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Feasibility Study for a Medical Assessment Unit Service in Monaghan Hospital

January 2012

CONFIDENTIAL
Contents
Glossary .........................................................................................................................3 1. 2. 3. 4. 5. 6. 7. 8. 9. Executive Summary ................................................................................................ 5 1.1. Major Issues Identified.........................................................................................5 1.2. Limitations of the Study .......................................................................................5 Background .............................................................................................................6 Terms of Reference ................................................................................................ 7 Project Deliverable ................................................................................................. 7 Process .................................................................................................................... 7 Methodology ........................................................................................................... 7 6.1 Limitations of Methodology ..................................................................................7 Medical Assessment Units.....................................................................................8 7.1 Acute Medical Assessment Units.........................................................................8 7.2 Medical Assessment Units...................................................................................8 Description of Current Services ............................................................................8 8.1 Gap Analysis ....................................................................................................... 8 Establishing a Clinical Need ................................................................................ 10 9.1 Advantages of an MAU in Monaghan ................................................................ 11 9.2 Disadvantages of an MAU in Monaghan............................................................11 9.3 Major Issues Identified ....................................................................................... 11 Resource Requirement ........................................................................................ 11 Discussion ............................................................................................................ 12 Conclusions .......................................................................................................... 12 References ............................................................................................................ 13 Appendices ........................................................................................................... 14 Team Membership ............................................................................. 14 Gap Analysis Monaghan Hospital .................................................... 15 Gap Analysis Monaghan Hospital Vs Model 2 Hospital............................15 Gap Analysis Monaghan Hospital Vs the Model 2 Hospital (National Acute Medicine Programme) Interdependencies with other Clinical Programmes ............................................................... 21 Gap Analysis Monaghan Hospital Vs Model 1 Hospital............................24 Gap Analysis Monaghan Hospital Vs the Model 1 Hospital (National Acute Medicine Programme) Interdependencies with other Clinical Programmes ............................................................... 29

10. 11. 12. 13. 14.

Appendix 1 Appendix 2 Appendix 2a Appendix 2b


Appendix 2c Appendix 2d

Appendix 3 Activity Statistics................................................................................ 32 Appendix 3a Cavan & Monaghan Hospital Yearly Stats 2008-2011 .............................32 Appendix 3b Cavan Hospital MAU Stats 2009-2011 ....................................................34 Appendix 3c Cavan ED Figures 2008-2011 .................................................................35 Appendix 3d Cavan ED Triage Figures 2008-2011 ...................................................... 36 Appendix 3e Minor Injury Unit, Monaghan Hospital Figures 2009-2011 ....................... 37 Appendix 3f Cavan Hospital OPD Waiting Time for OPD Appointments...................... 38 Appendix 3g Drogheda Stats........................................................................................ 39 Appendix 4 Resource Requirements .................................................................... 40

CONFIDENTIAL
Glossary
The following definitions were obtained from the Report of the National Acute Medicine Programme1, 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 a wide range of medical conditions who present to a model 4 (tertiary) hospital. Its aim is to provide a dedicated location for the rapid assessment, diagnosis and commencement of appropriate treatment. Physicians, supported by a multidisciplinary team, will carry out patient assessment and treatment. It is envisaged that AMUs will operate on a 24/7 basis. The AMU should be co-located with the ED. Every AMU should have a designated lead consultant physician, clinical nurse manager and therapy lead. If required, patients can be admitted to the short stay medical beds within the unit for a short period for acute treatment and/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 the following 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 service need; and it will not have contiguous short stay medical beds. The AMU/AMAU lead physician is a consultant physician with a special interest in acute 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 model 2 (local) hospital will manage GP referred, differentiated medical patients who have a low risk of requiring full resuscitation. Only patients referred by a GP will be 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 a model 2 hospital. Patients who deteriorate unexpectedly will have guaranteed transfer 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 neurological support) for assessment in the MAU during daytime hours. Patients with a significant risk of clinical deterioration should be referred to the associated model 3 or 4 hospital. However, patients should not be transferred if a Do Not Resuscitate order is made and/or if patients make an informed decision to remain in the model 2 hospital.

CONFIDENTIAL
A decision regarding discharge/admission should be made within 6 hours and will be facilitated by dedicated radiology, laboratory and other services, including nursing, therapy professionals and medical social workers. In the event of discharge, the relevant GP will be informed (on the same day) of the decision together with all relevant clinical details and care plans. Every MAU should have a designated lead consultant physician, who will be jointly appointed to the model 2 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 days per week. The models of hospitals involve 4 levels of acute hospitals in relation to acute medicine patients, as proposed by the national clinical programmes. The models are: model 4 - tertiary hospital; model 3 - general hospital; model 2 local with selected (GP-referred) medical patients; and model 1 community/district.

CONFIDENTIAL
1. Executive Summary
The delivery of safe, quality care in a timely manner and in the appropriate setting has been identified as the aim of the National Acute Medicine Programme1. The programme provides a framework for the delivery of acute medical services which seeks to substantially 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 of both counties. Acute medical services are based in Cavan General Hospital including a new Acute Medical Assessment Unit (AMAU) which opened in 2009. Step down and rehabilitation services are based in Monaghan hospital and also some outpatient services. 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 referred patients. From a local perspective it would be a welcome and convenient development however on current evidence this development is not feasible. To provide the necessary structures 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 at present within current resources. 1.1. Major Issues Identified Monaghan is not a model 2 hospital (c.f. Appendix 2) and as such does not currently 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 staff 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 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 a clear and concise document. The degree of flexibility in relation to the interpretation of this document was the subject of much debate in the group. In the 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 unit was not agreed. As a guide the costings for the AMAU in Cavan are included to illustrate the cost of setting up a unit in a hospital which already has many of the basic requirements.

CONFIDENTIAL
2. Background
The development of Medical Assessment Units in acute hospitals has been a recent successful initiative. It greatly improves the timeliness of treatment for medical patients and streamlines the admission process. Instead of being referred to Emergency Departments (ED) medical patients are admitted to assessment units where they are seen by a senior clinician and have rapid access to appropriate diagnostics. They are then 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 Testing Over days Triage Inpatient Treatment Discharge Evaluation of results Reporting back Timeliness Duration of stay Level of competency of assessor Days Days, weeks or months Depends on bed availability Days Intern to Consultant Same day if performed Same day Same day Hours-depends on triage ED SHO+/- Reg Med SHO+/-Reg Next or other visit Weeks to months Weeks to months Hours Intern to Consultant Day of visit Day of visit Same or next day Hours Consultant ED OPD AMAU/MAU

On attendance

On attendance

In 2009 an Acute Medical Assessment Unit (AMAU) was commissioned for patients in the 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 of Operations, Dublin North East, to establish a representative group to undertake an independent feasibility study of the development of a Medical Assessment Unit (MAU) at Monaghan Hospital. The terms of reference for this group are outlined below:

CONFIDENTIAL
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 services associated 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 to completion.

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 services associated with the establishment and running of a MAU in Monaghan. The project will demonstrate evidence of the local health demographic and local health data of the Monaghan population relevant to medical assessment unit services.

5. Process

The 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. Methodology
The 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

CONFIDENTIAL
7. Medical Assessment Units
In an attempt to provide standardisation nationally, the National Acute Medicine Programme 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 has been 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 decided to 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 present with a wide range of medical conditions. Its aim is to provide a dedicated location for the rapid assessment, diagnosis and commencement of appropriate treatment. Physicians, supported by a multidisciplinary team carry out patient assessments and treatment. This is 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 acute medical conditions.

8. Description of Current Services


Cavan hospital is a general hospital which provides a wide range of services. It fits the description of a Model 3 hospital under the definition in the acute services programme and has an acute medical assessment unit (AMAU) which provides a service to the population 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 20 rehabilitation beds and a wide range of day services. The physician services are provided 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 currently does not meet the criteria for either a model 1 or a model 2 hospital but falls somewhere in between. (c.f. appendix 2)

8.1 Gap Analysis


It has been clearly stated in the report of the National Acute Medicine Programme that a model 1 hospital shall not have an ED, ICU, High dependency unit (HDU) coronary care unit 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 the current situation in Monaghan

CONFIDENTIAL
Table 2
MAU

Gap Analysis for Monaghan in Relation to MAU


Criteria Monaghan Admission currently is requested by consultant/geriatrician. No dedicated area at present Gap There are no acute beds, only rehabilitation and convalescence There is a potential area which could be developed No facility for admission of patients to Monaghan from a unit such as this Patients would have to be transferred to Cavan Limited radiology service Samples couriered to Cavan with subsequent time delay Staffing insufficient to cover MAU There is currently no medical officer on site and no out of hours medical cover No NCHDs are currently assigned to Monaghan Resident medical registrar/SpR and SHO and a consultant on call Additional nursing staff would have to be employed Would have to be recruited Staffing and cost implications

GP referred patients who are at low risk of requiring resuscitation Assessment beds in defined area 4-12 beds/trolleys Admission will be to model 2 hospital

Monaghan is not a Model 2 hospital under the criteria laid down in acute medicine programme

Dedicated radiology Dedicated laboratory Dedicated nursing Designated lead consultant physician NCHD staff NCHD at night Nursing staff Dedicated nurse manager for MAU Operational 8-8 seven days per week

On call x-ray only for Minor injuries unit No laboratory facility on site in Monaghan Dedicated nurses would have to be employed All medical consultants are currently based in Cavan All NCHDs are currently based in Cavan There are no medical staff resident on site at night Limited number of nursing staffmanaged from Cavan Based in Cavan Not available at present

CONFIDENTIAL
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 MAU or general medical suitable for AMAU only The AMAU in Cavan became operational in March 2009. In 2011 the population for the Cavan/Monaghan region was 133,369, Monaghan (60,495) and Cavan (72,874)2 .
Table 3 Attendances at Cavan AMAU by County of Residence
Cavan AMAU Year Total numbers attending 4360 3746 Patients with CAVAN Addresses Numbers attending 2639 (61%) 2273 (61.2%) Daily numbers 10 8.7 Rate per 10,000 of population 3.6 3.1 Patients with MONAGHAN Addresses Numbers attending 1310 (34.5%) 1137 (30.6%) Daily numbers 5 4.3 Rate per 10,000 population 2.1 1.8

2010 2011

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 remainder from other counties.3 In 2011 these figures reflect 3.5 visits per 10,000 population for Cavan and 2.1 visits per 10,000 population for Monaghan. This equates to 3 more patients from Cavan being seen per day than from Monaghan. This discrepancy of 3 patients may be accounted for in Monaghan patients attending Drogheda and other hospitals. To achieve equal rates 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 a different finding. On average 20 patients per month from Monaghan attend Drogheda AMAU. (c.f. Appendix 3)

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CONFIDENTIAL
The type of patient attending would also need to be clearly identified. Only low risk patients would be suitable to attend an MAU and it is not currently possible to determine 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 Monaghan there 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 more comprehensive figures on the issues raised above. Activity data for Cavan/Monaghan is included 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 in Cavan 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 sessional OPD 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 administrative staff 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 the costing for the Cavan AMAU in Appendix 4. The major cost is in relation to pay, approximately 1.2 million. Because the throughput of an MAU in Monaghan cannot be clearly outlined the costings must remain an estimate and although a slightly lesser number of staff may be required the cost would still be substantial. A critical mass of patients is required to make a service cost effective and sustainable and a substantial number of patients would be required to justify such a large resource investment.

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CONFIDENTIAL
11. Discussion
Every community desires a comprehensive medical service in close proximity to them to provide 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 the .4 clinicians to maintain and develop their skills In 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 the equally important step down and rehabilitation facilities. Extensive OPD and day surgery is also a feature of what Monaghan can provide. They also have access to an AMAU in Drogheda Two AMAUs are available and accessible within a reasonable distance to the population of Monaghan. These units would appear to serve the population well as there is no clear 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 six weeks. Further analysis of data would be necessary to give a more definitive conclusion.

12. Conclusion
The population of Cavan/Monaghan have access to a wide variety of acute medical services within a reasonable distance of their residence. Patient safety must remain our priority when deciding where services are located. This is about patients receiving the right 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 as quickly 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 of patients must attend the service available. To develop an MAU in Monaghan at this current time would entail a considerable input of resources and would necessitate moving scarce resources from other services to serve a relatively small number of patients.

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CONFIDENTIAL
References
1. 2. 3. 4. Health Service Executive. Report of the National Acute Medicine Programme, 2010 Central Statistics Office. Reports on Vital Statistics. Yearly summary. Dublin: Central Statistics Office, 2011 Hospital Inpatient Enquiry System. Dublin. The Economic and Social Research Institute, 2011 Hospital volumes and health care outcomes, costs and patient access. Effective Healthcare Bulletin 1996; 2(8):1-8.

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CONFIDENTIAL
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 Hospital Group Mr Gerry Clerkin, Risk Advisor, Cavan & Monaghan Hospital Group (Group Facilitator) 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 Model 14/0311 Status Report Implemented partially implemented Is it feasible to achieve requirement within resources Yes/No Not feasible within resources not implemented Persons who would be responsible for leading on this initiative N/A 23 (39%) 13 (22%) 23 (39%) Status Implemented or Not implemented Additional comments

Characteristics of a Level 2 Hospital

Current status of Monaghan Hospital

Implications of achieving the Characteristics of a level 2 hospital i.e Structural, capacity, resources financial & human Significant resources to facilitate this service. Full Medical team required with anesthetic cover and nursing.

Hospital has a day time MAU

No MAU

Not implemented

GP will refer low risk (i.e. unlikely to require high intensity cardiopulmonary and/or neurological support) medical patients for assessment in the MAU during daytime hours

No MAU

N/A

Not implemented

The Hospital will provide in-patient and out-patient care for differentiated, low risk medical patients, who are not likely to require full resuscitation. All patients will have an appropriate care plan

Patients in the 26 bedded unit are medically discharged and therefore deemed as being low risk. There is an emergency protocol which is to be initiated in the event of patient becoming medically compromised. There is a minor injury unit only with clear criteria for GPs/patients as to what condition will be assessed in the MIU. Treatment plans are in place.

implemented

15

This hospital will not have an ICU, so the patient will be assessed and tracked using the national early warning score (ref section 6.4) and where appropriate, this score will prompt an acute medicine response and if necessary, transfer to the associated model 3 or 4 hospital. A patient's condition may deteriorate and after detection and treatment by acute medicine a patient's acuity may be ICS Level 2 unstable or Level 3 (ref appendix 17.9) requiring critical care retrieval and transfer to ICU in a model 3 or 4 hospital There will be guaranteed acceptance of transfer of all patients who deteriorate by the associated model 3 or 4 hospital (bi-directional patient flow must also occur if required) patients requiring palliative, respite, rehabilitation and predischarge care and patients for direct GP to consultant referral (via MAU) can be admitted to this hospital Patients can be admitted from the MAU under the care of the named consultant and out-of-hours selected medical patients can be admitted by agreement between the GP and the on call medical team /consultant

No ICU, daily obs undertaken routinely on all patients, if pt comes ill Potts score is calculated.

implemented

Not applicable as there is no acute medical team on call.

Non applicable

transfer protocol in place

implemented

Rehabilitation service only for medically discharged patients. Direct referrals from GP not accepted, pre-discharge care not available, no respite,

partially implemented

No MAU

Non applicable

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The medical department and medical staff need to be part of a wider rotation under governance of the acute medicine service in the ISA linked model 3 or 4 hospital. During the day there will be appropriate NCHD presence in the MAU and wards The Medical staffing at night will be a resident medical registrar/SpR and the senior house officer (both of whom are advanced cardiac life support (ACLS) certified). In addition there will be a consultant on call. Nurse staffing at night will include a nurse manager/supervisor for the nursing services. Therapy staffing will be at a senior grade within each therapy discipline with additional therapy resource comprising staff and assistant grade positions. Clinical specialists in ISA model 3 and 4 hospitals will provide advice and /or support as required.

No MAU

Not implemented

Not available

Not implemented

not in place

Not im plemented

in place

implemented

standards of care should be measured and should be comparable to those delivered in model 3 and 4 Hospitals The hospital may have a minor injury unit (MIU)

in place, cross site clinical governance committees oversee the standards of service delivery in each specialty, Medical governance committee to incorporate 26 beds MH in place

partially implemented

implemented

17

The following day services could be made available 5 days a week based on local need.
Day surgery Pre-operative clinics Day services /ambulatory care assessment for older persons Antenatal/Post natal care Endoscopy /PEG tube insertion Non invasive cardiology Cardiac Failure clinic Cardiac Rehabilitation Venesction, infusion and transfusion therapy Bone Marrow aspiration and trephine biopsy Abdominal paracentesis and thoracentesis lumbar puncture Diabetic Day centre Rheumatology day services Dermatology day services Oncology /hematology day ward Mental Health day services COPD outreach Pulmonary rehabilitation Heptatology day services Diagnostic Imaging in place in place falls clinic planned, ante natal only, post natal always carried out by GP endoscopy only in place in place in place in place Not available Not available Not available in place planned 2012 Not available in MH, is available in CGH not available St Davnets site planned 2012-13 in place planned 2014 in place implemented implemented partially implemented partially implemented implemented implemented implemented not implemented not implemented not implemented implemented Not implemented not implemented not implemented implemented Not implemented implemented Not implemented implemented

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other services depending local policies and protocols

ENT, Community audiology, OPD to include Medical, Surgical, Gynae, orthopaedics, Paediatrics, Dental, AHP led services, CNS clinics,

partially implemented

Patient flow will be enhanced by expanded nursing and therapy practice (e.g. nurse prescribing of medicinal products and ionising radiation /xrays and therapy facilitated discharge) These services will be developed in response to service need. Clinical Pharmacy services will be provided by clinical pharmacists attached to model 3 or 4 hospitals All model 1 & 2 hospitals must have an in-house clinical pharmacy service or formal access to and reporting relationship with the service in a model 3 or 4 hospital All hospitals must have a person trained and responsible for infection prevention and control on site and formal access to advice from a consultant microbiologist /infectious disease physician

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

partially implemented

not available

not implemented

Not available

not implemented

in place

implemented

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Consultant physician work practices The consultant physician on-call for the MAU will have a primary responsibility to be present and make management decisions during core working hours. There will be ward rounds every day on all newly admitted patients, patients whose clinical status deteriorates and patients identified for potential discharge. Board rounds (i.e. desktop review of patient status with a view to potential discharge) will occur on all medical patients, once daily before 11am, including Public Holidays and weekends. At least 2 comprehensive ward rounds on all patients should take place weekly.

Current status of Monaghan Hospital in achieving level 2 status

Implications of achieving the Consultant work practices of a level 2 hospital

Is it feasible to achieve requirement within resources Yes/No

Persons who would be responsible for leading on this initiative

Status Implemented or Not implemented

Additional comments

Not available

Not implemented

Not available

Not implemented

Not available

Not implemented

Not available

Not 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 Programmes

Gap 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 clinical protocols. 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 services

GPs, hospital staff and ambulance services will agree the protocols for ambulance 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

Diabetes

Diabetic day care, including chiropody and ophthalmology, may be available.

in place

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Diagnostic Imaging

Plain film X-ray, ultrasound and CT-scanning will be provided. There will be an on-call diagnostic imaging service.

in place on call Xray only for MIU

Endoscopy

Upper and lower gastrointestinal endoscopy and bronchoscopy may be available.

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 be employed 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 lead consultant 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. A full 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 hospitals with appropriate support from the specialist palliative care services as required. Services provided in model 2 hospitals should be sufficiently flexible and integrated with specialist palliative care services to allow rapid and efficient movement of patients from one care setting to another depending on their clinical needs and personal preferences. Admission criteria, discharge protocols and interface with specialist palliative care services will be according to agreed national palliative care programme protocols

OPD only

Primary Care

Direct access for some of the services listed (i.e. radiology, endoscopy, laboratory etc.) as part of agreed protocols.

endoscopy & radiology only, indirect access to laboratory.

Rheumatology

Rheumatology 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 14/0311

Status Report Implemented partially implemented not implemented Is it feasible to achieve requirement within resources Yes/No 24 (62%) 6 (15%) 9 (23 %) Status Implemented or Not implemented Additional comments

Characteristics of a Level 1 Hospital

Current status of Monaghan Hospital

Implications of achieving the Characteristics of a level 1 hospital i.e Structural, capacity, resources financial & human

Persons who would be responsible for leading on this initiative

The hospital will be a community hospital with sub-acute in-patient beds

in place, beds referred to as non-acute beds

implemented

admissions can be requested by a GP, consultant geriatrician and/or consultants following agreement with a medical officer

consultant /geriatrician only not GPs

partially

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patients with rehabilitation, respite and /or complex palliative care needs and patients who remain under the care of GPs may be admitted appropriately to in-patient beds in this hospital. These patients will be managed under the care of a medical officer(e.g. designated GP or groups of GPs) who will be supported as necessary by consultant physicians. All patients have an appropriate care plan. This hospital will not have an ED, ICU, high dependency unit (HDU), coronary care unit or an AMU/AMAU/MAU

Rehabilitation only, service not available to respite or palliative care patients, medical officer is under discussion

partially

in place,

implemented

As this hospital will not have an ICU, patients requiring a higher level of care will be transferred to the ISA model 2,3 or 4 hospital

in place

implemented

25

there will be guaranteed transfer of patients whose clinical status deteriorates from the model 1 hospital to the ISA model 2, 3, or 4 hospital (s). Where a patient is critically ill (ICS levels 2 & 3), the regional critical care retrieval team will effect safe transfer. Remote critical care retrieval will include continued resuscitation, stabilisation and safe transport by the retrieval team (ref appendix 17.9).

in place

implemented

Patients whose clinical status has improved sufficiently may be transferred from a model 3 or 4 hospital to a model 1 or 2 hospital for further cae (bidirectional patient flow must also occur). However, patients should not be transferred is a "Do not resuscitate" order is made and/or if patients make an informed decision to remain in the model 1 hospital.

in place

implemented

26

The following day services could be made available 5 days a week based on local need.
Out patient department (OPD) Day services /ambulatory care assessment for older persons Venesection / phlebotomy warfarin service COPD outreach Pulmonary rehabilitation Cardiac Failure clinic Supra-pubic catheter reinsertion percutaneous endoscopic gastrostomy (PEG) tube reinsertion Antenatal/postnatal services other services depending local policies and protocols Many of these services will be nurse led and /or therapy led with expansion of nursing and therapy practice in response to service need Clinical Pharmacy services will be provided by clinical pharmacists attached to model 3 or 4 hospitals in place falls clinic planned, in place in place planned for 2014 + in place in place in place (replacement of Supra-pubic catheter) no antenatal in place post natal undertaken by GPs ENT other services will be introduced depending local policies and protocols implemented not implemented implemented implemented not implemented implemented implemented implemented not implemented implemented Partially implemented

in place

implemented

no clinical pharmacy

not implemented

27

All model 1 & 2 hospitals must have an in-house clinical pharmacy service or formal access to and reporting relationship with the service in a model 3 or 4 hospital All hospitals must have a person trained and responsible for infection prevention and control on site and formal access to advice from a consultant microbiologist /infectious disease physician

not available

not implemented

in place

implemented

Consultant physician work practices

Current status of Monaghan Hospital in achieving level 2 status

Implications of achieving the Consultant work practices of a level 2 hospital

Is it feasible to achieve requirement within resources Yes/No

Persons who would be responsible for leading on this initiative

Status Implemented or Not implemented

Additional comments

The medical officer (s) or his /her deputy, will carry out weekday ward 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 and medical officer is planned

partially

28

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 patients with a suspected acute coronary syndrome should not be admitted to or treated in a model 1 hospital except under defined circumstances Gap analysis

Acute cardiology

in place

Ambulance services

GPs, 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 provided

Not available to in patients, provided for Day services ENT, Gynae, Surgery and pre-operative assessment

Asthma

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

in place

COPD

Out reach programmes and pulmonary rehabilitation may be available

rehabilitation only

29

Diabetes

Diabetic clinics 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's disease).

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 be employed on site. Formal access to advice from a consultant microbiologist/infectious diseases physician is required. Medical officers will manage patients with heart failure according to guidelines. The hospital may provide ambulatory services for diagnostics and OPD management of heart failure. ambulatory care assessments for older persons may be provided on site. Out patient clinics may be available 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 care services will be according to agreed national palliative care programme protocols

part time cover from a cross site IPCT

Heart Failure

in place

Medicine for Older people

planned for 2015 +

Mental Health services

on St Davnets site

Palliative Care

Not in place

30

Primary Care

Close liaison with GPs and Primary care teams with regard to direct access for services admission criteria and discharge policies and procedures

Not in place

Rheumatology

Rheumatology out-patient services will be linked to the nearest rheumatology unit

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

Stroke

The hospital may have a stroke rehabilitation unit on site

stroke rehabilitation service in place, no dedicated stroke unit

Surgery

Surgical OPD may be available

in place

31

Appendix 3a
YEARLY STATS

Cavan & Monaghan Hospital Yearly Stats 2008 2011

CAVAN/MONAGHAN HOSPITAL GROUP Items marked in red are Jan-Nov 2011 figures 2008 CGH Site Admissions Surgical Medical Paeds Obs Gynae Rehab Stepdown Psychiatry Total Births Daycases Surg General Surg Endoscopy Medical Gen Med Endoscopy *Other Total Daycases Outpatients New Review Total 3297 4877 1729 3064 746 0 0 131 13844 1957 MH Site 0 2431 0 0 0 0 0 0 2431 0 Cross Site Total 3297 7308 1729 3064 746 0 0 131 16275 1957 CGH Site 2937 6220 1626 3164 739 0 0 140 14826 1945 2009 MH Site 0 1400 0 0 0 67 98 0 1565 0 Cross Site Total 2937 7620 1626 3164 739 67 98 140 16391 1945 CGH Site 2566 7136 1636 3080 693 0 0 108 15219 2032 2010 MH Site 0 0 0 0 0 157 264 0 421 0 Cross Site Total 2566 7136 1636 3080 693 157 264 108 15640 2032 CGH Site 2588 6696 1630 3152 539 0 0 112 14717 1879 2011 Jan-Dec MH Site 0 0 0 0 0 113 245 0 358 0 Cross Site Total 2588 6696 1630 3152 539 113 245 112 15075 1879

784 2439 597 299 13098 17217

1381 1316 556 1585 73 4911

2165 3755 1153 1884 13171 22128

813 2450 522 256 14426 18467

1524 1538 700 1325 56 5143

2337 3988 1222 1581 14482 23610

808 2852 724 259 13708 18351

1689 1495 946 1088 109 5327

2497 4347 1670 1347 13817 23678

766 2915 755 287 14105 18828

1772 1017 841 1128 123 4881

2538 3932 1596 1415 14228 23709

9998 29161 39159

3455 12256 15711

13453 41417 54870

9602 29672 39274

3574 11562 15136

13176 41234 54410

10085 28955 39040

3510 10793 14303

13595 39748 53343

8804 29575 38379

3188 10069 13257

11992 39644 51636

32

X-Ray Inpatients Outpatients Total A&E New Review Total MITU New Review Total MAU Attend only Admitted Total Attended

11089 38098 49187

6119 12744 18863

17208 50842 68050

13898 39201 53099

4538 10954 15492

18436 50155 68591

16115 39519 55634

2376 10565 12941

18491 50084 68575

15848 37016 52864

658 13596 14254

16506 50612 67118

25285 1830 27115

9540 2374 11914

34825 4204 39029

26400 1777 28177

5105 1154 6259

31505 2931 34436

25742 1990 27732

0 0 0

25742 1990 27732

26609 1968 28577

0 0 0

26609 1968 28577

0 0 0

0 0 0

0 0 0

0 0 0

1808 406 2214

1808 406 2214

0 0 0

5446 1438 6884

5446 1438 6884

0 0 0

6595 1542 8137

6595 1542 8137

0 0 0

0 0 0

0 0 0

1217 2219 3436

0 0 0

1217 2219 3436

1734 2626 4360

0 0 0

1734 2626 4360

1687 2059 3746

0 0 0

1687 2059 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

33

Appendix 3b Cavan Hospital MAU Stats 2009 2011


2009
Description Attend only Admitted Total Attendance Jan 0 0 0 Feb 0 0 0 Mar 8 5 13 Apr 75 208 283 May 130 232 362 Jun 124 226 350 Jul 125 300 425 Aug 136 264 400 Sep 109 266 375 Oct 172 244 416 Nov 174 253 427 Dec 164 221 385 Y.T.D. 1217 2219 3436

2010
Description Attend only Admitted Total Attendance Jan 133 216 349 Feb 148 202 350 Mar 149 225 374 Apr 177 227 404 May 183 200 383 Jun 138 237 375 Jul 126 230 356 Aug 139 260 399 Sep 167 224 391 Oct 147 206 353 Nov 116 206 322 Dec 111 193 304 Y.T.D. 1734 2626 4360

2011
Description Attend only Admitted Total Attendance Jan 106 156 262 Feb 108 202 310 Mar 124 187 311 Apr 99 105 204 May 140 228 368 Jun 137 188 325 Jul 140 151 291 Aug 164 173 337 Sep 132 172 304 Oct 174 129 303 Nov 180 208 388 Dec 183 160 343 Y.T.D. 1687 2059 3746

34

Appendix 3c Cavan ED Figures 2008 2011


2008
Description New Review Total Jan 1959 114 2073 Feb 1871 123 1994 Mar 2075 154 2229 Apr 2221 160 2381 May 2351 188 2539 Jun 2156 146 2302 Jul 2228 154 2382 Aug 2096 165 2261 Sep 2098 142 2240 Oct 1995 156 2151 Nov 1970 155 2125 Dec 2265 173 2438 Y.T.D. 25285 1830 27115

2009
Description New Review Total Jan 1978 114 2092 Feb 1997 118 2115 Mar 2336 146 2482 Apr 2331 157 2488 May 2344 161 2505 Jun 2221 148 2369 Jul 2243 162 2405 Aug 2195 155 2350 Sep 2171 140 2311 Oct 2268 150 2418 Nov 2118 153 2271 Dec 2198 173 2371 Y.T.D. 26400 1777 28177

2010
Description New Review Total Jan 2021 168 2189 Feb 1894 124 2018 Mar 2319 137 2456 Apr 2205 143 2348 May 2334 151 2485 Jun 2135 180 2315 Jul 2250 161 2411 Aug 2140 172 2312 Sep 2236 196 2432 Oct 2124 212 2336 Nov 2037 197 2234 Dec 2047 149 2196 Y.T.D. 25742 1990 27732

2011 Description New Review Total Jan 2257 186 2443 Feb 2019 171 2190 Mar 2262 165 2427 Apr 2317 132 2449 May 2265 161 2426 Jun 2195 157 2352 Jul 2137 130 2267 Aug 2287 163 2450 Sep 2212 163 2375 Oct 2215 159 2374 Nov 2217 193 2410 Dec 2226 188 2414 Y.T.D. 26609 1968 28577

35

Appendix 3d Cavan ED Triage Figures 2008 2011


Description P1 P2 P3 P4 P5 Dressings Physician Review Code Not Entered Jan 6 282 1002 626 16 14 19 131 Feb 8 264 1005 519 5 7 17 92 Mar Apr 14 2 332 1153 586 5 14 19 115 330 1090 748 10 9 23 142 2008 May Jun 3 19 326 1138 835 12 24 28 186 410 1131 547 19 7 32 137 Jul 11 405 1022 710 4 13 25 135 Aug 8 294 989 812 9 11 26 92 Sep 13 323 1053 683 11 6 32 131 Oct 9 345 1110 610 6 10 32 135 Nov 11 314 1046 582 4 16 29 125 Dec 22 350 1279 620 9 10 32 128 Y.T.D. 126 3975 13018 7878 110 141 314 1549

2009
Description P1 P2 P3 P4 P5 Dressings Physician Review Code Not Entered Jan 15 280 1068 568 4 6 18 132 Feb 4 352 1073 549 15 8 22 141 Mar 2 366 1227 651 5 3 31 197 Apr 10 370 1378 551 2 3 21 164 May 12 417 1334 601 3 4 21 123 Jun 8 413 1269 571 4 3 25 94 Jul 12 390 1336 543 7 6 20 98 Aug Sep 16 11 398 363 1233 1282 551 543 7 6 4 4 34 16 108 88 Oct 15 444 1278 543 9 13 27 82 Nov Dec 14 19 376 430 1273 1351 517 450 6 8 4 10 20 28 94 94 Y.T.D. 138 4599 15102 6638 76 68 283 1415

2010
Description P1 P2 P3 P4 P5 Dressings Physician Review Code Not Entered Jan 17 344 1246 461 3 8 20 82 Feb 14 351 1094 455 5 3 18 79 Mar 10 380 1233 618 3 4 21 177 Apr 9 355 1308 528 6 4 15 110 May 10 352 1411 581 6 2 20 81 Jun 12 355 1112 579 8 6 25 234 Jul 14 366 1342 581 4 5 22 86 Aug 10 319 1199 667 7 4 33 87 Sep 11 343 1289 625 5 4 42 108 Oct 7 363 1208 502 3 9 29 237 Nov 12 334 1334 434 3 7 20 84 Dec 18 360 1273 430 3 8 14 93 Y.T.D. 144 4222 15049 6461 56 64 279 1458

2011
Description P1 P2 P3 P4 P5 Dressings Physician Review Code Not Entered Jan 16 386 1371 537 3 5 17 139 Feb 13 371 1241 453 3 12 11 100 Mar 18 343 1267 639 4 7 20 138 Apr 17 343 1353 548 3 4 12 171 May 6 356 1347 568 7 8 17 126 Jun 8 338 1237 583 2 10 10 172 Jul 7 332 1309 450 2 7 15 146 Aug 24 356 1410 493 8 4 14 160 Sep 11 337 1369 474 2 3 13 195 Oct 18 337 1368 441 5 1 18 218 Nov 19 354 1400 416 4 2 11 234 Dec 20 394 1342 490 14 10 16 138 Y.T.D. 177 4247 16014 6092 57 73 174 1937

36

Appendix 3e

Minor Injury Unit, Monaghan Hospital Figures 2009 2011


2008
Jan 786 235 1021 210 Feb 728 208 936 189 Mar 789 204 993 176 Apr 910 178 1088 192 May 963 184 1147 199 Jun 892 244 1136 201 Jul 817 228 1045 186 Aug 787 183 970 167 Sep 796 169 965 186 Oct 701 162 863 196 Nov 635 177 812 198 Dec 736 202 938 213 Y.T.D 9540 2374 11914 2313

Description New Review Total Admissions thru

2009-Treatment Room Description New Review Total Admissions thru Jan 726 244 970 229 Feb 645 202 847 188 Mar 764 235 999 221 Apr 810 212 1022 209 May 816 96 912 222 Jun 835 98 933 215 Jul 509 67 576 92 Aug 0 0 0 0 Sep 0 0 0 0 Oct 0 0 0 0 Nov 0 0 0 0 Dec 0 0 0 0 Y.T.D. 5105 1154 6259 1376

2009 -MITU
Description New Review Total Jan Feb Mar Apr May Jun Jul 77 13 90 Aug 365 39 404 Sep Oct 368 356 87 91 455 447 Nov 324 89 413 Dec 318 87 405 Y.T.D. 1808 406 2214

MITU 2010 2010


Description New Review Total Jan 333 108 441 Feb 297 77 374 Mar 397 120 517 Apr 507 143 650 May 578 182 760 Jun 481 171 652 Jul 492 184 676 Aug 469 120 589 Sep 469 102 571 Oct 532 35 567 Nov 421 85 506 Dec 470 111 581 Y.T.D. 5446 1438 6884

MITU 2011 2011


Description New Review Total Jan 414 112 526 Feb 393 97 490 Mar 549 110 659 Apr 619 179 798 May 630 181 811 Jun 647 180 827 Jul 750 85 835 Aug 700 113 813 Sep 605 146 751 Oct 564 149 713 Nov 430 101 531 Dec 294 89 383 Y.T.D. 6595 1542 8137

37

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 in weeks Specialty General Medicine Consultant Dr. Hayes Dr. Pinherio Dr. Pinherio MH Dr Sheikh Dr Murugasu Dr Muthu Dr. Muthu MH Dr Mac Mahon Dr. McDermott Dr. Smith Dr. Hannon 0 to 12 79 18 26 72 17 23 16 58 15 22 38 Wait in weeks 13 to 25 85 5 38 18 10 10 8 77 10 15 27 Wait in weeks 26 to 39 63 0 12 4 0 5 2 70 2 4 5 Wait in weeks 40 to 52 9 2 3 0 2 0 1 23 2 4 2 Wait in weeks Greater than 52 3 0 0 0 1 0 0 0 0 0 1 Wait in weeks Total 239 25 79 94 30 38 27 228 29 45 73 907

Total

384

303

167

48

907

38

Appendix 3g

Drogheda Statistics

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

2011 Month January February March April May June July August September October November December No of Patient 14 19 23 18 13 24 26 21 26 18 21 19

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

39

Appendix 4

Resource Requirements for Setting up the AMAU in Cavan


NAME OF AGENCY Cavan General Hospital AMAU WTE 3.00 1.00 0.00 SALARY 34,178 69,850 COST 102,534 69,850 0

GRADE OF POST Administration Clerical Grade 3 - Wards Clerk - 9 to 5 Mon to Sun Bed Manager Grade 7 (33hrs)

Medical & Dental Consultant Radiologist Nursing CNM II CNM II Staff Nurses Chest Pain Nurse (CNS) Allied Health Professionals Radiographer 0.50 0.00 0.00 0.00 0.00 0.00 Support Services Attendants Other Pay TOTAL PAY COSTS 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) Please include any additional non pay costs if not adequately refelected in the 70:30% above 2 contract computers 1 Photocopier 2,200 4,500 547,658 19 1,277,870 2.58 37,915 97,821 66,718 66,718 66,718 66,718 66,718 66,718 33,359 0 0 0 0 0 1.00 1.00 7.15 1.00 69,111 59,210 48,500 59,210 69,111 59,210 346,775 59,210 1.00 1.00 220,000 220,000 220,000 220,000

40

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