The grey tsunami is on its way. This demographic shift will necessitate changes in the organisation of our emergency departments.
The study by Nummedal et al., published in this edition of the Journal of the Norwegian Medical Association (1), confirms predictions from various national actors that the number of patient contacts in the health service is increasing. The retrospective observational study from the emergency departments at Haukeland Hospital in Bergen and St Olav's Hospital in Trondheim shows an increase in patient contacts over a ten-year period. The biggest increase in the number of contacts was in the age group 67–79 years, and the most common reasons for contact were abdominal pain, chest pain, dyspnoea and suspected stroke.
The fact that the study was conducted at hospital emergency departments with no minor injury clinic and different patient pathways for a number of specialties outside of internal medical, means that the figures must be interpreted with caution. It would also have been interesting to know more about the increase in the number of patients referred to the specialist health service for minor injuries. The inclusion of hospital emergency departments with a minor injury clinic would have increased the generalisability of the study.
It is easy to practise what you are good at, but that will not necessarily make you a good generalist
My experience after ten years at Drammen Hospital is that almost 50 % of the emergency department's patient population is treated in the minor injury clinic. This means that the proportion of internal medicine patients will naturally be lower as we also treat patients within the surgical and neurological specialties. I raise this concern because emergency medicine and prehospital care is a broad specialty that is intended to ensure a uniform standard of treatment for all patients in the emergency department.
This specialty involves a broad internal medicine education, but doctors who specialise in this area must also be able to treat acutely ill children or patients with, for example, fractures. It is easy to practise what you are good at, but that will not necessarily make you a good generalist.
The population's expectations are regarded as the main driver of the increased patient influx and medical overactivity in the specialist health service. This has particularly been observed in the group over 70 years of age. In order to provide appropriate treatment within a professional framework, more expertise is needed in emergency departments (2). The Health Personnel Commission has also called attention to the trend being highlighted here, and is calling on us to bring together the medical communities to address future expectation gaps (3. 15).
We need doctors with permanent positions in the emergency department in order to secure expertise around the clock
As also mentioned by Nummedal et al., Norwegian emergency departments have received repeated and strong criticism about, for example, the lack of frontline expertise and local management. In my opinion, the current situation is still too heavily characterised by junior doctors (LIS2 and LIS3) from other departments who only have a 2–4 month perspective and tend to focus on the learning objectives in their future specialty outside the emergency department. We need doctors with permanent positions in the emergency department in order to secure expertise around the clock. Only then can we facilitate a high standard of care and establish systems that are continuously monitored and improved, as recommended in the national clinical guidelines for somatic emergency departments (4, point 14).
Emergency departments should be organised as a separate department with a permanent staff, where the person in charge has overall responsibility for ensuring that procedures and systems are in place
However, we need to address an even more important systemic weakness: the requirement for uniform management in emergency departments. These departments should be organised as a separate department with a permanent staff, where the person in charge has overall responsibility for ensuring that procedures and systems are in place (4, point 16). This requires the emergency departments to be independent organisations with 'end-to-end responsibility', directly accountable to the hospital director, in the same way as other specialist departments. We will of course develop the emergency medicine and prehospital care speciality together with other disciplines, but those working in emergency departments must take responsibility for proper management.
Responsibility cannot and should not be delegated. Today, there is still too much consensus-driven dilution of accountability, where the line manager in any disagreement is the hospital director.
As Nummedal et al. point out, emergency medicine and prehospital care can be part of the solution to a future problem. We also need to ensure that emergency departments become independent, responsible and reliable organisations that deliver a high standard of care and can contribute to wise choices now and in the future.