Hospital emergencies: the refugee camp of the healthcare system

@varelalaf

The society witnesses the emergence of population groups with social and health care needs that are difficult to fit in the current model of service offer. Thus, we see how fragile and vulnerable people are picked up by ambulances and go to hospital emergency rooms, which become like refugee camps, as Sara Kreindler, head of health systems innovation research at the University of Manitoba (Canada), likes to call them. Many initiatives, observed everywhere, aim to put an order in these refugee camps of healthcare: implantation of triage, observation units, geriatric units, new case management nurses, nurses trained in geriatric evaluation. To help us analyze a problem that we don’t know how to address, Sara Kreindler has developed a qualitative study in the framework of a region of Canada. The study has concluded that partial interventions aiming to improve the flow of urgent care for patient’s complex show three paradoxes:

1) Small successes don’t fix the general system failure

2) Your innovation is my complication

3) Your order is my chaos

The theory of the doors

Many partial initiatives, especially those promoted at the community level, seek difficult-to-handle groups to intervene through service integration methodologies. For this reason, they must be very restrictive in their admission criteria, where the Leutz axiom (or fourth paradox) is born: "your integration is my fragmentation". This axiom expresses the confusion of the system when there is no agreement between the criteria of the different doors, especially since many patients, reached the point of complexity, don’t respond to unique categorizations. The result is that the most praised programs are the ones that select patients most rigorously, while those that have to fix problems on the spot, such as hospital emergencies, are the ones that have the most issues of fluidity and functioning. The contradiction of limited innovative projects is that those who design triages do it with the confidence that refugee camps with gates wide open will serve unclassifiable patients, even though emergency services are overflowing and struggling to give adequate answers to each person.

Kreindler's three paradoxes advise against attempting to reform the systems from within and urges us to design a new model based on the needs of each population segment, the analysis of clinical trajectories as a whole and the genesis of professional multidisciplinary teams that deal comprehensively with the management of health and social care services tailored to each environment and each person.

Jordi Varela

Editor