Feasibility Study MAU

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Feasibility Study for a Medical

Assessment Unit Service inMonaghan Hospital

January 2012


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Contents

Glossary .........................................................................................................................3

1. Executive Summary................................................................................................5

1.1. Major Issues Identified.........................................................................................51.2. Limitations of the Study .......................................................................................5

2. Background.............................................................................................................63. Terms of Reference ................................................................................................74. Project Deliverable .................................................................................................7

5. Process....................................................................................................................76. Methodology ...........................................................................................................7

6.1 Limitations of Methodology..................................................................................7

7. Medical Assessment Units.....................................................................................87.1 Acute Medical Assessment Units.........................................................................87.2 Medical Assessment Units...................................................................................8

8. Description of Current Services ............................................................................88.1 Gap Analysis .......................................................................................................89. Establishing a Clinical Need ................................................................................ 10

9.1 Advantages of an MAU in Monaghan ................................................................11

9.2 Disadvantages of an MAU in Monaghan............................................................119.3 Major Issues Identified .......................................................................................11

10. Resource Requirement ........................................................................................1111. Discussion ............................................................................................................12

12. Conclusions ..........................................................................................................1213. References ............................................................................................................1314. Appendices ...........................................................................................................14

Appendix 1 Team Membership.............................................................................14

Appendix 2 Gap Analysis Monaghan Hospital.................................................... 15Appendix 2a Gap Analysis Monaghan Hospital Vs Model 2 Hospital............................15

Appendix 2b Gap Analysis Monaghan Hospital Vs the Model 2 Hospital(National Acute Medicine Programme) Interdependencieswith other Clinical Programmes ...............................................................21

Appendix 2c Gap Analysis Monaghan Hospital Vs Model 1 Hospital............................ 24

Appendix 2d Gap Analysis Monaghan Hospital Vs the Model 1 Hospital(National Acute Medicine Programme) Interdependencieswith other Clinical Programmes ...............................................................29

Appendix 3 Activity Statistics................................................................................ 32Appendix 3a Cavan & Monaghan Hospital Yearly Stats 2008-2011 .............................32

Appendix 3b Cavan Hospital MAU Stats 2009-2011 ....................................................34Appendix 3c Cavan ED Figures 2008-2011 ................................................................. 35

Appendix 3d Cavan ED Triage Figures 2008-2011 ...................................................... 36Appendix 3e Minor Injury Unit, Monaghan Hospital Figures 2009-2011 ....................... 37Appendix 3f Cavan Hospital OPD Waiting Time for OPD Appointments...................... 38Appendix 3g Drogheda Stats........................................................................................ 39

Appendix 4 Resource Requirements ....................................................................40


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GlossaryThe following definitions were obtained from the Report of the National Acute MedicineProgramme1, 2010 and are key to understanding the principles underlying this report.

An acute medical unit (AMU) is a facility whose primary function is the immediate

and early specialist management of adult patients (i.e. aged 16 and older) with awide range of medical conditions who present to a model 4 (tertiary) hospital. Itsaim is to provide a dedicated location for the rapid assessment, diagnosis and

commencement of appropriate treatment. Physicians, supported by amultidisciplinary team, will carry out patient assessment and treatment. It isenvisaged that AMUs will operate on a 24/7 basis. The AMU should be co-locatedwith the ED. Every AMU should have a designated lead consultant physician,

clinical nurse manager and therapy lead. If required, patients can be admitted tothe short stay medical beds within the unit for a short period for acute treatmentand/or observation where the estimated length of stay is less than 48 hours.

An acute medical assessment unit (AMAU) will operate as an AMU with thefollowing exceptions: It will be located in a model 3 (general) hospital; the hours of

operation may vary from 12 to 24 hours, 7 days per week, depending on serviceneed; and it will not have contiguous short stay medical beds.

The AMU/AMAU lead physician is a consultant physician with a special interest inacute medicine who has overall responsibility for the effective management of the

AMU/AMAU.

A medical assessment unit (MAU). A medical assessment unit (MAU) in a model2 (local) hospital will manage GP referred, differentiated medical patients who

have a low risk of requiring full resuscitation. Only patients referred by a GP willbe seen. This unit will have assessment beds in a defined area and serve a

clinical decision support function. Admissions will be to in-patient beds in amodel 2 hospital. Patients who deteriorate unexpectedly will have guaranteedtransfer to a model 3 or model 4 hospitals. GPs will refer low-risk medical patient(i.e. unlikely to require high intensity cardiopulmonary and/or neurologicalsupport) for assessment in the MAU during daytime hours. Patients with a

significant risk of clinical deterioration should be referred to the associated model3 or 4 hospital. However, patients should not be transferred if a Do NotResuscitate order is made and/or if patients make an informed decision toremain in the model 2 hospital.


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A decision regarding discharge/admission should be made within 6 hours and willbe facilitated by dedicated radiology, laboratory and other services, includingnursing, therapy professionals and medical social workers. In the event of

discharge, the relevant GP will be informed (on the same day) of the decisiontogether with all relevant clinical details and care plans. Every MAU should have

a designated lead consultant physician, who will be jointly appointed to the model2 and associated model 3 or 4 hospital, a designated clinical nurse manager and

assigned therapy resource. MAUs may be operational from 8am to 8pm, 7 daysper week.

The models of hospitals involve 4 levels of acute hospitals in relation to acutemedicine patients, as proposed by the national clinical programmes. Themodels are: model 4 - tertiary hospital; model 3 - general hospital; model 2 -

local with selected (GP-referred) medical patients; and model 1 -community/district.


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1. Executive SummaryThe delivery of safe, quality care in a timely manner and in the appropriate setting hasbeen identified as the aim of the National Acute Medicine Programme1. The programme

provides a framework for the delivery of acute medical services which seeks tosubstantially improve patient care. It also clarifies the structures and processes of

hospitals and acute medical care provided therein.

The Cavan/Monaghan hospital network currently provides services to the population ofboth counties. Acute medical services are based in Cavan General Hospital including anew Acute Medical Assessment Unit ( AMAU) which opened in 2009. Step down andrehabilitation services are based in Monaghan hospital and also some outpatientservices. Both services are complementary and provide a wide range of patient care.

Patients also have an option of accessing services in other hospitals in Drogheda,Navan or outside the region.

A Medical Assessment Unit (MAU) in Monaghan would provide services to a limited

number of patients who fulfilled certain criteria and would be low risk, GP referredpatients. From a local perspective it would be a welcome and convenient developmenthowever on current evidence this development is not feasible. To provide the necessarystructures and staffing would entail a significant cost and the volume of patients

anticipated would be unlikely to warrant such expenditure. It could not be developed atpresent within current resources.

1.1. Major Issues Identified

Monaghan is not a model 2 hospital (c.f. Appendix 2) and as such does notcurrently have many of the requirements for setting up an MAU

Does not currently have medical personnel on site apart from sessional out

patients (OPD) therefore patient safety would be a major concern Does not have laboratory on site so samples must be transported to Cavan

Does not have access to a wide range of emergency diagnostics

Does not currently have sufficient medical, professional and administrative staffavailable to staff MAU

Has no facility to admit patients from an MAU

Extra resources to develop an MAU would be needed

Patient safety must remain a major consideration

1.2. Limitations of the Study

This study was carried out within a very short time frame which limited the time

for discussion and data collection Data available was limited and it was agreed that prospective collection of data

would have provided more accurate information

All definitions used were from the National Acute Services Programme which is aclear and concise document. The degree of flexibility in relation to theinterpretation of this document was the subject of much debate in the group. Inthe end the majority agreed to adhere to the written document but there was a

view that this interpretation was excessively rigid.

Costs could not be clearly defined as the size and scope of the proposed unitwas not agreed. As a guide the costings for the AMAU in Cavan are included toillustrate the cost of setting up a unit in a hospital which already has many of the

basic requirements.


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2. BackgroundThe development of Medical Assessment Units in acute hospitals has been a recentsuccessful initiative. It greatly improves the timeliness of treatment for medical patients

and streamlines the admission process. Instead of being referred to EmergencyDepartments (ED) medical patients are admitted to assessment units where they are

seen by a senior clinician and have rapid access to appropriate diagnostics. They arethen discharged home, admitted to the hospital for further treatment or transferred to a

more specialised unit.

Table 1 Comparison of Acute Medical Services

Acute Hospital

in Patient

ED OPD AMAU/MAU

Testing Over days Triage

Inpatient

Treatment

Discharge

On attendance On attendance

Evaluation of results Days Same day if

performed

Next or other

visit

Day of visit

Reporting back Days, week s or months

Same day Weeks tomonths

Day of visit

Timeliness Depends on

bed availability

Same day Weeks to

months

Same or next

day

Duration of stay Days Hours-depends ontriage

Hours Hours

Level of competency

of assessor

Intern to

Consultant

ED SHO+/- Reg

Med SHO+/-Reg

Intern to

Consultant

Consultant

In 2009 an Acute Medical Assessment Unit (AMAU) was commissioned for patients inthe Cavan/Monaghan hospital network and was based in Cavan General Hospital.Monaghan hospitals role changed to provide rehabilitation, step down beds and out

patient services.

A request from Minister Reilly, Minister of Health, was made to the Regional Director ofOperations, Dublin North East, to establish a representative group to undertake anindependent feasibility study of the development of a Medical Assessment Unit (MAU) atMonaghan Hospital. The terms of reference for this group are outlined below:


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3. Terms of Reference of the Committee Establish a schedule of meetings to enable the collation of data and analysis of

the health demographic of the Monaghan population pertaining to acute

medical service needs. Evaluate current acute service provision and access to Acute Medical Services

to the Monaghan population as part of the Cavan & Monaghan Service Area. Establish if there is a clinical need for an MAU in Monaghan Hospital

Provide a detailed analysis of the pay and non pay costs and support servicesassociated with provision of an MAU Service in Monaghan Hospital.

The meeting quorum is 4 People Provide the Hospital Group General Manager with a report outlining the

feasibility or not of a Medical Assessment Unit on the Monaghan Hospital site.

Deliver the report in a timely fashion 6 weeks from commencement tocompletion.

4. Project Deliverables

This Group will complete an independent feasibility study; To establish if a there is a clinical need for a Medical Assessment Unit in

Monaghan Hospital for the Monaghan population.

To establish the pay and non pay costs and internal/external support servicesassociated with the establishment and running of a MAU in Monaghan.

The project will demonstrate evidence of the local health demographic and local healthdata of the Monaghan population relevant to medical assessment unit services.

5. ProcessThe process commenced on 17th October 2011 and consisted of six meetings held in

Monaghan hospital. Activity data was collated by Mr. G. Clerkin, Risk Advisor.

6. MethodologyThe methodology employed was as follows:

Agree terms of reference Define Medical Assessment Unit Evaluate the resources available in Monaghan

Compare resources to standards outlined by Acute Medicine Programme Identify deficiencies Determine resources required

6.1 Limitations of Methodology Time constraints-project timeframe was 6 weeks Lack of data in relation to current use of services


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7. Medical Assessment UnitsIn an attempt to provide standardisation nationally, the National Acute MedicineProgramme Report 20111 defined what was necessary for the setting up and optimal

working of an MAU. (For a full description please see the Glossary)This document hasbeen accepted as the blueprint for the development of acute hospital services in Ireland.

While we accept there are deviations from this model the majority of the group decidedto accept the definition as laid down in the document (Dr Duffy did not agree with this

decision)

7.1 Acute Medical Assessment Unit (AMAU)1

This unit which is based in a model 3 hospital manages all adult patients who presentwith a wide range of medical conditions. Its aim is to provide a dedicated location for therapid assessment, diagnosis and commencement of appropriate treatment. Physicians,supported by a multidisciplinary team carry out patient assessments and treatment. Thisis the type of unit based in Cavan General Hospital.

7.2 Medical Assessment Unit (MAU)1

This unit, which is the one proposed for Monaghan hospital, manages low risk patients

only. This is a small proportion of the total population of patients attending with acutemedical conditions.

8. Description of Current ServicesCavan hospital is a general hospital which provides a wide range of services. It f its thedescription of a Model 3 hospital under the definition in the acute services programmeand has an acute medical assessment unit (AMAU) which provides a service to thepopulation of Cavan/Monaghan. Patients are referred directly to this unit by their GP or

they are referred on by the triage nurse in the emergency department. Patients in

Monaghan may be referred either to the AMAU in Cavan or Drogheda.

Monaghan hospitals primary role includes the continuing care for medically discharged

patients requiring in-patient step down and rehabilitation care and extensive out patient,theatre, Day Services and a Minor Injury Unit. There are 6 step down beds and 20rehabilitation beds and a wide range of day services. The physician services areprovided by staff based in Cavan general hospital that travel to Monaghan to carry out

their duties. There are no doctors based in the hospital in Monaghan and it currentlydoes not meet the criteria for either a model 1 or a model 2 hospital but falls somewherein between. (c.f. appendix 2)

8.1 Gap AnalysisIt has been clearly stated in the report of the National Acute Medicine Programme that amodel 1 hospital shall not have an ED, ICU, High dependency unit (HDU) coronary careunit or an AMU/AMAU/MAU In a model 2 hospital the requirements for a MAU are very

clearly outlined as detailed below. Table 2 illustrates the criteria for an MAU and thecurrent situation in Monaghan


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Table 2 Gap Analysis for Monaghan in Relation to MAU

MAU Criteria Monaghan Gap

GP referred patients who

are at low risk of requiringresuscitation

Admission currently is requested by

consultant/geriatrician.

There are no acute beds, only

rehabilitation and convalescence

Assessment beds in

defined area 4-12

beds/trolleys

No dedicated area at present There is a potential area which could

be developed

Admission will be to model2 hospital

Monaghan is not a Model 2 hospitalunder the criteria laid down in acutemedicine programme

No facility for admission of patientsto Monaghan from a unit such as this

Patients would have to be

transferred to Cavan

Dedicated radiology On call x-ray only for Minor injuriesunit Limited radiology service

Dedicated laboratory No laboratory facility on site in

Monaghan

Samples couriered to Cavan with

subsequent time delay

Dedicated nursing Dedicated nurses would have to be

employed

Staffing insufficient to cover MAU

Designated leadconsultant physician

All medical consultants are currentlybased in Cavan

There is currently no medical officeron site and no out of hours medicalcover

NCHD staff All NCHDs are currently based inCavan

No NCHDs are currently assigned toMonaghan

NCHD at night There are no medical staff resident onsite at night

Resident medical registrar/SpR andSHO and a consultant on call

Nursing staff Limited number of nursing staff-

managed from Cavan

Additional nursing staff would have

to be employed

Dedicated nurse manager

for MAU

Based in Cavan Would have to be recruited

Operational 8-8 sevendays per week Not available at present Staffing and cost implications


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9 Establishing a Clinical Need

Relevant information that was required here:

The number of patients from Monaghan currently attending AMAUs in Cavan

and Drogheda

Type of patient attending, i.e. low risk who would be suitable to attend an MAUor general medical suitable for AMAU only

The AMAU in Cavan became operational in March 2009. In 2011 the population for theCavan/Monaghan region was 133,369, Monaghan (60,495) and Cavan (72,874)2.

Table 3 Attendances at Cavan AMAU by County of Residence

CavanAMAU

Patients with CAVAN Addresses Patients with MONAGHAN Addresses

Year Totalnumbersattending

Numbersattending

Dailynumbers

Rate per10,000 ofpopulation

Numbersattending

Dailynumbers

Rate per 10,000population

2010 43602639

(61%)10 3.6

1310

(34.5%)5 2.1

2011 37462273

(61.2%)8.7 3.1

1137

(30.6%)4.3 1.8

In 2011, 61.2% of patients attending Cavan AMAU had Cavan addresses and 30.6%

(1137) had Monaghan addresses. The remaining 336 were from neither county.

In 2010, 61.6% of patients were from Cavan, 30.6% from Monaghan and the remainderfrom other counties.3

In 2011 these figures reflect 3.5 visits per 10,000 population for Cavan and 2.1 visits per10,000 population for Monaghan. This equates to 3 more patients from Cavan beingseen per day than from Monaghan. This discrepancy of 3 patients may be accountedfor in Monaghan patients attending Drogheda and other hospitals. To achieve equalrates of attendance to the AMAU in Cavan would entail 3 extra patients per day being

seen from Monaghan. A limitation of these figures is that they reflect the experience of

two years only. It is quite possible that the trend over several years may show quite adifferent finding.

On average 20 patients per month from Monaghan attend Drogheda AMAU. (c.f.Appendix 3)


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The type of patient attending would also need to be clearly identified . Only low riskpatients would be suitable to attend an MAU and it is not currently possible todetermine how many of the patients attending the the AMAU in Drogheda and

Cavan would be in this category. If an MAU were to be made available in Monaghanthere is no clear evidence that the critical mass of low risk patients needed would be

available.

In the six weeks available to carry out this study it was not possible to obtain morecomprehensive figures on the issues raised above. Activity data for Cavan/Monaghan isincluded in Appendix 3

9.1 Advantages of an MAU in Monaghan Convenient and accessible for local patients

Timely access for GPs to specialist medical care-this is currently available inCavan

Timely access to limited diagnostics

9.2 Disadvantages of an MAU in Monaghan Patient safety issues as there are no medical personnel on site and there is

no facility for admission

Resource intensive for small critical mass

Cost

9.3 Major Issues Identified Monaghan is not a model 2 hospital and as such does not currently have

many of the requirements for setting up a MAU

Does not currently have medical personnel on site apart from sessionalOPD therefore patient safety would be a major concern

Does not have laboratory on site but samples can be fast tracked to Cavan

Does not have access to wide range of emergency diagnostics

Does not currently have sufficient medical, professional and administrativestaff available to staff MAU

Has no facility to admit patients from an MAU

Extra resources to develop an MAU would be needed

Patient safety must remain a major consideration

10. Resource Requirement

The cost of setting up and running an MAU is considerable as can be seen from thecosting for the Cavan AMAU in Appendix 4. The major cost is in relation to pay,

approximately1.2 million. Because the throughput of an MAU in Monaghan cannot beclearly outlined the costings must remain an estimate and although a slightly lessernumber of staff may be required the cost would still be substantial. A critical mass ofpatients is required to make a service cost effective and sustainable and a substantialnumber of patients would be required to justify such a large resource investment.


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11. DiscussionEvery community desires a comprehensive medical service in close proximity to them toprovide the highest quality medical care. However extensive research has shown that to

provide an excellent service a critical mass of patients must be available for theclinicians to maintain and develop their skills

. 4In the current climate it is also vital that

services are cost effective and scarce resources are used in the best manner possible.The population of Cavan/ Monaghan have access to excellent medical services provided

on two sites in the Cavan/Monaghan network. Each hospital has quite a different role,and while Cavan is focused on providing acute medical care, Monaghan provides theequally important step down and rehabilitation facilities. Extensive OPD and day surgeryis also a feature of what Monaghan can provide. They also have access to an AMAU inDrogheda

Two AMAUs are available and accessible within a reasonable distance to the populationof Monaghan. These units would appear to serve the population well as there is noclear evidence of an unmet need in this population although further analysis would be

necessary to confirm this.

One limitation of this study was that it was carried out in a very short time frame of sixweeks. Further analysis of data would be necessary to give a more definitive

conclusion.

12. ConclusionThe population of Cavan/Monaghan have access to a wide variety of acute medicalservices within a reasonable distance of their residence. Patient safety must remain ourpriority when deciding where services are located. This is about patients receiving theright care, in the right place, at the right time. The objective is to provide the highest

quality care to patients and ensuring that those who require care can get access to it asquickly and as safely as possible. The cost of maintaining such services is immense.To ensure cost effectiveness and the maintenance of skills a satisfactory critical mass ofpatients must attend the service available. To develop an MAU in Monaghan at thiscurrent time would entail a considerable input of resources and would necessitate

moving scarce resources from other services to serve a relatively small number ofpatients.


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References1. Health Service Executive. Report of the National Acute Medicine Programme,

2010

2. Central Statistics Office. Reports on Vital Statistics. Yearly summary. Dublin:

Central Statistics Office, 2011

3. Hospital Inpatient Enquiry System. Dublin. The Economic and Social ResearchInstitute, 2011

4. Hospital volumes and health care outcomes, costs and patient access. EffectiveHealthcare Bulletin 1996; 2(8):1-8.


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Appendix 1

Group Membership

Core Membership:

Dr Louise Doherty, Specialist in Public Health Medicine, HSE North West (Chair)

Dr James Hayes, Clinical Director, Cavan & Monaghan Hospital Group

Ms Eileen Whelan, Director of Nursing, Louth/Meath Hospital Group

Ms Ruth Murdiff, Service User Representative, Cavan & Monaghan Hospital Group

Mr Robert Dancey, Service User Representative, Cavan & Monaghan HospitalGroup

Mr Gerry Clerkin, Risk Advisor, Cavan & Monaghan Hospital Group (GroupFacilitator)

Mr Cathal Hand, Service Development Manager, Cavan & Monaghan HSE Area

Dr Ilona Duffy, GP Representative from Cavan/Monaghan


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Appendix 2 Gap Analysis Monaghan Hospital

Appendix 2a Gap Analysis Monaghan Hospital Vs Model 2 Hospital (Acute Medicine Programme)

MH Vs Level 2 ModelStatus Report

14/0311 Implemented 23 (39%)

partiallyi mp le me nte d 1 3 ( 22 %)

not implemented 23 (39%)

Characteristics of a Level 2

Hospital

Current status of Monaghan

Hospital

Implications of achieving the

Characteristics of a level 2hospital i.e Structural, capacity,resources financial & human

Is it feasible toachieve requirement

within resourcesYes/No

Persons whowould be

responsible forleading on thisinitiative

Status

Implemented orNot implemented

Additional

comments

Hospital has a day time MAU No MAU

Significant resources tofacilitate this service. FullMedical team required with

anesthetic cover and nursing.

Not feasible within

resourcesN/A Not implemented

GP will refer low risk (i.e. unlikelyto require high intensity

cardiopulmonary and/orneurological support) medicalpatients for assessment in the

MAU during daytime hours

No MAU N/A Not implemented

The Hospital will provide in-patientand out-patient care fordifferentiated, low risk medical

patients, who are not likely torequire full resuscitation. Allpatients will have an appropriate

care plan

Patients in the 26 bedded unit aremedically discharged and therefore

deemed as being low risk. There isan emergency protocol which is tobe initiated in the event of patient

becoming medically compromised.There is a minor injury unit onlywith clear criteria for GPs/patients

as to what condition will beassessed in the MIU. Treatmentplans are in place.

implemented


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This hospital will not have an ICU,

so the patient will be assessedand tracked using the national

early warning score (ref section6.4) and where appropriate, thisscore will prompt an acutemedicine response and if

necessary, transfer to theassociated model 3 or 4 hospital.

No ICU, daily obs undertakenroutinely on all patients, if pt comesill Potts score is calculated.

implemented

A p atient's condition maydeteriorate and after detection and

treatment by acute medicine apatient's acuity may be ICS Level2 unstable or Level 3 (ref

appendix 17.9) requiring criticalcare retrieval and transfer to ICU

in a model 3 or 4 hospital

Not applicable as there is no acute

medical team on call.Non applicable

There will be guaranteed

acceptance of transfer of allpatients who deteriorate by theassociated model 3 or 4 hospital

(bi-directional patient flow mustalso occur if required)

transfer protocol in place implemented

patients requiring palliative,

respite, rehabilitation and pre-discharge care and patients fordirect GP to consultant referral

(via MAU) can be admitted to thishospital

Rehabilitation service only for

medically discharged patients.Direct referrals from GP notaccepted, pre-discharge care not

available, no respite,

partiallyimplemented

Patients can be admitted from theMAU under the care of the namedconsultant and out-of-hours

selected medical patients can beadmitted by agreement between

the GP and the on call medicalteam /consultant

No MAU Non applicable


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The medical department and

medical staff need to be part of awider rotation under governanceof the acute medicine service in

the ISA linked model 3 or 4hospital. During the day there willbe appropriate NCHD presence in

the MAU and wards

No MAU Not implemented

The Medical staffing at night willbe a resident medicalregistrar/SpR and the senior

house officer (both of whom areadvanced cardiac life support(ACLS) certified). In addition there

will be a consultant on call.

Not available Not implemented

Nurse staffing at night will includea nurse manager/supervisor for

the nursing services.

not in place Not implemented

Therapy staffing will be at a seniorgrade within each therapy

discipline with additional therapyresource comprising staff andassistant grade positions. Clinical

specialists in ISA model 3 and 4hospitals will provide advice and/or support as required.

in place implemented

standards of care should be

measured and should becomparable to those delivered inmodel 3 and 4 Hospitals

in place, cross site clinical

governance committees oversee

the standards of service delivery ineach specialty, Medicalgovernance committee toincorporate 26 beds MH


The hospital may have a minorinjury unit (MIU)



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The following day services could be made available 5 days a week based on local need.

Day surgery in place implemented

Pre-operative clinics in place implemented

Day services /ambulatory care

assessment for older personsfalls clinic planned, partially

Antenatal/Post natal careante natal only, post natal always

carried out by GPimplemented

Endoscopy /PEG tube insertion endoscopy only partially

Non invasive cardiology in place implemented

Cardiac Failure clinic in place implemented

Cardiac Rehabilitation in place implemented

Venesction, infusion andtransfusion therapy


Bone Marrow aspiration andtrephine biopsy

Not availablenotimplemented

Abdominal paracentesis andthoracentesis

Not availablenotimplemented

lumbar puncture Not availablenotimplemented

Diabetic Day centre in place implemented

Rheumatology day services planned 2012Notimplemented

Dermatology day servicesNot available in MH, is available inCGH

notimplemented

Oncology /hematology day ward not availablenot

implemented

Mental Health day services St Davnets site implemented

COPD outreach planned 2012-13Notimplemented

Pulmonary rehabilitation in place implemented

Heptatology day services planned 2014Not

implemented

Diagnostic Imaging in place implemented


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other services depending localpolicies and protocols

ENT, Community audiology, OPD

to include Medical, Surgical,Gynae, orthopaedics, Paediatrics,Dental, AHP led services, CNS

clinics,


Patient flow will be enhanced byexpanded nursing and therapypractice (e.g. nurse prescribing of

medicinal products and ionisingradiation /xrays and therapyfacilitated discharge) These

services will be developed inresponse to service need.

Nurse prescribing in place in MIU,Heart failure, Diabetes day centre


Clinical Pharmacy services will beprovided by clinical pharmacistsattached to model 3 or 4 hospitals

not availablenotimplemented

All model 1 & 2 hospitals musthave an in-house clinicalpharmacy service or formal

access to and reportingrelationship with the service in amodel 3 or 4 hospital

Not availablenot

implemented

All hospitals must have a persontrained and responsible for

infection prevention and control onsite and formal access to advicefrom a consultant microbiologist/infectious disease physician



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Consultant physician work

practices

Current status of Monaghan

Hospital in achieving level 2 status

Implications of achieving theConsultant work practices of a

level 2 hospital

Is it feasible toachieve requirementwithin resources

Yes/No

Persons whowould beresponsible for

leading on thisinitiative

StatusImplemented orNot

implemented

Additional

comments

The consultant physician on-callfor the MAU will have a primaryresponsibility to be present and

make management decisionsduring core working hours.

Not availableNot

implemented

There will be ward rounds everyday on all newly admitted patients,patients whose clinical status

deteriorates and patients identifiedfor potential discharge.

Not availableNot

implemented

Board rounds (i.e. desktop

review of patient status with aview to potential discharge) willoccur on all medical patients,

once daily before 11am, includingPublic Holidays and weekends.

Not availableNotimplemented

At least 2 comprehensive wardrounds on all patients should take

place weekly.

Not availableNot

implemented


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Appendix 2b Gap Analysis Monaghan Hospital Vs the Model 2 Hospital (National Acute medicine

Programme) Interdependencies with other National Clinical ProgrammesGap analysis Monaghan Hospital Vs the Model 2 Hospital (National Acute Medicine Programme)

Interdependencies with other national clinical programmes

National Clinical Programme National Recommendation Gap analysis

Acute cardiology

Patients should be managed according to referral guidelines and clinicalprotocols. An out-patient clinic session should be provided by a visiting

cardiologist one day per week to review the results of non-invasive tests.Patients with acute presentations should be transferred to a model 3 or 4

hospital according to protocol.

Not available

Ambulance servicesGPs, hospital staff and ambulance services will agree the protocols forambulance transfer to and between hospitals.

in place

Asthma There will be out-patient services available on site utilising spirometry in place

COPD In-patients will have care up to, and including, non-invasive ventilation(NIV). OPD, pulmonary rehabilitation and outreach may be available.

OPD & rehabilitation only

DiabetesDiabetic day care, including chiropody and ophthalmology, may be

available.in place


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Diagnostic ImagingPlain film X-ray, ultrasound and CT-scanning will be provided. There will bean on-call diagnostic imaging service.

in place on call Xray only for MIU

EndoscopyUpper and lower gastrointestinal endoscopy and bronchoscopy may beavailable.

endoscopy only

Epilepsy and Neurology services Epilepsy and neurology out-patient management may be available. Not available

Health Care Associated Infection

A person trained and responsible for infection prevention and control will beemployed on site. Formal access to advice from a consultant

microbiologist/infectious diseases physician is required.part time cover

Heart Failure

A heart failure service will be established under the governance of a leadconsultant physician. Selected heart failure patients with a clearly defined

care plan who develop decompensated heart failure may be admitted.There will be a rapid access clinic for out-patient IV therapy to stablilise

patients with deteriorating heart failure, possibly including inotropic care. Afull out-patient service for diagnosis and specialist review will be provided.

OPD only


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Palliative Care

Patients with palliative care needs may be managed in model 2 hospitalswith appropriate support from the specialist palliative care services as

required. Services provided in model 2 hospitals should be sufficientlyflexible and integrated with specialist palliative care services to allow rapid

and efficient movement of patients from one care setting to anotherdepending on their clinical needs and personal preferences. Admission

criteria, discharge protocols and interface with specialist palliative careservices will be according to agreed national palliative care programme

protocols

OPD only

Primary CareDirect access for some of the services listed (i.e. radiology, endoscopy,

laboratory etc.) as part of agreed protocols.

endoscopy & radiology only, in-

direct access to laboratory.

RheumatologyRheumatology out-patient services will be linked to the nearest

rheumatology unit in a model 3 or 4 hospital.

currently not in place, however

this is planned for 2015 +

Stroke Stroke rehabilitation will be provided in place

Surgery Day surgery and pre -admission assessment clinics will be provided. in place


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Appendix 2c Gap Analysis Monaghan Hospital Vs Model 1 Hospital (Acute Medicine Programme)

MH Vs Level 1 Model Status Report

14/0311 Implemented 24 (62%)

partially implemented 6 (15%)

not implemented 9 (23 %)

Characteristics of a Level 1

Hospital

Current status of

Monaghan Hospital

Implications of achieving theCharacteristics of a level 1

hospital i.e Structural,capacity, resources financial

& human

Is it feasible

to achieverequirement

withinresources

Yes/No

Persons who would beresponsible for leading

on this initiative

StatusImplemented

or Notimplemented

Additional

comments

The hospital will be a community

hospital with sub-acute in-patientbeds

in place, beds referred toas non-acute beds

implemented

admissions can be requested by

a GP, consultant geriatricianand/or consultants following

agreement with a medical officer

consultant /geriatricianonly not GPs

partially


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patients with rehabilitation,respite and /or complex palliative

care needs and patients whoremain under the care of GPs

may be admitted appropriately toin-patient beds in this hospital.

These patients will be managedunder the care of a medical

officer(e.g. designated GP orgroups of GPs) who will be

supported as necessary byconsultant physicians. All

patients have an appropriatecare plan.

Rehabilitation only,service not available to

respite or palliative carepatients, medical officer

is under discussion

partially

This hospital will not have anED, ICU, high dependency unit

(HDU), coronary care unit or anAMU/AMAU/MAU

in place, implemented

As this hospital will not have anICU, patients requiring a higher

level of care will be transferredto the ISA model 2,3 or 4

hospital



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there will be guaranteed transferof patients whose clinical status

deteriorates from the model 1hospital to the ISA model 2, 3, or

4 hospital (s). Where a patient iscritically ill (ICS levels 2 & 3), the

regional critical care retrievalteam will effect safe transfer.

Remote critical care retrieval willinclude continued resuscitation,

stabilisation and safe transportby the retrieval team (ref

appendix 17.9).


Patients whose clinical statushas improved sufficiently may be

transferred from a model 3 or 4hospital to a model 1 or 2

hospital for further cae (bi-directional patient flow must also

occur). However, patients shouldnot be transferred is a "Do not

resuscitate" order is madeand/or if patients make an

informed decision to remain inthe model 1 hospital.



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The following day services could be made available 5 days a week based on local need.

Out patient department (OPD) in place implemented

Day services /ambulatory careassessment for older persons

falls clinic planned,notimplemented

Venesection / phlebotomy in place implemented

warfarin service in place implemented

COPD outreach planned for 2014 +notimplemented

Pulmonary rehabilitation in place implemented

Cardiac Failure clinic in place implemented

Supra-pubic catheter re-

insertion

in place (replacement of

Supra-pubic catheter)implemented

percutaneous endoscopicgastrostomy (PEG) tube re-

insertion

nonot

implemented

Antenatal/postnatal servicesantenatal in place post

natal undertaken by GPsimplemented

other services depending localpolicies and protocols

ENT other services will

be introduced dependinglocal policies and

protocols

Partiallyimplemented

Many of these services will benurse led and /or therapy led

with expansion of nursing and

therapy practice in response toservice need


Clinical Pharmacy services willbe provided by clinical

pharmacists attached to model 3or 4 hospitals

no clinical pharmacynot

implemented


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All model 1 & 2 hospitals must

have an in-house clinicalpharmacy service or formal

access to and reportingrelationship with the service in a

model 3 or 4 hospital

not availablenot

implemented

All hospitals must have a persontrained and responsible for

infection prevention and controlon site and formal access to

advice from a consultantmicrobiologist /infectious disease

physician


Consultant physician work

practices

Current status of

Monaghan Hospital inachieving level 2 status

Implications of achieving the

Consultant work practices ofa level 2 hospital

Is it feasible

to achieverequirement

withinresources

Yes/No

Persons who would be

responsible for leadingon this initiative

StatusImplemented

or Notimplemented

Additional

comments

The medical officer (s) or his /her

deputy, will carry out weekdayward rounds and will be

available on call or as part of an

"out of hours" GP service.

partially in place, Out of

Hours not in place andmedical officer is

planned

partially


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Appendix 2d Gap analysis Monaghan Hospital Vs the Model 1 Hospital (National Acute Medicine

Programme) Interdependencies with other Clinical Programmes

Gap Analysis Monaghan Hospital Vs the Model 1 Hospital (National Acute Medicine Programme)

Interdependencies with other

national clinical programmes

National Clinical Programme National Recommendation Gap analysis

Acute cardiologypatients with a suspected acute coronary syndrome should

not be admitted to or treated in a model 1 hospital exceptunder defined circumstances

in place

Ambulance servicesGPs, hospital staff and ambulance services will agree the

protocols for ambulance transfer to and between hospitals.in place

Anaesthesia An anesthesia service will not be providedNot available to in patients, provided for Day servicesENT, Gynae, Surgery and pre-operative assessment

Asthma

There will be out-patient services available on site utilising

spirometry in place

COPDOut reach programmes and pulmonary rehabilitation maybe available

rehabilitation only


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Diabetes Diabetic cl inics may be available in place

Diagnostic Imaging There may be imaging depending on local need in place on call Xray only for MIU

Epilepsy /Neurological

services (e.g. Parkinson'sdisease).

Epilepsy and neurology out-patient management may be

available. Not available

Health Care Associated

Infection

A person trained and responsible for infection preventionand control will be employed on site. Formal access to

advice from a consultant microbiologist/infectious diseasesphysician is required.

part time cover from a cross site IPCT

Heart Failure

Medical officers will manage patients with heart failureaccording to guidelines. The hospital may provide

ambulatory services for diagnostics and OPD managementof heart failure.

in place

Medicine for Older peopleambulatory care assessments for older persons may be

provided on site.planned for 2015 +

Mental Health services Out patient clinics may be available on St Davnets site

Palliative Care

Patients whose palliative care needs could be met by their

GP in a model 1 hospital environment e.g.. end of life care,titration medication. Admisssion criteria, discharge

protocols and interface with specialist palliative careservices will be according to agreed national palliative care

programme protocols

Not in place


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Primary CareClose liaison with GPs and Primary care teams with regard

to direct access for services admission criteria anddischarge policies and procedures

Not in place

Rheumatology Rheumatology out-patient services will be linked to thenearest rheumatology unit

Currently not in place, however this is planned for 2014+

Stroke The hospital may have a stroke rehabilitation unit on sitestroke rehabilitation service in place, no dedicatedstroke unit

Surgery Surgical OPD may be available in place


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Appendix 3a Cavan & Monaghan Hospital Yearly Stats 2008 2011

CAVAN/MONAGHAN HOSPITAL GROUP

YEARLY ST ATS

Items marked in red are Jan-Nov 2011 figures

2008 2009 2010 2011 Jan-Dec

CGHSite MH Site

Cross SiteTotal

CGHSite M H Site

Cross SiteTotal

CGHSite MH Site

CrossSite Total

CGHSite M H Site

Cross SiteTotal

Admissions

Surgical 3297 0 3297 2937 0 2937 2566 0 2566 2588 0 2588Medical 4877 2431 7308 6220 1400 7620 7136 0 7136 6696 0 6696

Paeds 1729 0 1729 1626 0 1626 1636 0 1636 1630 0 1630

Obs 3064 0 3064 3164 0 3164 3080 0 3080 3152 0 3152

Gynae 746 0 746 739 0 739 693 0 693 539 0 539

Rehab 0 0 0 0 67 67 0 157 157 0 113 113

Stepdown 0 0 0 0 98 98 0 264 264 0 245 245

Psychiatry 131 0 131 140 0 140 108 0 108 112 0 112

Total 13844 2431 16275 14826 1565 16391 15219 421 15640 14717 358 15075

Births 1957 0 1957 1945 0 1945 2032 0 2032 1879 0 1879

Daycases

Surg General 784 1381 2165 813 1524 2337 808 1689 2497 766 1772 2538

Surg Endoscopy 2439 1316 3755 2450 1538 3988 2852 1495 4347 2915 1017 3932

Medical Gen 597 556 1153 522 700 1222 724 946 1670 755 841 1596

Med Endoscopy 299 1585 1884 256 1325 1581 259 1088 1347 287 1128 1415*Other 13098 73 13171 14426 56 14482 13708 109 13817 14105 123 14228

Total Daycases 17217 4911 22128 18467 5143 23610 18351 5327 23678 18828 4881 23709

Outpatients

New 9998 3455 13453 9602 3574 13176 10085 3510 13595 8804 3188 11992

Review 29161 12256 41417 29672 11562 41234 28955 10793 39748 29575 10069 39644

Total 39159 15711 54870 39274 15136 54410 39040 14303 53343 38379 13257 51636


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X-Ray

Inpatients 11089 6119 17208 13898 4538 18436 16115 2376 18491 15848 658 16506

Outpatients 38098 12744 50842 39201 10954 50155 39519 10565 50084 37016 13596 50612

Total 49187 18863 68050 53099 15492 68591 55634 12941 68575 52864 14254 67118

A&E

New 25285 9540 34825 26400 5105 31505 25742 0 25742 26609 0 26609

Review 1830 2374 4204 1777 1154 2931 1990 0 1990 1968 0 1968

Total 27115 11914 39029 28177 6259 34436 27732 0 27732 28577 0 28577

MITU

New 0 0 0 0 1808 1808 0 5446 5446 0 6595 6595

Review 0 0 0 0 406 406 0 1438 1438 0 1542 1542

Total 0 0 0 0 2214 2214 0 6884 6884 0 8137 8137

MAU

Attend only 0 0 0 1217 0 1217 1734 0 1734 1687 0 1687

Admitted 0 0 0 2219 0 2219 2626 0 2626 2059 0 2059

Total Attended 0 0 0 3436 0 3436 4360 0 4360 3746 0 3746

*Other daycases include Renal dialysis, GDU, Gynae, Orthopaedic, Oncology, Paeds, Obstetric, Dermatology & ENT

COMMENTS:

In July 09 Medical inpatient services in MGH Ceased

In July 09 Rehab & Stepdown services commenced in MGH

In July 09 Treatment room services in MGH Ceased

In July 09 MITU commenced in MGH

30th March 09 MAU opened in CGH


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Appendix 3b Cavan Hospital MAU Stats 2009 2011

2009

Description Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Y.T.D.

Attend only 0 0 8 75 130 124 125 136 109 172 174 164 1217

Admitted 0 0 5 208 232 226 300 264 266 244 253 221 2219

Total Attendance 0 0 13 283 362 350 425 400 375 416 427 385 3436

2010


Attend only 133 148 149 177 183 138 126 139 167 147 116 111 1734

Admitted 216 202 225 227 200 237 230 260 224 206 206 193 2626


2011


Attend only 106 108 124 99 140 137 140 164 132 174 180 183 1687

Admitted 156 202 187 105 228 188 151 173 172 129 208 160 2059



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Appendix 3c Cavan ED Figures 2008 2011

2008


New 1959 1871 2075 2221 2351 2156 2228 2096 2098 1995 1970 2265 25285

Review 114 123 154 160 188 146 154 165 142 156 155 173 1830

Total 2073 1994 2229 2381 2539 2302 2382 2261 2240 2151 2125 2438 27115

2009


New 1978 1997 2336 2331 2344 2221 2243 2195 2171 2268 2118 2198 26400

Review 114 118 146 157 161 148 162 155 140 150 153 173 1777

Total 2092 2115 2482 2488 2505 2369 2405 2350 2311 2418 2271 2371 28177

2010


New 2021 1894 2319 2205 2334 2135 2250 2140 2236 2124 2037 2047 25742

Review 168 124 137 143 151 180 161 172 196 212 197 149 1990

Total 2189 2018 2456 2348 2485 2315 2411 2312 2432 2336 2234 2196 27732

2011


New 2257 2019 2262 2317 2265 2195 2137 2287 2212 2215 2217 2226 26609

Review 186 171 165 132 161 157 130 163 163 159 193 188 1968

Total 2443 2190 2427 2449 2426 2352 2267 2450 2375 2374 2410 2414 28577


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Appendix 3d Cavan ED Triage Figures 2008 2011

2008


P1 6 8 14 2 3 19 11 8 13 9 11 22 126

P2 282 264 332 330 326 410 405 294 323 345 314 350 3975

P3 1002 1005 1153 1090 1138 1131 1022 989 1053 1110 1046 1279 13018

P4 626 519 586 748 835 547 710 812 683 610 582 620 7878

P5 16 5 5 10 12 19 4 9 11 6 4 9 110

Dressings 14 7 14 9 24 7 13 11 6 10 16 10 141

Physician Review 19 17 19 23 28 32 25 26 32 32 29 32 314

Code Not Entered 131 92 115 142 186 137 135 92 131 135 125 128 1549

2009


P1 15 4 2 10 12 8 12 16 11 15 14 19 138

P2 280 352 366 370 417 413 390 398 363 444 376 430 4599

P3 1068 1073 1227 1378 1334 1269 1336 1233 1282 1278 1273 1351 15102

P4 568 549 651 551 601 571 543 551 543 543 517 450 6638

P5 4 15 5 2 3 4 7 7 6 9 6 8 76

Dressings 6 8 3 3 4 3 6 4 4 13 4 10 68


Code Not Entered 132 141 197 164 123 94 98 108 88 82 94 94 1415

2010

Description Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Y.T.D.P1 17 14 10 9 10 12 14 10 11 7 12 18 144

P2 344 351 380 355 352 355 366 319 343 363 334 360 4222

P3 1246 1094 1233 1308 1411 1112 1342 1199 1289 1208 1334 1273 15049

P4 461 455 618 528 581 579 581 667 625 502 434 430 6461

P5 3 5 3 6 6 8 4 7 5 3 3 3 56

Dressings 8 3 4 4 2 6 5 4 4 9 7 8 64


Code Not Entered 82 79 177 110 81 234 86 87 108 237 84 93 1458

2011


P1 16 13 18 17 6 8 7 24 11 18 19 20 177

P2 386 371 343 343 356 338 332 356 337 337 354 394 4247

P3 1371 1241 1267 1353 1347 1237 1309 1410 1369 1368 1400 1342 16014

P4 537 453 639 548 568 583 450 493 474 441 416 490 6092

P5 3 3 4 3 7 2 2 8 2 5 4 14 57

Dressings 5 12 7 4 8 10 7 4 3 1 2 10 73


Code Not Entered 139 100 138 171 126 172 146 160 195 218 234 138 1937


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Appendix 3e Minor Injury Unit, Monaghan Hospital Figures

2009 2011

2008

Description Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Y.T.D

New 786 728 789 910 963 892 817 787 796 701 635 736 9540

Review 235 208 204 178 184 244 228 183 169 162 177 202 2374

Total 1021 936 993 1088 1147 1136 1045 970 965 863 812 938 11914

Admissions thru 210 189 176 192 199 201 186 167 186 196 198 213 2313

2009-Treatment Room


New 726 645 764 810 816 835 509 0 0 0 0 0 5105

Review 244 202 235 212 96 98 67 0 0 0 0 0 1154

Total 970 847 999 1022 912 933 576 0 0 0 0 0 6259

Admissions thru 229 188 221 209 222 215 92 0 0 0 0 0 1376

2009 -MITU


New 77 365 368 356 324 318 1808

Review 13 39 87 91 89 87 406

Total 0 0 0 0 0 0 90 404 455 447 413 405 2214

MITU 20102010


New 333 297 397 507 578 481 492 469 469 532 421 470 5446

Review 108 77 120 143 182 171 184 120 102 35 85 111 1438

Total 441 374 517 650 760 652 676 589 571 567 506 581 6884

MITU 2011

2011


New 414 393 549 619 630 647 750 700 605 564 430 294 6595

Review 112 97 110 179 181 180 85 113 146 149 101 89 1542

Total 526 490 659 798 811 827 835 813 751 713 531 383 8137


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Appendix 3f Cavan Hospital OPD Waiting Time for OPD

Appointments

OPD Validation Baseline Data Template

HOSPITAL NAME: Cavan/ Monaghan General Hospital

COMPLETED BY: Gary Keenan

DATE OF COMPLETION: 03/01/2012

Wait inweeks

Wait inweeks

Wait inweeks

Wait inweeks

Wait inweeks

Wait inweeks

Specialty Consultant 0 to 12 13 to 25 26 to 39 40 to 52Greaterthan 52 Total

General Medicine Dr. Hayes 79 85 63 9 3 239

Dr. Pinherio 18 5 0 2 0 25

Dr. Pinherio MH 26 38 12 3 0 79

Dr Sheikh 72 18 4 0 0 94

Dr Murugasu 17 10 0 2 1 30

Dr Muthu 23 10 5 0 0 38

Dr. Muthu MH 16 8 2 1 0 27

Dr Mac Mahon 58 77 70 23 0 228

Dr. McDermott 15 10 2 2 0 29

Dr. Smith 22 15 4 4 0 45

Dr. Hannon 38 27 5 2 1 73

907

Total 384 303 167 48 5 907


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Appendix 3g Drogheda Statistics

In total 242 patients with Monaghan addresses attended the MAU/AMAU, this worksout at an average of 20 patients per month but clearly there are variations in relationto the monthly trend (see table):

2011

Month No of Patient

January 14

February 19

March 23

April 18

May 13

June 24

July 26

August 21

September 26

October 18

November 21

December 19

The analysis of the patient addresses showed that the majority of patients come fromCastleblayney and Carrickmacross. There are single numbers of patients withaddresses from Ballybay, Inniskeen, Smithsboro, Monaghan town which are all inthe vicinity of south Co. Monaghan. It is important to note that a high percentage ofthese patients would be patients of the medical department of Louth County Hospitaland subsequently are now patients of Our Lady of Lourdes Hospital, Drogheda.


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Appendix 4 Resource Requirements for Setting up the AMAU in

Cavan

NAME OF AGENCY Cavan General Hospital AMAU

A GRADE OF POST WTE SALARY COST

Administration

Clerical Grade 3 - Wards Clerk - 9 to 5 Mon to Sun 3.00 34,178 102,534

Bed Manager Grade 7 (33hrs) 1.00 69,850 69,850

0.00 - 0

Medical & Dental

Consultant 1.00 220,000 220,000

Radiologist 1.00 220,000 220,000

Nursing

CNM II 1.00 69,111 69,111

CNM II 1.00 59,210 59,210

Staff Nurses 7.15 48,500 346,775

Chest Pain Nurse (CNS) 1.00 59,210 59,210

Allied Health Professionals

Radiographer 0.50 66,718 33,359

0.00 66,718 0

0.00 66,718 0

0.00 66,718 0

0.00 66,718 0

0.00 66,718 0

Support Services

Attendants 2.58 37,915 97,821

Other Pay

TOTAL PAY COSTS 19 1,277,870

B NON PAY COSTS

Non Pay Costs-- 70:30 ratio of Pay to NonPay

(Automatically calculated by dividing pay costs by 70 and multiplying by 30) 547,658

Please include any additional non pay costs if not adequately refelected in the 70:30% above

2 contract computers 2,200

1 Photocopier 4,500

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