An initiative to provide emergency healthcare for older people in the community: the impact on carers

The increase in the size and age of the UK older population has had a major effect on emergency services. Many older people will visit the emergency department but not necessarily require significant clinical intervention. The Paramedic Practitioner in Older People's Support (PPOPS) scheme was set up to provide community-based clinical assessment of older patients contacting the emergency services with minor acute conditions as an alternative approach to emergency department transfer. Patient carers were followed-up to evaluate the impact of this scheme when compared with standard transfer to the emergency department. Postal questionnaires, including items on the level of care provided, satisfaction with care received and carer impact, were administered to 561 carers. The overall response rate was 71.5% (401/561). The carers were predominantly female, approximately 60 years of age and family members, with more than three-quarters providing some form of physical care before the patient episode. Overall, carers did report an increase in the level of care provided before episode, significantly more so in the emergency department group (p=0.003). These increases related to more input needed in supporting physical activities. The carers in the PPOPS group were more likely to report greater satisfaction with their impression of care and staff attitude and would prefer treatment at home for the patient than those in the emergency department group (p<0.001). A minor health event does impact on the life of a carer. However, community-based schemes, such as PPOPS, do not increase the burden on carers and have high levels of satisfaction among this important group of the community.

Male and female Fmr1 knockout mice on C57 albino background exhibit spatial learning and memory impairments

Impaired spatial learning is a prominent deficit in fragile X syndrome (FXS). Previous studies using the Fmr1 knockout (KO) mouse model of FXS have not consistently reported a deficit in spatial learning. Fmr1 KO mice bred onto an albino C57BL/6J-Tyr(c-Brd) background showed significant deficits in several primary measures of performance during place navigation and probe trials in the Morris water maze. Fmr1 KO mice were also impaired during a serial reversal version of the water maze task. We examined fear conditioning as an additional cognitive screen. Knockout mice exhibited contextual memory deficits when trained with unsignaled shocks; however, deficits were not found in a separate group of KO mice trained with signaled shocks. No potentially confounding genotypic differences in locomotor activity were observed. A decreased anxiety-like profile was apparent in the open field, as others have noted, and also in the platform test. Also as previously reported, startle reactivity to loud auditory stimuli was decreased, prepulse inhibition and social interaction increased in KO mice. Female Fmr1 KO mice were tested along with male KO mice in all assays, except for social interaction. The female and male KO exhibited very similar impairments indicating that sex does not generally drive the behavioral symptoms of the disorder. Our results suggest that procedural factors, such as the use of albino mice, may help to reliably detect spatial learning and memory impairments in both sexes of Fmr1 KO mice, making it more useful for understanding FXS and a platform for evaluating potential therapeutics.

Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial

BACKGROUND

A scheme to train paramedics to undertake a greater role in the care of older people following a call for an emergency ambulance was developed in a large city in the UK.

OBJECTIVES

To assess the cost effectiveness of the paramedic practitioner (PP) scheme compared with usual emergency care.

METHODS

A cluster randomised controlled trial was undertaken of PP compared with usual care. Weeks were allocated to the study group at random to the PP scheme either being active (intervention) or inactive (control). Resource use data were collected from routine sources, and from patient-completed questionnaires for events up to 28 days. EQ-5D data were also collected at 28 days.

RESULTS

Whereas the intervention group received more PP contact time, it reduced the proportion of emergency department (ED) attendances (53.3% vs 84.0%) and time in the ED (126.6 vs 211.3 minutes). There was also some evidence of increased use of health services in the days following the incident for patients in the intervention group. Overall, total costs in the intervention group were 140 UK pounds lower when routine data were considered (p = 0.63). When the costs and QALY were considered simultaneously, PP had a greater than 95% chance of being cost effective at 20 000 UK pounds per QALY.

CONCLUSION

Several changes in resource use are associated with the use of PP. Given these economic results in tandem with the clinical, operational and patient-related benefits, the wider implementation and evaluation of similar schemes should be considered.

Can emergency medical service staff predict the disposition of patients they are transporting?

BACKGROUND

Emergency medical service (EMS) staff in the UK routinely transport all emergency responses to the nearest emergency department (ED). Proposed reforms in the ambulance service mean that EMS staff will transport patients not necessarily to the nearest hospital, but to one providing facilities that the patient is judged to require. No previous UK studies have evaluated how accurately EMS staff can predict which transported patients will require admission to hospital.

OBJECTIVES

To survey EMS staff regarding the appropriate use of their service and determine whether they can predict which patients will require hospital admission.

METHODS

A prospective ''service evaluation'' of EMS staff transporting patients to an adult ED in the UK. Staff were asked to state whether ED attendance by emergency ambulance was appropriate and whether transported patients would be admitted or discharged from the ED.

RESULTS

During the study period, there were 2553 emergency transports to the ED and questionnaires were completed in 396 cases (15.5%). EMS staff predicted that 182 (46.0%) would be admitted to hospital and 214 (54.0%) would be discharged. Actual dispositions were 187 (47.2%) versus 209 (52.8%) respectively. Sensitivity of predicting admission was 71.7% (95% CI 65 to 78) and specificity was 77.0% (95% CI 71 to 81). EMS staff were significantly better at predicting admission in non-trauma cases than trauma cases (75.9% vs 57.1%, 95% CI 2.2 to 35.4).

CONCLUSION

Staff in one UK ambulance service showed reasonable accuracy when predicting the likelihood of admission of patients they transport. They correctly identified most patients who would be able to leave. Further work is needed to support these findings and ensure that EMS staff safely triage patients to alternative destinations of care.

Long-term clinical and positron emission tomography outcome of fetal striatal transplantation in Huntington's disease

Two patients with moderate Huntington's disease (HD) received bilateral fetal striatal allografts. One patient demonstrated, for the first time, increased striatal D2 receptor binding, evident with 11C-raclopride positron emission tomography, and prolonged clinical improvement over 5 years, suggesting long term survival and efficacy of the graft. The other patient did not improve clinically or radiologically. Our results indicate that striatal transplantation in HD may be beneficial but further studies are needed to confirm this.