2024-03-19 00:05:07
PARIS, March 18, 2024 (APMnews) – To understand the place given to elderly people in hospital, “first go to the emergency room and spend a night there” and “not just an hour”, advises Philippe Vigouroux, former director general of CHU, to the new hospital directors, in a letter which will soon be published in the Tribunes de la santé de Sciences Po and which he spoke regarding Thursday during the 32nd days of the Association of Hospital Directors (ADH).
He spoke during a session on the adaptation of hospitals to the aging of the general population.
“If you have chosen the profession of hospital director, it is not out of passion for Excel, for the beauty of a plan to return to balance or for the pleasure of counting positions, but out of a taste for service public and for a central mission: to help doctors, caregivers and the entire hospital to take care, tomorrow better than today, of people affected by illness, age or disability”, observes Philippe Vigouroux, former director general of the University Hospitals of Limoges, Nancy and Bordeaux, in this letter.
He recalls that the first question asked to the emergency intern who is looking for a bed is “how old is he?”. It’s a “terrible” question because the answer to this question will determine the patient’s journey, and the chance of finding a bed is greater for a 40-year-old patient than for an 80-year-old patient, he said. -he pointed out Thursday.
For the elderly person, the second question asked aims to know if they are polypathological because, with the exception of specific health accidents (broken femur or heart attack), this implies taking the time to explore, he said. added.
In the emergency room, around 9 or 10 p.m., there will be stretchers with people “of all ages” then, as the night goes on, “the stretchers will have become very old” and, at 2 a.m., the people still on a stretcher are the “polypathological elderly people”, he observed.
Even if, with the job of hospital director, “you want equity in care, you will see that there is no equity at all and that there is an entire population that is bad [ou] much less well taken care of”, even if the caregivers are “excellent”.
“And by drawing this thread from the elderly person and their care in the emergency room, you will see what your hospital really is,” he insisted, addressing the new directors.
For Philippe Vigouroux, the problem is the organization, and we must take this question “head on”, for reasons of ethics, public service, fairness, deontology and “then, also, for the hospital itself.”
He considers it necessary to organize the hospital for elderly people with multiple pathologies, which will benefit more widely “fragile” people, that is to say disabled people, foreign people “who are lost in this complex world of the hospital ” and for all patients “weakened by surgical intervention” or serious pathology.
“In the different positions and in the different university hospitals that I have been in charge, each time, I have tried” but “I have not always succeeded” because sometimes there are “brakes”.
Increase medical beds and train in geriatrics
According to him, this situation is not explained by hostility of caregivers towards the elderly but by a lack of medical beds and staff.
Faced with aging and the explosion of chronic diseases, there should have been an increase in medical beds, particularly internal medicine and geriatrics, and not a reduction, he pointed out. “Taking care of someone with multiple pathologies at 95 years old for a problem” of which we are not sure of quickly finding the origin, “it will take time and […] we are going to freeze a bed, we are going to stop the operation of services,” he said.
Among the solutions, Philippe Vigouroux mentioned the establishment of emergency back-up services with medical and nursing staff trained in geriatrics, which allows elderly polypathological patients to return more quickly to their homes or institutions.
These multidisciplinary platforms, reserved for the elderly and backed by an internal medicine service, must be made up of emergency physicians, geriatricians, internists, or even generalists, with occasional interventions from specialized practitioners (cardiologists, neurologists, psychiatrists, etc. .), he specifies in his letter.
The former director general of CHU also pleaded on Thursday for direct access to hospital services in order to avoid emergencies, which is worked on upstream with treating doctors and nursing homes.
Finally, he considers it important that some caregivers in services not specialized in geriatrics are also trained in the care of the elderly.
“The organization of a unit dedicated to geriatric care within a specialized medicine or surgery department is another avenue,” he underlines in his letter. “Geriatric orthopedic surgery units have thus been created to take into account the increased risk of decompensation of geriatric people bedridden for more than a few days”, with specially trained caregivers, coming from the same department or from geriatrics, and a geriatrician who can intervene there, “at least part-time”.
He also insists on the fact that to “drive an entire hospital”, it is necessary to combine geriatric culture with a “political will shared by management, doctors and caregivers, ratified by supervisory boards and authorities”. “Thus a culture of service to the elderly is disseminated”, which benefits everyone, “because this fragility is common to the entire hospitalized population”.
Among the other avenues to explore, he notably mentions the transformation of beds into short-stay geriatric beds with the support of the regional health agency (ARS), the adaptation of circuits, signage and hotel services, the development of research in geriatrics (medical and nursing) as well as the adaptation of prices in order to promote geriatric practice.
During the round table, Anne-Laure Riquet-Schardt, hospital director and teacher-expert in human resources at the management institute of the School of Advanced Studies in Public Health (EHESP), observed that the majority of student directors had gone on an internship in the emergency room or in the care department. This eight-week internship was in fact carried out partly in the emergency room for certain student directors and was “rich in lessons”, commented Mathieu Bijoux, representative of promotion 62 on the ADH board of directors. .
For Philippe Vigouroux, it is important that student directors go out into the field and see the teams outside of internships as well.
Prevent vulnerable situations
During this same session, Professor Régis Aubry, member of the National Consultative Ethics Committee (CCNE) and head of the disability autonomy center at Besançon University Hospital, observed that our health system has “increased situations of vulnerability” due to advances in medicine, notably with the creation of secondary disabilities, but that it has not adapted in parallel to the complexity it creates. University hospitals, in particular, are “major producers of vulnerable situations”.
The hospital, however, has “less and less time to take the time to understand the situation” while aging is associated with a slowdown and the need for more time to understand, he lamented. Thus “the time of caregivers intersects less and less with the time of polypathological patients”, presenting functional dependence and sometimes cognitive disorders.
However, reducing listening time in particular to improve performance causes suffering among health professionals and results in a form of segregation and ageism, particularly in emergencies.
This should prompt one to ask whether one should do what one knows to do if it contributes to pain, but it takes time to ask oneself these questions, he observed.
For Professor Aubry, “the time for care, for listening, for respecting the time of others” should be valued.
In its region, Burgundy-Franche-Comté, an institute for health-related vulnerabilities will be tested to identify vulnerable people and set up a monitoring system to avoid re-entry to hospital, as part of an “article 51” experiment.
This will also involve research in geriatrics, with the establishment of a fund, and the creation of an observatory of vulnerable situations, in order to quantify them and be able to qualify them.
Demonstrating in particular the economic benefit of preventing vulnerabilities will make it one of the major levers of the health system, he hoped.
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