International Journal of Integrated Care, 9 July 2004 - ISSN 1568-4156
Emergency care should be integrated care

Well-written papers, based on research using scientific methods in a proper way, are accepted for publication in this journal provided they include co-operation, co-ordination or networking between different providers.

In “Integrated Care in Europe” (v Raak et al., Eds, Elsevier 2003) the framework described is an intersectoral co-operation between providers from both the health and social sector in order to deliver seamless care to the vulnerable elderly with multiple needs. The target group is mainly elderly with chronic mental or somatic conditions.

One aspect highlighted in the book is the increasing number of elderly patients in emergency departments, who would have been taken care of with higher quality, greater dignity, and lower costs in other settings. These patients are not coming due to emergencies or accidents, but because their daily network does not include mechanisms to deal with unplanned—not necessarily unforeseen!—deterioration in their health status. The integrated care network is not good enough, so the ambulance dispatch centre or the emergency department becomes the only available option.

However, old and very old persons are also included into programs using new medical technologies very early in the course of the disease or accident, having profound effects on the long-term outcome. In other words, the needs for long-term care are altered by emergency and pre-hospital interventions. These possibilities should not be allowed to drown in the flow of unnecessary unplanned visits.

According to the WHO, the single most disease for which people require care and cure in the world is stroke. Stroke is also the second most common reason for premature death in the world. However, new technologies are changing this perspective. It has recently been shown that early thrombolysis in selected cases can improve the outcome and also completely reverse the progress of vascular cerebral disease. In addition, even very old persons have significant gains from immediate transfer to a stroke unit.

The most common event leading to premature death is myocardial infarction. Today, most patients are treated successfully in the acute situation by medication. However, the long-term end result is often heart failure. This is the most rapidly increasing somatic disability in elderly persons. However, even in this case, new technologies such as early angiography and balloon dilatation with subsequent stenting lead to significantly improved end results.

Technological advances have also affected treatment, rehabilitation and long term needs of elderly persons with less life threatening but acute needs after events such as hip fracture and COPD. The above-mentioned diagnoses are a few where we today are witnessing great improvement to the benefit of the individual and also to society.

However, in order to achieve these favourable outcomes a new type of integrated care is necessary: the seamless chain linking the family physician, the alert or dispatch system, the pre-hospital care system, the emergency room, the X-ray and other laboratories, the ICU and the heart and stroke units. The possibilities of these revolutionary technologies to achieve the desired outcomes are all dependent on “The Golden Hour”. In addition, triage—setting priorities in the midst of a constant flow of multisymptomatic elderly—is crucial.

In most health systems fragmentation among financing authorities and providers and between providers is more the rule than the exception as shown in the above-mentioned “Integrated Care in Europe”. It is a formidable task to create well functioning networks involving alert systems, ambulances and emergency rooms. Any such effort and the scientific assessment of the methods deserve to be reported to the benefit of future patients and society.

IJIC has been extremely successful in highlighting the importance of integrated care during its first few years. However, the focus of submitted papers on integrated care has been very much on planned care in co-operation between providers focusing on elderly persons with medical and social needs of long-term care. The Journal would like to expand its scope, and invites researchers to include into the concept of integrated care also unplanned, acute and emergency interventions.

Ingvar Karlberg