2023-06-15 10:30:32
Tribune written by Philippe Leduc, doctor and health journalist, initially published on the Les Echos-Le Parisien website.
The emergencies are a reflection of the difficulties of reforming the health system. Here as elsewhere, the solutions have been known for a long time. The delay in their implementation leads to an increase in mortality in overcrowded emergency departments. How can this inertia be explained, despite not only the reports but also the injunctions. The latest – that of the President of the Republic – sets the deadline at the end of next year to unclog all emergency services.
The emergency doctors gathered in Congress at the beginning of June in Paris once once more alerted. Excess hospital mortality linked to emergency room overcrowding is, according to several studies, 9% for patients with all pathologies combined and of 30% for the most fragile patients.
A 50% increase in mortality
Today, a new study presented to Congress and in the process of being published reveals that the excess mortality would be on the order of 50% among those over 75 forced to spend the night in the emergency room on a stretcher lack of hospital bed. The 30-day hospital mortality rate would drop from 11.1% to 15.7%. It is considerable.
Today’s emergency physicians do not so much deplore the difficulties upstream of emergencies (city medicine) but the shortcomings downstream (“the big forgotten one”) of emergencies, that is to say the blockages in the transfer of patients to other services hospital facilities. And yet this observation is not new. Already 10 years ago Marisol Touraine, Minister of Health at the time, had been convinced of this, admitting that it was certainly “counter-intuitive”.
The emergency physicians forcefully insist:
“Yes, the mission of the emergency department is to welcome all patients who present themselves for an emergency, to qualify the urgency of their health need, to initiate treatment and then to direct the patient to the right course of care for the followingcare. For this, emergency examination rooms must be available to accommodate new patients. Without an available room, the emergency department can no longer fulfill its public service mission: to receive and treat emergency patients.
No, the emergency department does not have the capacity to keep hospitalized patients in the department to treat pathologies that fall under the specialties of the care departments. »
Upstream, the SAS, service of access to care, in the process of generalization with forced march, has the role of better distributing the patients towards the good chains of care, ambulatory or hospital.
“Waiting stretcher” and “stretcher abuse”
The problem is the downstream. Overcrowding in emergencies is mainly due to “stretcher waiting” responsible for “a abuse-stretcher » by difficulty of hospitalization downstream of the emergency room. But in some hospitals, it works. Those who have set up the “zero stretcher” challenge as a priority objective. This is not necessarily simple because it is the whole hospital, all the departments that must be mobilized. “The challenge is to profoundly transform the positioning of emergencies within the hospital.
The endorsement should be everyone’s concern. Improving emergency care must be carried out by the whole hospital and not just by the emergency services”already declared in June 2014 Marisol Touraine at the 8th Medical Emergencies Congress.
Faced with such inertia here and there to implement proven solutions, as in many other areas of the healthcare system, one can only wonder regarding the cause and how to proceed. Is it a lack of resources, motivation, training or governance ? Or also and above all clarification of objectives with a good participatory method. And one true leadershipas the Danes would say.
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