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physiotherapy working in the ED increased. A new physical
structure was created within the ED: a 24-hour short stay
unit that avoided admissions while increasing further the
scope of practice of the emergency physician.
At the same time as medical beds became a shrinking
commodity, so too was the infrastructure for patients with
mental health concerns. Many long term care facilities were
closed, resulting in increasing numbers of patients with
chronic mental health diseases in the street or under the
care of family members unable to cope. Visits to the ED
increased, requiring another paradigm shift: the establish-
ment of Emergency Psychiatry Units in the ED with the pres-
ence of psychiatry nurses and assessment teams. Increasing
demand was placed on social workers due to the lack of
community resources for this group of patients, expanding
further the non-medical resource demands in the ED.
The ED has been impacted by other influences as well:
infectious diseases such as SARS, TB, and H1N1 have forced
hospitals to forego an open concept for individual rooms,
increasing infrastructure costs and staffing needs. Violence
and terrorism have resulted in EDs with metal detectors
at entrances, and bullet proof glass at registration. While
EDs have decreased in number, they have the necessity to
become larger, with sub-areas of care under the direction
of the ED – essentially mini-hospitals.
Why have these paradigm shifts occurred and why have
they been imposed on the ED rather than finding novel
health care systems to support them? In large part, we
have been our own worst enemy. From the first days of our
specialty, we have said that the ED is the safety net of the
health care system rather than being the safety net for the
acutely ill and injured. Unlike other specialties, we have
not attempted to define inclusion and exclusion criteria
for care. No other specialty has accepted to be a ‘catch-all’;
for in-patients, the role of a Hospitalist had to be created
to take on this approach. When other areas come under
pressure, the easiest solution is to default that care to
the ED. Think of where patients without a primary care
provider, with post-op complications or with addiction
issues all go, to name but a few. The universal answer has
become the ED. Such an approach is justifiable in a private
health care system, where market share drives the hospital
bottom line. Outside of the United States, however, such
an approach can only be to the detriment of the acutely ill
or injured patient, as evidenced by the research available
(1). Unfortunately, the opportunity to advocate specifi-
cally for the suported area of expertise of EM, appears to
have been lost in North America, but has not yet passed in
South America.
THE NEXT PARADIGM SHIFT– THE AGING POPULATION
By 2050 more than 30% of the North American population
will be considered elderly; in South America it will rise to
approximately 25% (2). It has been said that more people
over age 65 are alive today than have ever died before.
Increasingly we will need to address the specific needs of
this growing age group. Unlike other age groups, multiple
non-medical problems are inherent and intertwined
with the medical ones. Inability to care for our elders will
become an ever increasing societal burden as both medical
and social complexities arise. Possible solutions could
include non-hospital ones. Studies have reported on EMS
teams evaluating home situations when dispatched, initi-
ating community support action rather than transporting
to the ED (3). An open access medical facility with a multi-
disciplinary team could manage new and ongoing medical
problems, and prevent others while organizing home and
community solutions for the elderly. Patients coming to
the ED could be safely discharged back to such facilities to
continue care and obtain the necessary support rather than
being admitting to an acute care bed. This would require
a revamping of existing health care models, for no system
has included all of the paramedical and social disciplines
required for the elderly in its universal care infrastructure.
Education of patients and their families about preparing
for needs of the aging needs to be integrated in a new
health care model that prioritizes
anticipation and preven-
tion
. In South America such discussion and preparation can
pre-empt the geriatric tsunami; in North America it is too
late. The compromise has been once again adapting the
emergency department to this new paradigm.
Government debt is rising while GDP per capita stagnates
or drops with an aging population. Combined with an ever
more expensive medication list, governments will be facing
a financial wall. Health care focus will have to become
more financially responsible, with the most cost effective
approach – prevention rather than reactive care–becoming
the base model. Focusing on staying healthy for as long
as possible rather than spending money on illness once it
occurs should become the expected norm. We need to stop
spending large amounts of money on the last 6-12 months
of life as currently happens. Supportive end-of-life facili-
ties could compensate for the diminishing younger popu-
lation base’s inability to care for the increasing number of
elderly. The societal debate over what
should
be done versus
what can be done must take place. Wherever that debate
leads us, however, the fallout of an aging population will be
that the sick elderly will still have to be seen somewhere;
already in United States those over age 75 represent the
age group with the largest number of visits to EDs(4). In
North America, that ‘somewhere’ entry point has by default
[REV. MED. CLIN. CONDES - 2017; 28(2) 273-276]