Building the case to invest in emergency department infrastructure

Will the construction of new emergency departments alleviate the chronic problem of crowding? Paul Mulholland reports

Emergency department (ED) crowding has been a chronic issue in the Irish health service for decades, drawing criticism of successive governments and media headlines. The problem shows no sign of abating, with the Irish Nurses and Midwives Organisation (INMO) stating that over 122,000 patients were treated on trolleys in hospitals in 2024.

The reasons have been identified for some time: ED crowding has been linked repeatedly to deficits in staffing and capacity.

Capacity deficits are not isolated to EDs, but reflect broader challenges within the overall hospital system. However, the issue of crowding has highlighted the limitations of the health service’s existing ED infrastructure.

The five most crowded hospitals in 2024 were: University Hospital Limerick (UHL); Cork University Hospital (CUH); University Hospital Galway (UHG); Sligo University Hospital; and St Vincent’s University Hospital in Dublin.

One of these hospitals is planning to build a new ED (UHG) and a second ED is being contemplated for the mid-west, such is the scale of the problem at UHL. In addition to the construction of new EDs, the HSE Capital Plan 2024 included projects to extend other departments (see panel below).

IAEM

“There is no doubt that one of the focuses we have had in the emergency medicine community has been on highlighting to the system the absolute need for inpatient beds,” the President of the Irish Association for Emergency Medicine (IAEM), Prof Conor Deasy, told the Medical Independent (MI).

Prof Deasy, who is Consultant in Emergency Medicine at CUH, pointed out that approximately 25 per cent of patients who attend EDs require inpatient admission. The remaining 75 per cent of attendees are discharged from EDs after being seen and treated in the departments. This highlights the importance of ensuring that EDs maintain a high standard of infrastructure to effectively support patient care and flow.

However, “more often than not, we do not have the physical infrastructure to deal with the volume of patients that come through the doors as it currently stands,” he said.

Prof Deasy explained there are international standards pertaining to ED infrastructure.

With this in mind, the IAEM sought to develop standards for ED design and specification within Ireland. The Association commissioned Archus, a healthcare design firm, for the project. Archus worked alongside an IAEM working group to produce a series of recommendations for officials involved in developing EDs in the Irish health service over the coming decade. The resulting document, Standards for Emergency Department Design and Specification for Ireland, was published in August 2024. It covers a range of areas including: Spatial requirements, layout, care pathways, infection control, information technology, and carbon emissions (see panel p5).

Prof Deasy said it was essential that clinicians were involved in producing the recommendations.

“We wanted to make sure, in the first instance, that consultants in emergency medicine could talk the same language as healthcare designers, healthcare architects, healthcare engineers; that they knew what the international situation was as regards to standards,” he explained.

“And hopefully this document is going to be a resource that can be used by funders as well as clinicians, as well as healthcare designers and architects, who might be involved in developing infrastructure for emergency departments in Ireland.”

Planning

Mr Conor Ellis is Director of Health Planning and Delivery at Archus Ireland. He said once projects are approved within the health system there is often “a desperate desire” to move forward into the design and construction phases as quickly as possible.

“Sadly, too often, when we work around the world, we note that the initial design planning work has been undertaken at a very high level rather than looking at the care pathway and completing the clinical specification to enable a real focus on achieving good quality spaces that match patient, staff and logistic movement,” Mr Ellis told MI.

“We know the further one progresses design and build, the higher the costs of changes and time delays.”

He said there are specific challenges in terms of planning for new EDs.

“Most Irish EDs are undersized versus most other countries we work in due to the age and growth in population and attendance type that has occurred since they were last substantially upgraded by the HSE,” Mr Ellis said. He added that many of these upgrades might not have occurred since the 1980s, 1990s, or early 2000s.

Space

To understand how to calculate space allocation for a new ED, it is essential to reflect demographics and the acuity levels of patients who will be attending, according to the IAEM document. It states there is a need to recognise the projected population growth in the area served and incorporate healthcare trends into planning. 

It is also important to examine factors beyond demographics. These include any ‘left-shift’ initiatives in the area (strategies aiming to deliver care earlier in the patient pathway) and the provision of related services, such as rapid assessment and treatment facilities and acute medical assessment units.

The document sets out a series of spatial requirements for various facilities within an ED. For example, the minimum acceptable floor area for both the ambulance entrance and the ambulance handover area should be 12m² each. The document states the floor area for an ambulatory care consultation room should not be below 16m². In addition, the minimum floor area for a triage/assessment cubicle should be 12m². However, “for flexibility, consider 16m² as the additional space facilitates greater case mix”, according to the document.

Prof Deasy said these spatial recommendations deserve to be highlighted.

“All too often, we are compromising patient care because large volumes of patients are coming to emergency departments that were never designed to see that volume… at a given time. Then we are putting patients at risk by treating them in a substandard environment,” according to Prof Deasy.

The issue of space is particularly important in a post-Covid-19 environment.

“It has put a lot more emphasis on the need for single-rooms, and single spaces, and infection prevention and control.”

Prof Deasy said the publication of the document is timely given some hospitals are planning, or considering, the construction of new EDs.

UHG is one such hospital. A new department for the region was proposed over a decade ago, but progress has been slow.

In October 2022, the ED moved to a temporary location in preparation for the new building.

At the time, Ms Chris Kane, General Manager, Galway University Hospitals (GUH), said: “Our current ED service is not resourced for the increased population and the changing demographics with growing levels of attendance by those aged 75 and over, which is a trend that will continue.”

Problems with crowding have persisted. UHG was the third most crowded hospital in the country in 2024, with 10,983 patients on trolleys.

But the process of developing the new ED has not been straightforward. In January 2024, outgoing Minister for Health Stephen Donnelly provided Independent Deputy Catherine Connolly with an update on the development. According to the Minister, the Department of Health carried out a review of the strategic assessment report (SAR) for the proposal and returned it to the HSE with feedback in June 2023.

The findings of this review were incorporated into a SAR/preliminary business case (PBC), which the HSE approved and submitted to the Department of Health for review in November 2023. In line with the requirements of the new infrastructure guidelines, which have replaced the public spending code, this SAR/PBC had to be subject to an external assurance process and presented to the Department of Public Expenditure, NDP Delivery and Reform’s major project advisory group, in addition to the Department of Health’s review.

The new ED is one of a number of infrastructural projects for hospitals within the Saolta University Health Care Group.

A Saolta spokesperson told MI that a GUH capital programme oversight board was established by the Group CEO in late 2023.

A design team has been appointed to develop the masterplan and a project manager took up post in July 2024.

The health planning team for UHG, which is led by Deloitte in partnership with MJ Medical, has consulted with clinical teams and the capital oversight group to ensure that the overall design/clinical scoping brief reflects best practice, the spokesperson said.

In response to a question from MI on whether the IAEM standards will be incorporated into the design of the new ED, the spokesperson pointed out that HSE Capital and Estates had no involvement in the IAEM’s document.

“When undertaking the design of new health infrastructure, the HSE considers all relevant national and international standards current at that time in addition to project-specific health planning/modelling,” they said.

The spokesperson was unable to provide a timescale for the project.

Dr James Foley is Consultant in Emergency Medicine at UHG and was also a member of the working group that developed the IAEM document. Dr Foley told this newspaper that he hopes the recommendations will be considered for the new ED.

He highlighted that the current temporary ED is not large and a number of cubicles are below the recommended size.

“You need to have adequate space to see people when they come in quickly, but also to allow them to go through their stay in ED in a structured manner which doesn’t impede further patients to come in. But if you don’t have the infrastructure, you are restricted. And you can move patients and move staff, but if you can’t move walls, it’s very difficult to improve your flow and your efficiency overall.”

Dr Foley noted that, based on conversations with colleagues, health management has listened to the views of consultants about how the new ED should be configured.

“You would keep your fingers crossed that they would take our input into consideration.”

However, he stressed that further inpatient capacity was also required in addition to the new building.

“You still need flow; you still need beds for the hospital,” Dr Foley said.

“The key thing is that we get an efficient building for our service. But it’s also recognising that trolleys may still be here. So there has to be something put in place in the hospital as well that allows the new ED not to be bed-blocked, similar to Limerick.”

[The pandemic] has put a lot more emphasis on the need for single-rooms, and single spaces, and infection prevention and control

Beaumont

Beaumont Hospital in Dublin is also planning to construct a new ED. Planning permission for the two-storey building was submitted in October 2024. As the projected cost is less than €200 million, the process was managed through the HSE capital development procedure rather than requiring direct submission to the Department of Health or Government for approval.

The facility will provide over 6,500m² of new clinical accommodation, comprising 54 treatment spaces, diagnostics, support accommodation, and staff support and bereavement support spaces.

A spokesperson for the hospital told MI the IAEM publication was reviewed and taken on board in the design process. 

“The recommendations were also referenced in discussions within the internal stakeholder engagements,” according to the spokesperson.

A comparison of the IAEM standards and the ED design was conducted by the architects for the Beaumont project, Moloney O’Beirne Architects/Cullen Payne Architects. The comparison document, which was seen by this newspaper, outlined that the new ED will exceed the minimum requirements outlined by the IAEM across a number of areas (ambulance access, triage, and resuscitation rooms). It also meets the minimum requirements in a range of other areas (treatment/major/urgent areas, multi-disciplinary assessment areas, diagnostic imaging, and isolation rooms.) Two mental health treatment rooms of 16m² and two mental health interview rooms of 12m² will be provided, which align with the IAEM standards. The new Beaumont ED has also been designed to meet the HSE’s net zero carbon emissions policy.

The comparison noted, however, that some of the specifications were not directly applicable. For instance, recommendations concerning eye casualty and ENT rooms could not be compared as these facilities were not contained in the design brief. It also pointed out that the ED does not contain a paediatric function and therefore does not have dedicated child areas as recommended by the IAEM.

Another member of the IAEM working group, and Honorary Secretary of the Association, Dr Owen Keane, is Consultant in Emergency Medicine at Beaumont.

He said currently the hospital ED “is no different” to many others in the country “in that we are infrastructurally challenged in terms of space to see the next patient”.

“But what we know is that when we have space to see patients in any emergency department in Ireland, we’re very good at getting to them,” Dr Keane told MI.

“Where we’re hindered, where things become very difficult, is when departments are overcrowded.”

Dr Keane said he “passionately” believes the crowding of admitted patients in EDs is “fixable”.

“It just becomes so difficult to see the next patient, if that cubicle space, or that clinical space, is occupied by an admitted patient who could be on the ward. So, health infrastructure investment in Ireland needs to increase; it needs to improve. But I do feel it will do so.”

In terms of the IAEM document, he highlighted the recommendation concerning the post-triage space.

“It’s how quickly we can front-load our diagnostics, front-load our senior decisions, as close to the patient’s arrival point as possible,” Dr Keane said.

“We know we have data that shows that when we do that, when we get that space and infrastructure married with process right at the earliest point in the patient’s journey, their journey is quicker. It’s more efficient and safer.”

Dr Keane also referred to how the IAEM document makes recommendations regarding support for staff in terms of rest and teaching facilities.

We know that when you don’t invest in the acute bed capacity of busy acute hospitals, things grind to a halt very quickly

Limerick

All three doctors that MI spoke to for this feature referenced the ongoing crowding crisis in UHL. In 2024, UHL was the most crowded hospital in the health service, with 23,203 patients waiting on trolleys.

The problem has shown the limitations of what can be achieved by new ED infrastructure. In May 2017, UHL opened the largest department in the country. The €24 million ED facility, which spans 3,850m², is over three times the size of the old department. At the time of opening, additional staff were recruited to work in the department. Despite this, the crowding problem in the hospital has not been relieved.

“The big issue in Limerick is, despite getting a new emergency department, they don’t have the beds in the hospital to facilitate the flow of patients who have been admitted, such that they can leave the emergency department in a timely manner,” Prof Deasy said.

“So the investment… isn’t being realised because the space is all getting taken up by admitted patients.”

He said that frequently the ED is not being used as an ED, but rather as an inpatient ward.

Dr Foley agrees with this assessment.

“You can build a shiny new ED, you can get more consultants, but ultimately, if you don’t have beds in the hospital, then you don’t have beds.”

Dr Keane said that “all of the evidence will tell you that unless the acute bed capacity is there in the system, in house, up house, then the emergency department and emergency medicine specialists working on the frontline will only be able to do so much”.

Second ED?

In May 2024, it was announced that Minister Donnelly requested HIQA to initiate a review into urgent and emergency care capacity in the mid-west region. This review will include an inquiry into whether a second ED is required within the region.

A statement from the Department of Health, accompanying the announcement, noted smaller EDs in the region closed 15 years ago. It said this was based on the “very clear clinical advice at the time” in regard to the “relationship between emergency teams providing high volume of service and better outcomes”.

However, the Department stated that since those “clinical decisions” were made, the population in the mid-west has grown considerably. In addition, it stated the population was older than in most other regions.

The Department added that there had been “record increases” in investment in UHL during the lifetime of the then Government, with 108 beds having opened since January 2020.

Since 2019, UHL has also had an increase in staffing by approximately 30 per cent, or 1,200 staff. This has included additional emergency consultants, NCHDs, and nurses in the ED.

However, despite these interventions, crowding in the ED has continued. Trolley numbers had increased by 39 per cent from the beginning of 2024 to the time of the Department’s statement.

Regarding the HIQA review, the Authority was asked to consider the recommendations of the HSE-commissioned review by former Chief Justice Frank Clarke into the circumstances surrounding the death of Ms Aoife Johnston at UHL in December 2022. It will also bring into consideration related reviews and its own previous investigations.

A final report will be provided to the Minister in summer 2025. To inform the review, HIQA has been undertaking a public consultation which is open until 15 January 2025.

Regarding the national picture, Dr Keane reiterated the importance of expanding inpatient capacity as well as community supports.

“You must have the egress points to send patients once the decision to admit has happened, you must have then the decanting and stepdown facilities in the community to keep that circle of flow moving,” he said.

“We know that when you don’t invest in the acute bed capacity of busy acute hospitals, things grind to a halt very quickly.”