Our emergencies are bad. This is not a new thing, it is even a journalistic chestnut that we bring out during a strike, a closure or a serious incident. Last resorts in a medical landscape which is deserting, the collapse is accelerating.
In recent years, we have seen the unthinkable happen: emergency closures for long periods at worst, regulations by the 15th at best, to decide who will enter or not – work as a nightclub bouncer rather than medical triage. Never before seen and above all an incredible state of affairs for the very people who a few years ago boasted of being able to accommodate everyone in the emergency room (I was one of them). This is an unacceptable situation for patients but also for other health professionals responsible for dealing with it. So everyone comes up with their more or less pragmatic proposal to “decongest”, a promise made by the President of the Republic and in which no one believes.
Like all good students who have learned the lesson, we know that the problem comes from upstream (patients who return to the emergency room) and downstream (those who leave to the hospital or another structure). For upstream, we created the access to care service, the famous SAS which consists of dialing 15 to get the best guidance and avoid going to the emergency room. It is currently not fully effective and although it is useful, the lack of community doctors or direct access to other health professionals remain obstacles to its deployment and use. Its implementation is gradual but it remains difficult to evaluate its direct effectiveness in emergencies, because its use is not obligatory and it does not prevent going to the emergency room if the patient decides to do so. We are also seeing the creation of multiple unscheduled care centers which take care of less serious patients. But these heterogeneous centers – some of which rely more on medical consumerism than on the care pathway – have not shown their influence on a drop in attendance at emergency reception services.
Audits that cost hospitals fortunes
For the downstream, we see the implementation of reporting tools towards the regional health agencies and the ministry, supposed to oblige hospitals to achieve organizational objectives. This involves verifying that hospitals apply a downstream organizational plan, such as the famous “bed manager” (bed manager, that sounds less Anglo-Saxon and a little more chandelier handles). In reality, depending on the establishment, we will have, under the same name, either a team dedicated to hospitalization and the regulation of scheduled or emergency hospitalizations dependent on general management, or an emergency medical secretary who will call her colleagues from hospitalization services only to be told that there are no beds available. The same can be said of hospital city contracts, hospitalizations independent of the specialty (accommodation), the number of beds to be provided, etc. The list is long, everyone in the hospital knows it. Reporting gives the impression of control. It often allows you to “pretend”. This does not solve the problems even when we insist on it. It will be noted that the campaign launched by a union of emergency doctors to count unexpected deaths in the departments resulted in systematically making the teams who took care of these patients responsible rather than questioning a system.
Despite everything, we cannot say that we are not interested in the functioning of emergencies themselves or their relationships with their environment. Every year, dozens of audits are carried out to find out what is going wrong in emergency rooms. These audits carried out by consulting firms cost hospitals a fortune. Some work with emergency doctors (how can we not think of the learned society of emergency medicine itself which offers this type of service!), others not. These audits allow us to say that all the players have taken a serious interest in the problem of emergencies, sometimes by hiring an emergency star. We remember that recently a regional hospital boasted of having taken advice from a famous Samu specialist, who had never set foot in an emergency department.
A task force of recognized professionals
Like other emergency doctors, I sometimes participate in an audit. I often discover that I arrive after an already long list of listeners, emergency doctors or not. And I often notice the same thing as the previous listeners, without anything having really changed, sometimes with completely baroque situations which could make you laugh if their consequences were not so serious. In general, some of the solutions are known to everyone and above all turn out to be the same from one center to another.
But even if the problems are identified, how will the team implement the change? Support is sometimes offered which will temporarily improve things and above all cost the hospital without committing in the long term. Let’s put ourselves in the place of a director or a doctor who is president of an establishment’s medical committee elected by his peers. What does he prefer? Having the emergency service on your back, or all the other services sometimes run by powerful bosses? Whether it is a simple small general hospital or a large university hospital center, how many have emergency departments with an obsolete organization, or disorganized by an incredible number of patients waiting for beds? How many emergency service chiefs are able to withstand pressure for a long time?
However, some services work better than others. It’s no secret to say that this is generally due to managers, who have been able to both organize their department but also regulate relations with the rest of the hospital. These professionals are known and recognized by their peers.
I propose to create a task force of these recognized professionals, doctors or nursing executives. They have specific expertise in the management of emergency services, are perfectly familiar with the realities of the work of department head and relationships with the rest of the hospital, internal processes, patient flows and interdepartmental interactions. They enjoy credibility with the medical and administrative teams of other emergency services. They are able to indicate concretely what must be done.
Sending emergency professionals to inspect and make proposals with institutional legitimacy will provide a pragmatic and effective approach to identifying problems and implementing significant improvements. Let this managerial intervention team go to the departments that are doing worst, make a diagnosis and offer treatment, not yet another report that will end up with the others in a drawer. And she comes back a few months later to see what was put in place or not and what difficulties were encountered.
It will then also be necessary to make the hospital responsible for the changes – or their absence. We can no longer accept the unacceptable. It should not be a punitive process either, because this approach will also allow neutral stakeholders to point out that once the organizations are put back in order, certain hospitals can no longer carry out their public service mission and that it will be necessary to really help them. Decongestion must no longer be a political refrain or a market, but an objective in itself, which must start with the emergencies themselves.
* Mathias Wargon is head of the Emergency Department – SMUR at the Saint-Denis hospital center (93).