Community surveillance of falls among the elderly using computerized EMS transport data

The prehospital management of ambulance-attended adults who fell: A scoping review

BACKGROUND

The ageing population is requiring more ambulance attendances for falls. This scoping review aimed to map and synthesise the evidence for the prehospital management of Emergency Medical Services (EMS) attended adult patients who fall.

METHODS

The Joanna Briggs Institute methods for scoping reviews were used. Six databases were searched (Medline, Scopus, CINAHL, Cochrane, EMBASE, ProQuest), 1st August 2021. Included sources reported: ambulance attended (context), adults who fell (population), injuries, interventions or disposition data (concept). Data were narratively synthesised.

RESULTS

One-hundred and fifteen research sources met the inclusion criteria. Detailed information describing prehospital delivered EMS interventions, transport decisions and alternative care pathways was limited. Overall, adults< 65 years were less likely than older adults to be attended repeatedly and/or not transported. Being male, falling from height and sustaining severe injuries were associated with transport to major trauma centres. Older females, falling from standing/low height with minor injuries were less likely to be transported to major trauma centres.

CONCLUSION

The relationship between patient characteristics, falls and resulting injuries were well described in the literature. Other evidence about EMS management in prehospital settings was limited. Further research regarding prehospital interventions, transport decisions and alternative care pathways in the prehospital setting is recommended.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Programs and Place: Risk and Asset Mapping for Fall Prevention

Identifying ways to measure access, availability, and utilization of health-care services, relative to at-risk areas or populations, is critical in providing practical and actionable information to key stakeholders. This study identified the prevalence and geospatial distribution of fall-related emergency medical services (EMS) calls in relation to the delivery of an evidence-based fall prevention program in Tarrant County, Texas over a 3-year time period. It aims to educate public health professionals and EMS first respondents about the application of geographic information system programs to identify risk-related “hot spots,” service gaps, and community assets to reduce falls among older adults. On average, 96.09 (±108.65) calls were received per ZIP Code (ranging from 0 calls to 386 calls). On average, EMS calls per ZIP Code increased from 30.80 (±34.70) calls in 2009 to 33.75 (±39.58) calls in 2011, which indicate a modest annual call increase over the 3-year study period. The percent of ZIP Codes offering A Matter of Balance/Volunteer Lay Leader Model (AMOB/VLL) workshops increased from 27.3% in 2009 to 34.5% in 2011. On average, AMOB/VLL workshops were offered in ZIP Codes with more fall-related EMS calls over the 3-year study period. Findings suggest that the study community was providing evidence-based fall prevention programming (AMOB/VLL workshops) in higher-risk areas. Opportunities for strategic service expansion were revealed through the identification of fall-related hot spots and asset mapping.

Coordinating Care for Falls via Emergency Responders: A Feasibility Study of a Brief At-Scene Intervention

Falls account for a substantial portion of 9-1-1 calls, but few studies have examined the potential for an emergency medical system role in fall prevention. We tested the feasibility and effectiveness of an emergency medical technician (EMT)-delivered, at-scene intervention to link elders calling 9-1-1 for a fall with a multifactorial fall prevention program in their community. The intervention was conducted in a single fire department in King County, Washington and consisted of a brief public health message about the preventability of falls and written fall prevention program information left at scene. Data sources included 9-1-1 reports, telephone interviews with intervention department fallers and sociodemographically comparable fallers from three other fire departments in the same county, and in-person discussions with intervention department EMTs. Interviews elicited faller recall and perceptions of the intervention, EMT perceptions of intervention feasibility, and resultant referrals. Sixteen percent of all 9-1-1 calls during the intervention period were for falls. The intervention was delivered to 49% of fallers, the majority of whom (75%) were left at scene. Their mean age (N = 92) was 80 ± 8 years; 78% were women, 39% had annual incomes under $20K, and 34% lived alone. Thirty-five percent reported that an EMT had discussed falls and fall prevention (vs. 8% of comparison group, P < 0.01); 84% reported that the information was useful. Six percent reported having made an appointment with a fall prevention program (vs. 3% of comparison group). EMTs reported that the intervention was worthwhile and did not add substantially to their workload. A brief, at-scene intervention is feasible and acceptable to fallers and EMTs. Although it activates only a small percent to seek out fall prevention programs, the public health impact of this low-cost strategy may be substantial.

Improving agricultural injury surveillance: a comparison of incidence and type of injury event among three data sources

BACKGROUND

Agriculture ranks as one of the most hazardous industries in the nation. Ongoing injury surveillance is key to identifying and preventing major sources of injury.

OBJECTIVE

The objective of this study was to compare the total number and types of injuries identified from community reporting versus two newly available medical data systems. These new systems are important because they are less time consuming and expensive to maintain.

METHOD

Farm injury case records from 2007 were collected for 10 NY counties from the following sources: ambulance reports, hospital data, and community surveillance data.

RESULTS

For the 107 ambulance report cases, horses (35%), tractors (15%), and livestock (10%) were the three leading injury sources. For the 261 hospital cases, the leading sources were hand tools (24%), farmstead machinery (23%), and buildings/structures/surfaces (22%). Tractor injuries (37%) were the most common source of injuries identified by the 44 community surveillance cases. Struck by object was the most frequent injury event type for hospital and surveillance data (34%, 30%). Falls were the highest category for ambulance reports (36%) and were also common for hospital data (29%). Nine of the 11 fatal cases were found through community surveillance.

CONCLUSION

Ambulance reports and hospital data contribute a large number of additional farm injury cases to existing surveillance data. From these cases, horse injuries, falls, and hand tool injuries appear to play a larger role in farm injuries. Future research should explore how to best use these electronic resources for agricultural injury surveillance.

Limitations of Secondary Data Sets for Road Traffic Injury Epidemiology:

OBJECTIVES

To evaluate the completeness of descriptive information and accuracy of ambulance data when compared with two other secondary sources of data, namely, medical examiners' reports and medical records, in the city of Karachi, Pakistan.

METHODS

A retrospective chart review was carried out of all road traffic injury (RTI) victims transported by an ambulance service in Karachi from January 1 to December 31, 2003. Information on the name, age, and gender of the victim, date, time, and place of injury, and type of injury and its outcome was obtained, and then compared with medical examiners' data and inpatient medical records. The variables missing in the ambulance service database were identified.

RESULTS

The ambulance service transported 1,245 RTI patients during 2003, 81% of whom were taken to one of three trauma centers. Twenty percent died before reaching hospital. There were missing variables in 340 (27%) cases, the majority of which were the unique identifiers such as name and age (67%). Data on other variables were reported in 95% or more cases. None of the medical examiners' reports or inpatient medical records contained a description of event of injury. The agreement rate for the variables available in the three data sets ranged from 61% to 100%.

CONCLUSION

Secondary data on injuries, such as ambulance reports, medical examiners' reports, and medical records, have significant limitations. In Karachi, except with regard to unique identifiers, ambulance data seem to provide information just as accurate as that in medical examiners' and inpatient medical records.

It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults

Systematic evidence reviews support the efficacy of physical activity programs and multifactorial strategies for fall prevention. However, community settings in which fall prevention programs occur often differ substantially from the research settings in which efficacy was first demonstrated. Because of these differences, alternative approaches are needed to judge the adequacy of fall prevention activities occurring as part of standard medical care or community efforts. This paper uses the World Health Organization Innovative Care for Chronic Conditions (ICCC) framework to rethink how fall prevention programs might be implemented routinely in both medical and community settings. Examples of innovative programs and policies that provide fall prevention strategies consistent with the ICCC framework are highlighted, and evidence where available is provided on the effects of these strategies on processes and outcomes of care. Finally, a "no wrong door" approach to fall prevention and management is proposed, in which older adults who are found to be at risk of falls in either a medical or community setting are linked to a standard fall risk evaluation across three domains (physical activity, medical risks, and home safety).

Monitoring the "tip of the iceberg'': ambulance records as a source of injury surveillance

AIMS

The aim of this study was to describe the epidemiology of moderate and severe injury morbidity in a defined population on the basis of ambulance records, and to validate ambulance records as a potential source of surveillance.

METHODS

A geographical target area was defined; the county of Värmland, Sweden. All ambulance attendances and hospitalizations for unintentional and intentional injury in 2002 were selected, analysed, and compared.

RESULTS

Ambulance data comprised 3,964 injury cases (14.5/1,000). Most injuries for which ambulance attention was sought occurred in road traffic areas (27%), followed by residential areas (20%), school and institutional areas (14%), and sports areas (8%). An ecological comparison between ambulance-based data and hospitalizations showed that ambulance services captured approximately the same amount of injury cases (3,235 ambulance reports, as compared to 3,456 hospital discharges) with a similar profile.

CONCLUSIONS

This study provides epidemiological support for ambulance services as a potential source of regular surveillance data on moderate and severe injuries. However, at a population level, our results indicate that ambulance data tend to overestimate some injury categories, and underestimate others, as compared to hospital data. The significance of these differences for preventive work, as well as other practical aspects of the feasibility of regular injury surveillance, will be analysed and discussed on the basis of general criteria for evaluation of surveillance systems in a forthcoming paper.

A study design to investigate the effect of intense Tai Chi in reducing falls among older adults transitioning to frailty

This paper describes the study design, methodological considerations, and baseline characteristics of a clinical trial to determine if intense (48 weeks, twice per week) Tai Chi practice can reduce the frequency of falls among older adults transitioning to frailty compared to a wellness education program. Twenty facilities will be stratified on socioeconomic status and facility type and randomly assigned to one of the two interventions. Secondary outcome measurements include variables related to function, behavior, and the biomechanics of movement. This study is unique because it represents an effort to offer a novel physical intervention to a large sample of transitional frail adults, a population that has received few formal exercise interventions. In addition to bringing the interventions into facilities, a 1-year follow-up is also included to assess rates of change in outcome measurements.

Hospitalized fall injuries and race in California

OBJECTIVE

To compare risks for falls and their consequences among four major race/ethnic groups in California.

METHODS

Cases are 104,902 hospital discharges of California residents with a same level fall injury as the principal external cause of injury. Included are all discharges for a first hospitalization for a given injury in any California non-federal hospital from 1995-97. Analysis includes crude and age standardized rates to describe risks, diagnoses, and consequences.

RESULTS

Rates per 100 000 for same level hospitalized fall injuries for whites (161) are distinctively higher than for blacks (64), Hispanics (43), and Asian/Pacific Islanders (35). Whites are more likely to have a fracture diagnosis and to be discharged to long term care rather than home, suggesting a poorer outcome or greater severity. Same level falls absorb a large proportion of hospital resources directed to the treatment of injuries.

CONCLUSIONS

In a four way comparison among race/ethnic groups, whites are distinguished by their high incidence, rates of fracture, and unfavorable discharge status. Prevention, particularly aimed at whites, has potential to improve health and save treatment resources.

The role of emergency medical services in primary injury prevention. East Carolina Injury Prevention Program

Injury is a leading cause of death and disability. Preventing injuries from ever occurring is primary injury prevention (PIP). The objective of this statement is to present the consensus of a 16-member panel of leaders from the out-of-hospital emergency medical services (EMS) community on essential and desirable EMS PIP activities. Essential PIP activities for leaders and decision makers of every EMS system include: protecting individual EMS providers from injury; providing education to EMS providers in PIP fundamentals; supporting and promoting the collection and utilization of injury data; obtaining support for PIP activities; networking with other injury prevention organizations; empowering individual EMS providers to conduct PIP activities; interacting with the media to promote injury prevention; and participating in community injury prevention interventions. Essential PIP knowledge areas for EMS providers include: PIP principles; personal injury prevention and role modeling; safe emergency vehicle operation; injury risk identification; documentation of injury data; and one-on-one safety education.

The role of emergency medical services in primary injury prevention. Consensus workshop. Arlington, Virginia, August 25-26, 1995

Injury is a leading cause of death and disability. Preventing injuries from ever occurring is primary injury prevention (PIP). The objective of this statement is to present the consensus of a 16-member panel of leaders from the out-of-hospital emergency medical services (EMS) community on essential and desirable EMS PIP activities. Essential PIP activities for leaders and decision makers of every EMS system include: protecting individual EMS providers from injury; providing education to EMS providers in PIP fundamentals; supporting and promoting the collection and utilization of injury data; obtaining support for PIP activities; networking with other injury prevention organizations; empowering individual EMS providers to conduct PIP activities; interacting with the media to promote injury prevention; and participating in community injury prevention interventions. Essential PIP knowledge areas for EMS providers include: PIP principles; personal injury prevention and role modeling; safe emergency vehicle operation; injury risk identification; documentation of injury data; and one-on-one safety education.

Injury prevention: is there a role for out-of-hospital emergency medical services?

OBJECTIVE

To review the literature for options for integrating injury prevention into the role of out-of-hospital emergency medical services (EMS).

DATA SOURCES

Computerized searches of the English-language literature from 1966 through 1994 were conducted using the MEDLINE and National Association of EMS Physicians (NAEMSP) databases. These were supplemented by hand searches of pertinent journals not indexed on MEDLINE or by NAEMSP and the reference lists of retrieved articles. Key words searched included emergency medical services, accident, injury, prevention, and safety.

ARTICLE SELECTION

The review included all articles that described the experience of EMS organizations or individuals providing primary injury prevention (PIP) services or that proposed EMS PIP activities.

SYNTHESIS

PIP EMS experiences and PIP activities proposed for EMS included: preventing injuries in EMS providers, serving as role models, identifying persons at risk for injury, providing prevention counseling, collecting injury data, surveying residences and institutions for injury risks and hazards, conducting educational programs and media campaigns, and advocating legislative changes that promote injury prevention. Few studies have evaluated the effectiveness of EMS PIP activities.

CONCLUSION

As changes in the market compel health care systems to focus more on prevention, EMS organizations and individual providers may be assuming new injury prevention roles. Some EMS systems in many parts of the country have incorporated PIP into their work. It is necessary, however, to determine which PIP roles are effective and how they will be supported.

Geriatric use of emergency medical services

STUDY OBJECTIVE

To quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients.

METHODS

We conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older.

RESULTS

Of the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05).

CONCLUSION

Use by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.