Question 1 (Deputy Denis Naughten)
To ask the Minister for Health & the HSE the location of each acute stroke unit which has 24/7 access to thrombolysis; the thrombolysis rate at each acute hospital and the plans to increase this rate in each of the hospitals concerned- Deputy Naughten
Part A – To ask the Minister for Health & the HSE the location of each acute stroke unit which has 24/7 access to thrombolysis;
Response:
As stroke thrombolysis has a narrow risk-benefit margin, it requires availability of advanced brain imaging and input from a senior doctor trained in emergency stroke care on a 24/7 basis. Therefore it is not feasible to deliver this service at all hospitals. The populations served by those hospitals where thrombolysis is not performed are provided a service via immediate ambulance transport to hospitals where the service is available, per regional and national protocols.
The following table sets out the location of each of the acute units and which unit has 24/7 access to thrombolysis:
HSE Area / Hospital / Provides Stroke Thrombolysis Service / Stroke Unit /DML / AMNCH, Tallaght / YES / Combined- Acute/Rehab
Midland Regional Hospital Mullingar / YES / Acute
Naas General Hospital / YES / Combined- Acute/Rehab
St James's Hospital / YES / Acute
St Vincent's University Hospital / YES / Combined- Acute/Rehab
North East / Beaumont Hospital / YES / Combined- Acute/Rehab
Cavan General Hospital / YES / Combined- Acute/Rehab
Connolly Hospital Blanchardstown / YES / Acute
Mater Misericordiae Hospital / YES / Combined- Acute/Rehab
Navan General Hospital / NO / YES
Our Lady of Lourdes Hospital, Drogheda / YES / Combined- Acute/Rehab
South / Bantry General Hospital / YES / Combined- Acute/Rehab
Cork University Hospital / YES / NO
Kerry General Hospital / YES / NO
Mercy University Hospital / YES / Combined- Acute/Rehab
South Tipperary General Hospital Clonmel / YES / Acute
St Lukes' Hospital Kilkenny / YES / Combined- Acute/Rehab
Waterford Regional Hospital / YES / Acute
Wexford General Hospital / YES / Combined- Acute/Rehab
West / Letterkenny General Hospital / YES / Combined- Acute/Rehab
Mayo General Hospital / YES / Acute
Sligo General Hospital / YES / Acute
Portiuncula Hospital, Ballinasloe / YES / Acute
Roscommon General Hospital / NO / Rehab
University College Hospital Galway / YES / Combined- Acute/Rehab
Mid Western Regional Hospital, Dooradoyle / YES / Interim Stroke Unit
Combined- Acute/Rehab
The National Stroke Programme is currently evaluating the level of function of stroke units and planning an audit for September/October which will include reviewing the structure, process and outcome of care for stroke patients, including thrombolysis rates.
In relation to the availability of a 24/7 service, the evaluation of the level of function of stroke units referred to in the original response has just been completed and 23/24 hospitals that responded (95.8%) reported that they offered 24/7 thrombolysis. In the hospital where thrombolysis cannot be delivered 24/7 patients are transferred directly to a neighbouring hospital.
Part B - The thrombolysis rate at each acute hospital and the plans to increase this rate in each of the hospitals concerned
Response:
Rates can vary substantially from quarter to quarter and from hospital to hospital due to the small number of patients’ eligible and treated in some hospitals, therefore the national rate is the more reliable rate.
The Quality and Patient Safety Directorate carried out an audit in 2012 and found an overall stroke thrombolysis rate of 9.5%. This rate is similar or better than national rates from other developed countries and the increase from 3.3% in late 2008/2009 is one of the most rapid increases reported internationally.
This success was recently reported at the European Stroke Conference in London and is due in no small part to work of stroke clinicians and specialist nurses around the country. The National Stroke Programme continues to empower local clinicians to increase thrombolysis rates, by providing access to telemedicine, education and national protocols.
Note re: The evaluation of the level of function of stroke units
The evaluation of the level of function of stroke units has been completed and the report is being finalised.
Question 2 (Deputy Denis Naughten)
To ask the Minister for Health & the HSE the current response times for ambulance services in each HSE region and each county; the specific steps which are being taken in each region & county to improve these response times
Response:
The HSE National Service Plan 2013 set out performance targets for response times, based on HIQA’s suite of performance indicators.
Life-threatening or potentially life-threatening calls account for approximately 40% of all 112/999 emergency ambulance calls in Ireland. 60% of emergency calls are excluded from response time KPIs, as they are neither life-threatening nor serious.
112/999 emergency calls are classified by clinical status, as follows.
§ Clinical Status 1 ECHO calls (life-threatening cardiac or respiratory) should have a patient carrying vehicle at the incident within 18 minutes 59 seconds (HIQA target is 85%)
§ Clinical Status 1 DELTA calls (life-threatening other) should have a patient carrying vehicle at the incident within 18 minutes 59 seconds (HIQA target is 85%)
The latest available data published in April 2013 is as follows:
Emergency Response Times / NSPTarget 2013 / NAS Performance / Leinster / West / South /
Clinical Status 1 ECHO incidents responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less (HIQA target 85%) / 70% / 62.8% / 66.27% / 77.50% / 81.48%
Clinical Status 1 DELTA incidents responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less (HIQA target 85%) / 68% / 61.89% / 68.21% / 60.97% / 63.78%
It is widely recognised that sole reliance on response times is restrictive and a poor measure of ambulance service work. Most jurisdictions are now preparing to move to clinical outcome indicators, as a truer reflection of the work of a modern ambulance service. For Ireland, this means developing a robust suite of clinical outcome KPIs. This work is underway and is expected to be completed by early 2014. The core issue will then be investment in an electronic patient care reporting system, integrated with the National Emergency Operations Centre and with the technical capacity to automatically audit key patient data and generate appropriate reporting.
The ongoing development of the NAS is providing a robust platform to continue to improve performance against response time standards. Coupled with the ongoing development of education and clinical governance, the safety of services to patients continues to improve.
Key challenges in addressing response time targets continue to be reliance on on-call arrangements, geography (eg west of Ireland), road networks, resourcing and the use of emergency ambulances for inter-hospital transfers.
The NAS is taking a number of steps to improve response times where possible.
Performance Improvement Action Plan
The performance improvement action plan is in place and focused on improving response time performance. The plan has 57 action points for improvement. These are being worked through by local managers and include:
§ Faster mobilization times for crews
§ Processes around call taking and dispatch
§ Engagement with and development of Community First Responder Schemes
Development of an Intermediate Care Service (ICS)
A key issue for the NAS, for effective responses to emergency calls, has been the continued use of emergency vehicles for inter-hospital transfers. The NAS and staff representatives have, under the Public Service Agreement, signed off on a framework agreement for development of an ICS within the ambulance service.
The ICS is specifically for inter-hospital transfers, freeing up existing emergency resources for emergency calls. Almost 50 intermediate care operatives were appointed in 2012, in areas such as Cork, Galway, Sligo, Letterkenny and South Dublin. The National Service Plan 2013 provides for further developments in in Castlebar, Limerick, Drogheda/Dundalk, Tralee, Cork, Limerick, Waterford, Sligo and Bantry, with 78 additional staff. To support the implementation of additional services, the NAS intends to procure 25 vehicles in 2013 at a capital cost of approximately €4m.
Control Centre Reconfiguration Project
The NAS is focused on improving its call taking and dispatch functions, for a positive impact on response times. This project will allow the NAS to see all available resources on one system, ensuring that the nearest available resource is dispatched to a call.
The NAS is also rationalising its ambulance control rooms, to one system across 2 sites, Tallaght and Ballyshannon. This project is in line with international best practice, the Mason Report and HIQA recommendations on patient safety. It requires 2 buildings, the Rivers Building in Tallaght and the existing centre in Ballyshannon, Co. Donegal.
The first phase of this project was the move of Naas and Wicklow Control Centres to Townsend St in 2011. The second phase saw the move of Cork and Kerry control operations to Townsend Street in May 2013, with the simultaneous introduction of national digital radio to both areas. In phase 3, Navan Control Centre moved to Townsend Street in July 2013.
The outcome of a tender process for the structural fit out of the 2 buildings is due in August 2013, with a completion date for works in February 2014.
Revenue funding for this project in 2013 is €4.44m with 55 additional WTEs. Capital costs for the project are approximately €10.3m. Up to 2012, €3.3m was spent on ICT development, with the balance to be drawn down by the end of 2014.
The development of the National Control Centre will also allow the NAS to engage with and utilise First Responder schemes on a more effective basis.
Current arrangements do not allow for effective capture of all data relating to a First Response on scene whereby technologies within the National Control Project will facilitate a more consistent approach.
The training of the first cohort of call takers for the national centre began on 8 July 2013, with a qualification date in October 2013. This training has a full completion date of the week of 10 March 2014.
The move from Townsend Street to Tallaght will be in line with the above.
New Technology
This project will deliver improved technology to the NAS, which will assist in improving response times. Technology developments such as national digital radio, national computer aided dispatch system (CAD), mobile data, route planning and electronic patient care reporting, will allow the NAS to deploy resources in a much more effective and efficient manner on a national basis, rather than within small geographic areas. CAD (capital funding €1.4m), mobile data and AVL (vehicle locator) solutions have gone to tender. Successful vendor notification and award of tender is expected by October 2013.
The unified digital integrated command and control system (ICCS) solution (capital funding €3m) is in place in conjunction with An Garda Siochana. This allows for voice communication traffic to be routed through the ICCS and to appear as touch button technology “on screen” in Control.
The national digital radio system (NDRS) TETRA roll out continues (capital funding €3.9m). The system is live in Cork and Kerry and due to go live in the north east from July. This system will roll out to other areas sequentially before year end. Maintenance and support agreements are in place for both the TETRA network and Sepura Terminals.
National Defibrillator Replacement Programme
To assist in the roll out of the acute coronary syndrome programme and the implementation of the clinical practice guidelines, as required by PHECC and HIQA, there has been capital investment in 2013 of approximately €2.5m for a national defibrillator replacement programme. Associated with this is a further €2m for mechanical CPR devices to address health and safety issues for staff performing CPR and to improve outcomes for patients.
Pilot Emergency Aeromedical Service (EAS)
The pilot EAS, which was established in June 2012, involved the Irish Air Corps providing aeromedical support to the HSE National Ambulance Service.
The Air Corps provided a dedicated helicopter and personnel, based in Costume Barracks, Athlone, to fly and maintain the craft. The NAS provided patient care through advanced paramedics. The Irish Coast Guard provided additional support to the primary aircraft.
The pilot has been reviewed and the report on the review is being considered. The service is being continued, pending completion of this consideration
Engagement under the Public Service Agreement
The NAS is engaged with staff representative bodies under the Public Service Agreement on a number of issues. A key area is more effective use of resources in order to improve performance against response time targets.
Additional Investment
The HSE and Department of Health have recognised the development of the National Ambulance Service as a key requirement for 2013. In this context, over €8m in additional development funding was provided to the NAS in 2013, an overall increase in budget of 5% against 2012.
Question 3 (Senator Jillian Van Turnhout)
In light of the growing childhood obesity epidemic in Ireland and Government policy as set out in Healthy Ireland-A Framework For Improved Health and Wellbeing 2013-2025, to ask the Minister for Health why under the new Framework for Junior Cycle the status of physical education and SPHE (amongst others) has changed from a subject to a short course, thereby reducing recommended teaching time, and what will now be done under Healthy Ireland to ensure physical education and social, personal and health education in schools gets the priority they need?
Response
I am aware that on 4 October 2012, the Minister for Education and Skills, Ruairí Quinn, TD, published A Framework for Junior Cycle which outlines his plan to reform the junior cycle in post-primary schools. I understand and am supportive of the overall vision being pursued with the framework and my Department will assist the Department of Education and Skills in achieving this vision. We believe that if the reforms are implemented as envisaged, they may increase student engagement with school due to the decreased emphasis on rote-learning and the broadening out of areas in which students can achieve recognition for their achievements. This will have a positive impact on health and wellbeing. I am aware that the Department of Education and Skills is supportive of health and wellbeing and I welcome the inclusion of wellbeing as one of the eight principles underpinning the Framework for Junior Cycle.