An inspection of Morriston Hospital's emergency department found delays in the assessment and review of patients with chest pains and heart attack symptoms. The length of wait between arrival and triage for one of these patients was two hours, said Healthcare Inspectorate Wales (HIW) in a report.
It said another patient had been lying on a spinal board for a significant period and that there was a delay in providing appropriate interventions, including an MRI scan, despite a "neurological deficit" being recorded. Inspectors were critical of some aspects of infection control. "We observed nursing and medical staff not changing gloves in between attending to patients and switching between clinical and non-clinical tasks," said the report.
The inspection team, which attended unannounced over three days in September, painted a picture of an over-stretched department facing unrelenting demand, caused by the volume of admissions and difficulties getting patients onto wards. "Patients were not always receiving the experience that they should expect," said the report. "This is because of a lack of timely care and treatment, despite constant efforts demonstrated by the health board to increase patient flow. However, patients were generally happy with the care provided by staff once they were seen."
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Overall inspectors found staff were committed to providing a good level of care despite the pressures, that they spoke to patients in a polite, professional, and dignified manner at all times, and that their immediate managers could be counted on to help. Senior clinicians and the management team at Swansea Bay University Health Board have produced a detailed action plan in response to the report and said they would work hard to implement it.
HIW said the set-up inside the emergency department compromised privacy and dignity. Two patients died in a bay with a number of beds in it during the inspection although their families were present. Waiting areas were frequently crowded and patients sat overnight on hard plastic chairs in some instances. Inspectors found one patient lying in a waiting area corridor whose relative had gone home and returned with a pillow to make them comfortable. Patients in A&E for "excessive lengths of time" were not offered food, and sufficient food was not regularly delivered to the department.
Inspectors also visited the children's emergency unit and two other areas called the rapid assessment unit and surgical decision making unit. One patient said staff in the rapid assessment unit were marvellous but that they'd had a "very stressful" emergency department experience for the first few days after being admitted due to a lack of sleep and being in pain. A relative of another patient said they'd phoned the surgeon's secretary, and that if they hadn't their loved one "would probably still be waiting".
A majority of 55 staff who gave feedback to inspectors said they didn't think the emergency department environment was appropriate for ensuring patients received the care they needed. One employee said the environment was "often not safe due to high volume of patients attending and (a) shortage of beds in the hospital". Another said overcrowding was a chronic problem, while another cited the lack of patient flow through the hospital but added that too many people attended A&E when they didn't need to.
Half of the employees said they felt their job was detrimental to their health, although the majority agreed that the health board took positive action on staff health and well-being. Just over half said they'd seen errors, near misses or incidents that could have hurt staff or patients although, again, a majority said the health board took action to ensure they didn't happen again. Just over half said they didn't think there were enough staff to enable them to do their job properly. The report noted a "heavy reliance" on agency nurses but said the majority of them were known to and familiar with the department.
HIW identified 25 general areas for improvement. It said it was aware of intense pressure within primary care, ambulance services and emergency departments across Wales, but that maintaining patient safety was paramount.
HIW chief executive Alun Jones said: "There are mounting pressures on NHS services, and like all hospitals across Wales, Morriston Hospital continues to face extraordinary challenges due to increased demand and staff shortages. Patient flow is a nationally recognised problem, caused by system-wide pressures and HIW acknowledges the health board is working hard to make improvements and reduce waiting times.
"We will continue to engage with Swansea Bay University Health Board to ensure progress against our findings. Key staff at the health board have been positive in their response to our feedback and in our subsequent communication, with a clear commitment to addressing the issues highlighted."
The health board has been redesigning its acute medical services and has just launched a new hub in Morriston Hospital. In a statement the health board said it welcomed HIW's report.
"Our senior clinicians and management team have already reviewed its findings in detail to produce a comprehensive action plan, and will work hard to implement the necessary changes in order to improve the service," it said. "As HIW points out, the inspection took place at a time of the intense pressure and unrelenting demand, which continues to be the case across the UK as we try to overcome the challenges experienced, brought about by the pandemic."
The health board said it was pleased that good management and leadership had been noted, and was particularly proud of staff working hard to provide patients with a positive experience and good levels of care despite extreme pressures.
It added: "We are completely overhauling our acute medicine service from this week, with the launch of a new acute hub at Morriston Hospital. This is designed to take a considerable amount of pressure off the emergency department once it beds in over the coming months."
The changes will be phased in and will result in more urgent but not critical patients being seen in the hub rather than the emergency department. The new hub focuses on same-day care and also has 45 self-contained beds for up to 48 hours, aimed at reducing the number of patients having to be admitted to wards. This, said the health board, should improve patient flow and reduce prolonged waits in the emergency department.
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