside Dublin First pulmonary rehab service outside Dublin 20022002 First joint inflammatory bowel disease clinic Ireland First joint inflammatory bowel disease clinic Ireland 2007 Syncope assessment service2007 Syncope assessment service 2009 Acute stroke unit with thrombolysis2009 Acute stroke unit with thrombolysis 2009 First fracture liaison service in non-orthopaedic 2009 First fracture liaison service in non-orthopaedic

centrecentre

S E Hospitals Comparison 2009S E Hospitals Comparison 2009

WaterfordWaterford WexfordWexford KilkennyKilkenny ClonmelClonmel

BedsBeds 572572 283283 330330 276276

Occupancy %Occupancy % 85.1685.16 93.4493.44 83.7383.73 94.5994.59

ALOSALOS 5.75.7 4.34.3 4.84.8 5.65.6

Inpatients Inpatients DischargedDischarged

21,28121,281 14,34714,347 15,78815,788 12,79412,794

Day casesDay casesDischargedDischarged

18,72118,721 6,5896,589 9,2819,281 6,6806,680

OPD OPD AttendanceAttendance

114,087114,087 52,36952,369 48,24148,241 45,24145,241

New OPD New OPD AttendanceAttendance

23,58023,580 12,20112,201 15,97215,972 12,59412,594

Return OPDReturn OPDAttendanceAttendance

90,50790,507 40,16840,168 32,26932,269 32,67732,677

Number of Number of Deliveries Deliveries (’08)(’08)

2,6082,608 2,4142,414 2,2012,201 1,365 (’09)1,365 (’09)

Projected Annual Activity of Projected Annual Activity of Regional Centre of Excellence South EastRegional Centre of Excellence South East

Elective Inpatients 12,290Elective Inpatients 12,290

Non- Elective 48,700Non- Elective 48,700

Total Inpatients 60,990Total Inpatients 60,990

Deliveries 8,900Deliveries 8,900

ED Attendance 127,000 ED Attendance 127,000 (Allowing for 50% reduction from peripheral hospitals)(Allowing for 50% reduction from peripheral hospitals)

Estimated Requirement for Acute Day & Estimated Requirement for Acute Day & Local Rehabilitation BedsLocal Rehabilitation Beds

Regional Centre of Excellence SERegional Centre of Excellence SE

Acute Inpatient Beds 900Acute Inpatient Beds 900

Day Beds 48Day Beds 48

Rehab Rehab 128128Total 1076Total 1076

Current Total 572Current Total 572

New Bed Requirement 496New Bed Requirement 496(Based on Horwath/Teamwork Report HSE Mid-West 2008)(Based on Horwath/Teamwork Report HSE Mid-West 2008)

Conditions for Conditions for Reconfiguration SE Reconfiguration SE

Hospitals Acute ServicesHospitals Acute Services 1 No acute service withdrawn until 1 No acute service withdrawn until

regional centre resourced & ready to regional centre resourced & ready to deliver servicedeliver service

2 The PCCC resourced, developed & 2 The PCCC resourced, developed & working to international best practice working to international best practice standards in & out of hours.standards in & out of hours.

3 Ambulance service has fully developed 3 Ambulance service has fully developed mobile response capabilities by training mobile response capabilities by training advanced paramedics and deploying them advanced paramedics and deploying them to all areas of SEto all areas of SE

Conditions for Conditions for Reconfiguration Reconfiguration

4 Helicopter medical emergency service is4 Helicopter medical emergency service is fully integrated into emergency care fully integrated into emergency care

system SE.system SE.5 Advanced nurse practitioner & clinical5 Advanced nurse practitioner & clinical nurse specialist workforce in place – nurse specialist workforce in place –

network of local nurse led urgent care network of local nurse led urgent care centres.centres.

6 Effective partnership across all elements 6 Effective partnership across all elements of pre-hospital & hospital systems. of pre-hospital & hospital systems.

ConclusionsConclusions

Thriving 3 year old hospital with Thriving 3 year old hospital with outstanding ethos of service & innovationoutstanding ethos of service & innovation

Ever expanding local & outreach workEver expanding local & outreach work Vital part of infrastructure of a major Vital part of infrastructure of a major

population & industrial centrepopulation & industrial centre Impossible to provide adequate Impossible to provide adequate

alternativealternative services without very major expenditureservices 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