2023-08-03 19:19:47
Protest by internal medicine doctors against the emergency room reform announced in recent days by the Lombardy Region, the subject of a resolution approved by the Council on the proposal of the Councilor for Welfare, Guido Bertolaso. On the one hand, the “regret for not having been consulted during the elaboration of the reorganization plan”, despite the fact that Internal Medicines are the wards that admit the majority of patients who resort to emergency-urgency care, and in spite of the workload endured in a pandemic, with 70% of Covid patients managed in Internal Medicine. On the other, the fears related to the contents of the provision, which presents “substantial problems” for hospitals, for the white coats that operate there and for the patients themselves. Which, as a result of the reform of the Lombard PS as described, may not obtain “a real advantage”, but may even run risks.
There are 7 problems that would hinder the application of the reorganization plan and which are put on paper by the Lombard sections of Fadoi (Federation of Associations of Hospital Internists) and Simi (Italian Society of Internal Medicine), in a letter addressed to Bertolaso and for information to the governor Attilio Fontana. “If on the one hand the resolution provides for some structural changes which are and will be fundamental for the improvement of the activity of the PS and for which we appreciate and share the commitment of the councilorship – the specialists write – on the other there are” precisely ” substantial criticalities that in the current setting we cannot fail to highlight, with the constructive approach that has always characterized the collaboration with the Directorate General for Welfare” of the Region and “with the councillorship”.
The letter, Fadoi and Simi Lombardia clarify, is meant to be “a constructive attempt to participate in the discussion and to share a truly sustainable path, which sees us at the forefront in the management of hospital activities together with urgent colleagues and other specialties, but which it must necessarily be tackled in a systemic way”, warn the internists, “putting the patient as a priority at the center of the treatment process”.
“The Emergency Room – recall Fadoi and Simi Lombardia – represents the entrance door to the hospital, the ‘first bulwark of defence’ for citizens with medical-surgical problems”, whose activities inevitably “reflect on the activities of specialist departments. Consequently, a reorganization plan of these structures cannot be detached from the consideration of the flow of patients in its entirety, from the Emergency Department to the hospitalization departments, upon returning to the territory”. Internal medicine doctors know this well, “significantly involved, with many sacrifices and a spirit of collaboration – they remark in the letter – in the shift work of many PS”. And it is precisely by virtue of this role that internal medicine specialists submit 7 observations to Bertolaso, “confidants that they will be considered”.
The first critical point identified by the experts concerns the point of the resolution which explains that the unavailability of beds in hospital stays is not sufficient justification to prevent the immediate hospitalization of the patient by the doctor of the Emergency Department/Ps. “In this way”, however, “the problem of PS boarding”, i.e. of patients for whom hospitalization is decided and who are waiting for a bed, “is not solved – the internists object – but only moved, unloading it on hospital wards, without a real advantage for the patient”. On the contrary, “as the literature demonstrates, hospitalization of the patient in an inadequate setting, or in support/supernumerary, as could easily happen, leads to an increase in clinical risk, with unfavorable effects on the outcomes”.
The second problem raised by Fadoi and Simi relates to the passage of the resolution in which, to support the needs of the PS, a rebalancing of the number of beds is envisaged on the basis of epidemiological data and taking into account the needs of the emergency room itself. “A greater number of beds available to the PS is essential. However – the specialists comment – since no increase in the total number of accredited beds is envisaged, but only a redistribution, this would probably be accompanied by a reduction in beds above all for choice, both medical and surgical, and consequently the capacity of public hospitals to respond to non-acute clinical needs, but equally important for the patients, would be reduced.Also the creation of beds for Emergency Medicine operating units- urgency (12-24 beds), in the absence of a change in the total number of accredited beds, it will accentuate this problem”.
The third “critical passage, which is difficult to understand clinically and organisationally”, continue the internist doctors in the letter to Bertolaso, “is that which concerns the ‘management of the interdivisional medical/surgical emergency'”. For specialists Fadoi and Simi “it is not clear whether this management of the interdivisional guard is in place of the current interdivisional guards, in charge of the specialists of the various hospital wards, or in addition. In both cases we wonder why, for example, an internist, in the case of a patient who presents ‘a deterioration of cardiorespiratory / haemodynamic parameters’, he has to call his urgent colleague and cannot instead manage the emergency himself (as he does now), deciding independently when to call the resuscitator”. Among other things, “this activity would involve the need to recruit an even greater number of urgent workers, to the detriment of the other specialties, equally suffering”.
The internists then ask for clarifications on a particularly technical fourth and fifth point, subsequently going on to point out, in point 6, how “the problem of human resources would seem to represent at the moment the real obstacle that is difficult to overcome in implementing the reorganization plan. The multiple tasks of the emergency doctor that are going to be configured – write the signatory companies – foresee an enormous increase in resources for the complex operating units of Emergency Medicine-Emergency Medicine, already today in extreme suffering and dependent on external contributions, which it seems, at least for the next 5 years, absolutely unfeasible”. The internal medicine doctors also reiterate that “most of the professionals who work in the PS-Emergency Medicine area in Lombardy come from the medical area, in particular from Internal Medicine”. Therefore, “if on the one hand it is essential to implement an adaptation of the resources available in Emergency Ps-Medicine, on the other this must not compromise extremely fragile balances in specialist departments (not only Medicine) where there is a similar lack” , if not “a real escape from the hospital”.
Finally, “one last consideration”, number 7, “concerns the activation of clinics for minor Codes. In 2022 – the internists point out – the minor Codes represented 76.8% of all accesses in the PS of Lombardy ( source Areu, Regional Emergency Emergency Agency). Starting from this data, it seems unlikely that continuity of care doctors (or their equivalents, even non-specialists) could take on such a heavy load. Furthermore, it should not be forgotten that even within the codes of priorities 4-5, not infrequently subtle symptoms can be hidden which must be supervised by professionals with adequate specialist competence, not to mention the responsibility in this sense which is directly entrusted to the triagist.At this point – it is the final perplexity of the internists – the doubt remains which medical figure can take charge of the minor Codes”.
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