The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Although there are older people, or even very old people, who can benefit from attending a critical unit, in general, emergencies and ICUs do not seem to be highly recommended places for fragile people and, therefore all possible strategies should be deployed to reduce income to strictly justified cases. Admitting that sometimes emergency trips make a lot of sense, such as with a fall or thoracic pain, but generally, the less they go the better. How, then, to avoid unnecessary trips? According to the English NHS, the number of elderly people over ninety visiting the emergency room had increased by 60% in the 2010-2016 period, a worrying upward trend given that a large percentage of them required more than x-rays, oxygen and serums The emergency services are very effective in emergencies but they do not have appropriate responses for the socio-sanitary decompensations of the very elderly or those in the advanced stage of chronic or oncological diseases.

Sir Bruce Keogh, former NHS National Medical Director, in a statement to The Telegraph, introduced the idea of external containment, that is, do everything possible in the home environment to prevent any critical or delicate situations arising in a fragile person and so avoiding them ending up in an ambulance. The proposal is most interesting, but how to achieve it? My recommendation is that emergency systems and emergency services define the "fragility code", just as they have done so brilliantly with other codes. For the definition of this new code, a prior agreement with the primary care and community social services on the most appropriate responses according to a comprehensive evaluation of each patient would be necessary, in addition to the collaboration of all available social and health resources in each territory, Therefore, the "fragility code" should offer a variant of multi-institutional responses according to each local reality.

There is no magic solution to the excess of emergency trips to the elderly, but as long as an anxious change of model does not happen, it is necessary to avoid that a call automatically equals a transfer, and it is at this point that the "fragility code" could be a valuable instrument.

Jordi Varela

Editor