Repeat emergency medical services use by older adults in a rural community: impact on research methods and study length

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database

STUDY OBJECTIVE

The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region.

METHODS

Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport.

RESULTS

During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14).

CONCLUSION

More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Prehospital Providers’ Perceptions of Emergency Calls Near Life’s End

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers’ perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory–descriptive pilot study was survey based and cross-sectional. Calls to nursing homes occur most often, (47.8% every shift). The MOLST was seen infrequently (57.9% rarely never). The most frequent signs and symptoms of dying were diagnosis (76%), hospice involvement (82%), apnea (75%), mottling (55%), and shortness of breath (48%). The MOLST identifies wishes about intubation (74%), resuscitation (74%), life-sustaining treatment (72%), and cardiopulmonary resuscitation (70%). Synergy exists between the fields of prehospital, hospice, and palliative medicine which offers potential for improved education and care.

Operation care: a pilot case management intervention for frequent emergency medical system users

OBJECTIVES

This study aims to determine if a prehospital case management intervention reduces transport and nontransport emergency medical system (EMS) responses to frequent EMS users.

METHODS

The 25 most frequent EMS users in a major metropolitan area were identified, and 10 were enrolled in the intervention. These patients received linkage to psychosocial and medical resources through weekly case management visits for 5 to 12 weeks between May and August 2008. Main outcome measures were the number of transport and nontransport EMS responses to patients during the intervention as compared with predicted EMS responses based on each patient's previous year's EMS use. Transport data were available for all patients, but nontransport data were unavailable for 1 patient who was homeless and 6 patients living in apartment buildings. Secondary outcome measures included cost savings to the entire health care system and the Baltimore City Fire Department.

RESULTS

Transport responses decreased 32% over the 76 predicted transport responses during the intervention, and nontransport responses decreased 79% over the 24 predicted nontransport responses during the intervention. Including the dedicated case manager's salary, this represented a cost savings to the entire health care system and to the Baltimore City Fire Department of $14 461 and $6311, respectively, over 12 weeks.

CONCLUSIONS

Prehospital case management may reduce EMS use in high-frequency EMS users and create significant cost savings to municipalities and the health care system. Additional large-scale studies are needed to validate these findings.

Injury hospitalization as a marker for emergency medical services use in elderly patients

BACKGROUND

The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs.

OBJECTIVE

To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients.

METHODS

This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization.

RESULTS

There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care.

CONCLUSION

An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.