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[REV. MED. CLIN. CONDES - 2017; 28(2) 273-276]
SUMMARY
The Emergency Department has witnessed multiple
paradigm shifts within a very short period of time. It is
likely that the aging of the population will create the
greatest shift to date. As the number of people over age
75 swells, the demands on the emergency department to
have available multi-disciplinary geriatric capabilities
to manage their complex non-medical problems risk
overwhelming the ability of the department to manage
the acutely ill and injured as is its mandate. Crowding
could spiral out of control, resulting inworsening outcomes
for emergency department patients. Anticipating the
geriatric tsunami and preparing a health care system,
both in and outside of a hospital will be critical. Creating a
geriatric emergency department in isolation risks having
governments designate the emergency department as the
portal of entry for all community geriatric needs, which
can only compromise further acute care, care already
threatened by tightened budgets, increasing health care
costs and insufficient community resources.
Key words: Overcrowding, hospital operations,
emergency department, emergency medicine.
INTRODUCTION: WHAT HAS COME BEFORE HAS
PAVED THE WAY
North America has witnessed remarkable paradigm shifts
in the clinical practice of emergency medicine (EM) over
the past 40 years. Prior to the existence of the specialty of
emergency medicine, the emergency room was essentially
a holding facility for specialists or Family Physicians to see
PREPARING FOR THE GERIATRIC
TSUNAMI – AN EMERGENCY
DEPARTMENT PARADIGM SHIFT
JAMES DUCHARME MD CM, FRCP (1)
(1) Clinical Professor of Medicine, McMaster University. Hamilton, Ontario, Canada.
Email:
paindoc22000@yahoo.comArtículo recibido: 13-10-2016
Artículo aprobado para publicación: 26-01-2017
their patients prior to admitting them to a hospital bed or
to returning them home. On site coverage was provided
by moonlighting physicians in need of additional revenue,
physicians often without any training in acute care. With the
advent of EM, a new paradigm was introduced, focusing on
acute care and resuscitation practiced increasingly by physi-
cians with specific training in emergency medicine. Even with
the arrival of this first EM paradigm, there were non-medical
imperatives: the homeless, the neglected elderly, the victims
of sexual assault or intimate partner violence.
Despite core EM training objectives focused almost exclu-
sively on acute illness and injury, clinical practice restricted
to that area of expertise was so temporary, one wonders
if it was only a mirage. Hospitals faced increasing financial
constraints. In Canada, large numbers of acute care beds
were closed, without increases in long term care facilities.
The percent of (reduced in number) acute care beds occu-
pied by long term care patients often exceeded 20% of total
bed capacity, placing additional pressure on emergency
departments (ED) to either discharge patients that would
have been previously admitted or to crowd them into hall-
ways. During that same time period in the United States, the
total number of hospitals decreased every year. Insurance
companies started dictating duration of stay and criteria for
reimbursement for various medical conditions. The causes
were different, but the results were the same as in Canada:
overcrowded EDs, with delays in initial care, and extended
duration of care by the emergency medical team. This new
paradigm became the next accepted norm despite accumu-
lating data demonstrating worse patient outcomes and satis-
faction. Need for paramedical services such as social work and