Many of us, stretcher bearers, caregivers, nurses, doctors fell ill. They all returned to their posts as soon as they could. In the difficulties, we saw the emergence of individuals and methods that allowed the system to hold on. All this should not be swept away by a return to previous conditions. This experience should serve as a foundation for refounding our hospitals and emergency departments.
The first consequence of the crisis was to impose a filter at the entrance to the emergency room. At the height of the wave, almost all alone, Covid patients showed up. We were freed from the cases of city medicine and patients already known to the hospital departments, who were taken care of directly by them. So we were able to focus on the patients who needed it most.
In the future, and except in a vital emergency, no one should be able to go to an emergency service without the prior agreement of a telephone or digital platform. A healthcare professional will judge the seriousness of the case over the phone. He will authorize the patient to go to the emergency room or offer him an alternative (consultation platform without appointment, appointment with a professional, liberal or not, advice, etc.). Such a system works successfully elsewhere in Europe.
Before the crisis, patient safety was not always sufficiently assured in our emergency departments. During this one, reinforcements made it possible to hold. We must now write in the marble of the law the means that a hospital must devote to its emergencies.
Twenty-five years ago, to fight against the proliferation of perioperative accidents, a decree had imposed on hospitals human and material standards to perform anesthesia. After trying to pretend that such obligations were out of their reach, health facilities had obviously adapted. They did not want to stop their surgical activity. Do the same with emergencies. Minimum ratios of staff, of square meters, but also of beds available in the establishment, of medical, biological, radiological, computer or communication equipment must be imposed by decree to allow hospitals to practice emergency medicine. As hospitals all need emergency rooms to recruit their patients, the new standards will obviously be quickly applied.
The task of rehumanizing emergencies is immense. Before the crisis, many patients slept on a stretcher at night for lack of a free bed in the hospital. In winter 2018, this affected more than 100,000 of them. It is not just a question of means. As incredible as it may seem, many hospitals never know exactly how many beds are actually available.
During the crisis, all of these problems disappeared. Emergency rooms everywhere found beds for patients who needed to be hospitalized. But in recent days, when the situation seems to be getting a little clearer, bad habits have reappeared. Again, patients are abandoned on a stretcher. We must learn from our experience and set the goal of zero nights spent in an emergency corridor at each hospital.
The issue of seniors has been bankrupt in this coronavirus crisis. Their management was unfortunately an adjustment variable in the face of the shortage.
Such a scandal must never happen again. Each emergency department will have to set up a specific unit for caring for the elderly, as they require more attention and time.
Furthermore, we know that 40% of transfers from retirement homes to emergencies are medically unnecessary, costly (over $ 3 billion [2,77 milliards d’euros] in unnecessary spending per year in the United States), uncomfortable and dangerous. These unnecessary emergency room admissions will need to be reduced. The strengthening of staff in accommodation establishments for dependent elderly people (Ehpad) as well as the development of telemedicine and modeling tools should help.
The situation is even more dramatic for end-of-life patients who come to the hospital to die. Some spend their last moments on stretchers in anonymous and unethical conditions. Hospitals will need to have a plan in place that will allow these patients to be admitted to the following departments as a priority.
Emergency services, like all health facilities, are still suffering from the incredible shortages of materials and medicines that this crisis has revealed. The resolution of these shortages (masks, outfits, glasses, overalls, drugs) and the rapid constitution of strategic stocks are essential. Staff protection and patient safety should no longer be adjustment variables.
The crisis has also shown that medical time is precious and must be turned entirely to care. Doctors must be freed from administrative tasks or those of searching for hours of beds for their patients. Hospital support services must do this 24 hours a day, 7 days a week.
Emergency departments were already places of innovation, for patients and healthcare teams. In the crisis, we also held on thanks to the “D system” made possible by the freedom that was given to us. We must continue on this path with a massive investment in ergonomics, architecture, digital or human resources. Well-being at work will have to be compensated for hard work. We will organize and recognize new career paths and skills, or we will value the years spent in an emergency department as a promotion or retirement.
The virtue of short decision circuits
How else can we accept that staff salaries are not aligned with those of the main countries of the European Union? The number of doctors will also have to be adapted to the legal working time and make it possible to organize a reinforced service in periods of high tension.
Doctors will have to be trusted in the management of the hospital. This crisis saw the emergence of “medical directors”, who were able to bring the structures to adapt to a changing situation, where the usual organization was paralyzing. These must be made permanent. The heads of departments must be able to be responsible and invested with a real management mission, by arbitrating and executing their budgets in operation as well as in investment and by becoming authorizing officers of public expenditure. This crisis reminded us of the virtue of short decision-making circuits.
We hear everywhere that lessons will be learned from this epidemic. Our experience shows that goodwill is often diluted in endless working groups, which give birth only to incantations where vigorous measures are necessary.
This is why we insist that the law or the sanction of non-certification guarantee these commitments. Most of these topics have been on the table for years. During the crisis, some were miraculously resolved under the pressure of necessity. Others do not. But already, the dysfunctions are returning.
President Emmanuel Macron announced a big plan for hospitals. This is what we think should be done.
In any case, we emergency physicians will not return to the previous situation, which consisted of scooping up what nobody could or no longer wanted to do. We will no longer experience the dysfunctions of a disorganized and impoverished system. We believe in promises and expect action.
Philippe Juvin is head of the emergency department at the European Georges-Pompidou Hospital in Paris.
Mathias Wargon is director of the Ile-de-France Observatory for Unscheduled Care and head of the emergency department of the Saint-Denis hospital center (Seine-Saint-Denis).