1
|
Friend TH, Ordoobadi AJ, Cooper Z, Salim A, Jarman MP. Identifying opportunities for community EMS fall prevention. Injury 2024:111915. [PMID: 39327113 DOI: 10.1016/j.injury.2024.111915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/19/2024] [Accepted: 09/16/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Falls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions. MATERIALS AND METHODS We linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall. RESULTS Of 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p < 0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p < 0.001; 10% vs. 6% enrolled in Medicaid, p < 0.001) compared to those without a prior EMS encounter. CONCLUSIONS A significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.
Collapse
Affiliation(s)
- Tynan H Friend
- Warren Alpert Medical School of Brown University, Providence, RI, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Alexander J Ordoobadi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Gillian Reny Stepping Strong Center for Trauma Innovation, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Gillian Reny Stepping Strong Center for Trauma Innovation, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Gillian Reny Stepping Strong Center for Trauma Innovation, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Friend TH, Thomas HM, Ordoobadi AJ, Bain PA, Jarman MP. Community emergency medical services approaches to fall prevention: a systematic review. Inj Prev 2024:ip-2023-045110. [PMID: 39038943 DOI: 10.1136/ip-2023-045110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 07/01/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Falls are a leading cause of morbidity and mortality among older adults in the USA. Current approaches to fall prevention often rely on referral by primary care providers or enrolment during inpatient admissions. Community emergency medical services (CEMS) present a unique opportunity to rapidly identify older adults at risk for falls and provide fall prevention interventions in the home. In this systematic review, we seek to assess the efficacy and qualitative factors determining success of these programs. METHODS Studies reporting the outcomes of fall prevention interventions delivered by EMS were identified by searching the electronic databases PubMed, Embase, Web of Science Core Collection, CINAHL and the Cochrane Central Register of Controlled Trials through 11 July 2023. RESULTS 35 studies including randomised and non-randomised experimental trials, systematic reviews and qualitative research primarily from Western Europe, the USA, Australia and Canada were included in our analysis. Current fall prevention efforts focus heavily on postfall referral of at-risk community members. CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes. CONCLUSIONS CEMS programmes provide an opportunity for direct, proactive fall prevention on the individual level. Addressing barriers to implementation in the context of current emergency medical systems in the USA is the next step toward widespread implementation of these novel fall prevention interventions.
Collapse
Affiliation(s)
- Tynan H Friend
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hannah M Thomas
- Department of Orthopaedic Surgery, University of California Irvine, Irvine, California, USA
- Harvard Medical School Orthopaedic Trauma Initiative, Boston, Massachusetts, USA
| | - Alexander J Ordoobadi
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul A Bain
- Harvard University Francis A Countway Library of Medicine, Boston, Massachusetts, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Watkins PM, Hill AM, Tohira H, Brink D, Finn J, Buzzacott P. Epidemiology of ambulance-attended adults who fell in Western Australia 2015 - 2021: An increasing incidence in an ageing population. Injury 2023; 54:111035. [PMID: 37777369 DOI: 10.1016/j.injury.2023.111035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Emergency Medical Services (EMS) are attending an increasing number of adults who fall. This study aimed to describe the incidence, patient characteristics, treatments and disposition of ambulance attended patients who fell in Western Australia (WA). METHODS An ordinal logistic regression (using STATA) was conducted in this retrospective cohort study, analysing predictors of lower compared to higher transport urgency levels. Participants were adults ( ≥ 18 years) who fell and required ambulance attendance in WA between 1st January 2015 - 31st December 2021. RESULTS A total of 188,720 patients (female = 107,811, 57 %) were attended by ambulances after falls, (median age = 80 years [IQR 67-87]). The age-standardized incidence rate of ambulance attended falls increased from 115 cases/100,000 person-years to 161 cases/100,000 person-years between 2015 and 2021. A total of 89,140 (47 %) patients had an injury recorded by paramedics, most often lacerations or suspected fractures. The electronic patient care record showed, 50,044 (26.5 %) patients received medication and 30,954 (16.4 %) patients received other intervention, e.g., ECG. A total of 148,050 (78 %) patients were transported to hospital with the following urgency levels: 2,371 (2 %) via urgency one; 27,882 (19 %) via urgency two, 93,447 (63 %) via urgency three and 22,584 (15 %) via urgency four and five ( < 1 % unknown urgency). Positive predictors of lower level transport urgency to hospital included being female and older than 65 years of age. CONCLUSION Older, female patients had higher odds of being transported via a lower urgency, with 50 % of this cohort transported via urgency three. While 19 % of patients were attended via a Priority one, only 1 % were transported to hospital via urgency one. The incidence rate of falls requiring ambulance attendance has increased over time, increasing the demand placed on EMS annually.
Collapse
Affiliation(s)
- Paige M Watkins
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia.
| | - Anne-Marie Hill
- School of Allied Health, University of Western Australia, Perth, Australia
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia; Discipline of Emergency Medicine, Medical School, The University of Western Australia, Perth, Australia
| | - Deon Brink
- St John Western Australia, Belmont, Australia
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia; St John Western Australia, Belmont, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Buzzacott
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia
| |
Collapse
|
4
|
Bouzid W, Tavassoli N, Berbon C, Qassemi S, Vaysset S, Poly M, Bounes V, Shourick J, Nourhashémi F. Exploring Population Characteristics and Recruitment Challenges in Older People Experiencing Falls at Home without Hospitalization or with an Emergency Department Visit: Insights from the RISING-DOM Experience. Clin Interv Aging 2023; 18:1995-2008. [PMID: 38058551 PMCID: PMC10697010 DOI: 10.2147/cia.s421053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/05/2023] [Indexed: 12/08/2023] Open
Abstract
Background An increasing number of falls among community-living older adults are reported in emergency calls. Data on evidence of appropriate fall prevention interventions are limited and challenges in recruiting this population in randomized trials are acknowledged. Purpose The main aim of this study was to provide demographic data, circumstance and fall-related outcomes of the population in the RISING-DOM study [Impact d'une évaluation des facteurs de RISque de chute et d'une prise en charge personnalisée, sur la mortalité et l'institutionnalisation, après INtervention du SAMU chez la personne âGée à DOMicile], a multicenter, randomized interventional trial involving community-dwelling older adults who have experienced a fall at home and were not hospitalized. Additionally, the challenges of remote recruitment in this population were discussed. Patients and Methods Participants were identified through the Occitania Emergency Observatory database. Participant recruitment and data collection were performed through telephone interviews (October 2019-March 2022). Additionally, a sample survey of Emergency Medical Services calls was carried out. Results Out of the 1151 individuals screened, a total of 951 participants were included in the trial follow-up, resulting in an acceptance rate of 82.62%. The screening delay was extended due to the COVID-19 pandemic. Recruiting difficulties were mainly related to identifying potential participants, unavailable contact information and unreachability. Participants' mean age was 84.1 years, 65.8% were women, and 44.3% lived alone. Pain was the most frequent outcome (53%). In the previous year, 73.5% of participants reported experiencing a fall, with 66.7% of those falls requiring assistance from Emergency Medical Services (EMS). Nearly, 40% did not take proactive steps to prevent future falls and walking aids (79.8%) were the most common preventive action. Conclusion Indicators of a high-risk group of falls have been identified underscoring the need for appropriate fall interventions in the target population. Challenges of large sampling for randomized fall prevention trials were provided. Trial Registration Clinicaltrials.gov identifier: NCT04132544. Registration date: 18/10/2019. https://www.clinicaltrials.gov/ct2/show/NCT04132544?term=rising-dom&draw=2&rank=1.
Collapse
Affiliation(s)
- Wafa Bouzid
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
- Regional Health Agency of Occitanie, Toulouse, 31000, France
| | - Neda Tavassoli
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
| | - Caroline Berbon
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
| | - Soraya Qassemi
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
| | - Sandrine Vaysset
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
| | - Magali Poly
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
| | - Vincent Bounes
- Emergency Medicine Unit, University of Toulouse Hospital Center, Toulouse, France
| | - Jason Shourick
- Research Methodology Support Unit (USMR), Clinical Epidemiology and Public Health Department, University of Toulouse Hospital Center, Toulouse, France
- CERPOP, UMR 1295, INSERM – University of Toulouse III, Toulouse, France
| | - Fati Nourhashémi
- Geriatric Medicine Unit (Gérontopole), University of Toulouse Hospital Center, Toulouse, France
- CERPOP, UMR 1295, INSERM – University of Toulouse III, Toulouse, France
| |
Collapse
|
5
|
Peters A, Lim D, Naidoo N. Down with falls! Paramedicine scope regarding falls amongst older adults in rural and remote communities: A scoping review. Aust J Rural Health 2023. [PMID: 37200405 DOI: 10.1111/ajr.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION Australian rural and remote areas are faced with the double burden of an ageing population paired with inequitable access to health resources due to the paradigm of major city centred health care. This complicates fall management within this space. Paramedics are a registered health profession, which provides mobile, equitable health care. However, this resource is not being effectively utilised in rural and remote areas where primary care access barriers may cause patient needs to go unmet. OBJECTIVE To describe the existing literature and describe the international scope of current paramedicine practice in the out-of-hospital management of falls amongst older adults in rural and remote settings. DESIGN Joanna Briggs Institute scoping review methodology was employed. CINAHL (EBSCO), MEDLINE (Ovid), EMBASE (Ovid), SCOPUS (Elsevier), Google Scholar and These Global were searched and Australian, New Zealand and the UK ambulance service guidelines were sought. FINDINGS Two records met inclusion criteria. Currently, rural and remote paramedic fall management involves preventative health promotion through patient education, population-based screening and referrals. DISCUSSION The use of paramedics to screen at-risk populations and refer is vital, as many rural adults had screened positive to fall risks and other unmet needs. There is poor recollection of physically printed education material and low acceptance of further in-home assessments following paramedic departure. CONCLUSION This scoping review has highlighted a significant knowledge gap on this topic. Further research is needed to effectively utilise paramedicine within areas where access to primary care is not possible to achieve downstream, risk reducing care in the home.
Collapse
Affiliation(s)
- Aidan Peters
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - David Lim
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- Centre for Remote Health, Alice Springs, Northern Territory, Australia
| | - Navindhra Naidoo
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| |
Collapse
|
6
|
Lederman J, Löfvenmark C, Djärv T, Lindström V, Elmqvist C. A phenomenological interview study with patients being non-conveyed in the ambulance service. BMC Emerg Med 2023; 23:30. [PMID: 36927353 PMCID: PMC10021955 DOI: 10.1186/s12873-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients' non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context. METHODS A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region. RESULTS Patients' lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security. CONCLUSIONS Patients' lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation's complexity from a patient's perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.
Collapse
Affiliation(s)
- Jakob Lederman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
- Academic Emergency Medical Services/AISAB Ambulance care in Greater Stockholm Ltd, Region Stockholm, Sweden.
| | - Caroline Löfvenmark
- Department of Health promoting science, Sophiahemmet University, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Lindström
- Department of Neurobiology, Care Sciences and Society, section of nursing, Karolinska Institutet, Stockholm, Sweden
- Samariten Ambulance, Stockholm, Sweden
| | - Carina Elmqvist
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Cooperation within Emergency care (CICE), Linnaeus University, Växjö, Sweden
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
| |
Collapse
|
7
|
The prehospital management of ambulance-attended adults who fell: A scoping review. Australas Emerg Care 2023; 26:45-53. [PMID: 35909044 DOI: 10.1016/j.auec.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
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.
Collapse
|
8
|
Gorji MAH, Sahebi AK, Yaghoubi T, Cherati JY, Ahmed S, Zhianfar L. Investigating the link between organisational justice, positive organisational behaviour and productivity in emergency nurses. Emerg Nurse 2023; 31:33-40. [PMID: 36217750 DOI: 10.7748/en.2022.e2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Human resource management and employees' performance are fundamental to the success of healthcare organisations. Therefore, it is important to consider the factors that may affect employees' performance. AIM To determine the relationship between perceived organisational justice, positive organisational behaviour (POB) and the productivity of emergency nurses. METHOD This was a descriptive-analytical study that involved distributing questionnaires to emergency nurses working in hospitals affiliated with Mazandaran University of Medical Sciences in Iran. The researchers used proportionate stratified sampling to calculate the sample size. Three questionnaires were used to collect data on organisational justice, POB and productivity. The data were analysed using the Pearson correlation coefficient and multiple regression tests. RESULTS The questionnaires were distributed to 284 emergency nurses and completed by 234 of them. The results demonstrated a significant relationship between the productivity of the emergency nurses and the variables of perceived organisational justice and POB. CONCLUSION Higher levels of perceived organisational justice and POB in the ED setting are likely to lead to increased productivity among emergency nurses, and as a result the quality of patient care is likely to improve. Therefore, healthcare organisations should pay particular attention to the application of organisational justice, with the aim of promoting POB among nurses and increasing their productivity.
Collapse
Affiliation(s)
| | | | - Tahereh Yaghoubi
- Traditional and Complementary Medicine Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Jamshid Yazdani Cherati
- Faculty of Health, Health Sciences Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Leila Zhianfar
- Community Health Department, Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|
9
|
Bouzid W, Tavassoli N, Berbon C, Qassemi S, Bounes V, Azema O, Shourick J, Nourhashémi F. Impact of a personalised care plan for the elderly calling emergency medical services after a fall at home: The RISING-DOM multi-centre randomised controlled trial protocol. BMC Geriatr 2022; 22:182. [PMID: 35246053 PMCID: PMC8894840 DOI: 10.1186/s12877-022-02850-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A growing number of emergency calls are made each year for elderly people who fall. Many of them are not taken to hospital or are rapidly discharged from the Emergency Department (ED). Evidence shows that, with no further support, this vulnerable population is particularly at risk of injuries, dependency and death. This study aims to determine the effectiveness of a comprehensive geriatric assessment and a tailored intervention in the elderly calling on an Emergency Medical Service (EMS) for a fall at home, but not conveyed to the ED or rapidly discharged from it (less than 24 h from hospitalisation), to the time to institutionalisation or death. METHODS Rising-Dom is a two-arm randomised (ratio 1:1), interventional, multi-centre and open study. Community-dwelling elderly people (≥ 70 years) who call an EMS for a fall at home are recruited. The intervention group receives home visits by a nurse with a comprehensive fall risk assessment and a personalised intervention care plan with a planned follow-up (six nurse home visits and five nurse phone calls). Subjects enrolled in the usual care-control group continue to receive their routine care for the prevention or treatment of diseases. Primary (time to institutionalisation or death) and secondary (unscheduled hospitalisations, additional EMS calls relating to falls, functional decline and quality of life) outcome data will be collected for both groups through five phone calls made by Clinical Research Associates (CRA) blind to the participants' group during the follow-up period (24-months). Twelve hospital centres in the South-West of France are participating in the study as study sites. The inclusion period started in October 2019 and will end in March 2022. By the end of this period, 1,190 subjects are expected to be enrolled. DISCUSSION Studies on elderly home falls have rarely concerned people who were not taken to hospital. The Rising-Dom intervention scheme should enhance understanding of features related to this vulnerable population and investigate the impact of a nurse care at home on delaying death and institutionalisation. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04132544. Registration date: 18/10/2019. SPONSOR University Hospital, Toulouse. https://www.clinicaltrials.gov/ct2/show/NCT04132544?term=rising-dom&draw=2&rank=1.
Collapse
Affiliation(s)
- Wafa Bouzid
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
| | - Neda Tavassoli
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Caroline Berbon
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Soraya Qassemi
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Vincent Bounes
- Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Azema
- Observatoire Régional Des Urgences d'Occitanie (ORU Occitanie), Hôpital La Grave, Place Lange, 31300, Toulouse, France
| | - Jason Shourick
- Unité de Soutien Méthodologique À La Recherche (USMR), Service d'Epidémiologie Clinique Et de Santé Publique, CHU de Toulouse, Toulouse, France
- CERPOP, UMR 1295, INSERM - Université de Toulouse III, Toulouse, France
| | - Fati Nourhashémi
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- CERPOP, UMR 1295, INSERM - Université de Toulouse III, Toulouse, France
| |
Collapse
|
10
|
Mikolaizak AS, Harvey L, Toson B, Lord SR, Tiedemann A, Howard K, Close JCT. Linking health service utilisation and mortality data-unravelling what happens after fall-related paramedic care. Age Ageing 2022; 51:6514234. [PMID: 35077557 DOI: 10.1093/ageing/afab254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A randomised controlled trial implemented and evaluated a new model of care for non-transported older fallers to prevent future falls and unplanned health service use. This current study uses linked data to evaluate the effects of the intervention beyond the initial 12-month study period. METHOD Study data from an established cohort of 221 adults were linked to administrative data from NSW Ambulance, Emergency Department Data Collection, Admitted Patient Data Collection and Registry of Births, Deaths and Marriages evaluating health service use at 12, 24 and 36 months following randomisation including time to event (health service utilisation) and mortality. Negative binomial and Cox's proportional hazard regression were performed to capture the impact of the study between groups and adherence status. RESULTS At 36 months follow-up, 89% of participants called an ambulance, 87% attended the Emergency Department and 91% were admitted to hospital. There were no significant differences in all-cause health service utilisation between the control and intervention group (IG) at 12, 24 and 36 months follow-up. Fall-related health service use was significantly higher within the IG at 12 (IRR:1.40 (95%CI:1.01-1.94) and 24 months (IRR:1.43 (95%CI:1.05-1.95)). Medication use, impaired balance and previous falls were associated with subsequent health service use. Over 40% of participants died by the follow-up period with risk of death lower in the IG at 36 months (HR:0.64, 95%CI:0.45-0.91). CONCLUSION Non-transported fallers have a high risk of future health service use for fall and other medical-related reasons. Interventions which address this risk need to be further explored.
Collapse
|
11
|
Pakdemirli A, Bayram B, Güvenç E, Ellidokuz H. Evaluation of ambulance calls for patients over 65 years of age in İzmir, Turkey: a two- year retrospective analysis. Turk J Med Sci 2021; 51:1253-1260. [PMID: 33726483 PMCID: PMC8283469 DOI: 10.3906/sag-2010-152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background/aim Analysis of interventions for special patient groups is important for the planning of health services, especially emergency medical services. In this study, we aimed to evaluate emergency medical service (EMS) interventions for the elderly and determine the decisive factors affecting transfer to the hospital of EMS team over 2 years (2017 and 2018) in İzmir. Materials and methods Records of 112 emergency calls that were made between 2017 and 2018 followed up with interventions for patients aged 65 years and older were obtained from the 112 system. The reasons for the calls, outcomes, possible diagnoses of the patients, differences in time intervals and seasons, characteristics of the patients transferred to the hospital, and factors affecting the need for transfer to the hospital were investigated. Results A total of 176,104 elderly patients with a mean age of 78.02 ± 8.0 years required ambulance services, and out of them, 66% were transferred to the hospital. Transfer to the hospital was significantly associated with the event location, sex, time interval, international classification of diseases (ICD) codes, and physical examination findings. Conclusion Ambulance interventions are more frequently required in urban areas than in the countryside, and calls are mostly made during daytime hours and during winter months. The decision to transfer a patient to the hospital is based on the patient’s respiratory status, skin examination, state of consciousness, pulse, systolic blood pressure, call time, and the preliminary diagnosis of the crew.
Collapse
Affiliation(s)
- Ahu Pakdemirli
- Department of Physiology, Gülhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Başak Bayram
- Department of Emergency Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Erkan Güvenç
- Department of Emergency Medicine, Buca Seyfi Demirsoy State Hospital, İzmir, Turkey
| | - Hülya Ellidokuz
- Department of Preventative Oncology, Dokuz Eylül University, İzmir, Turkey
| |
Collapse
|
12
|
Bonner M, Capsey M, Batey J. A paramedic's role in reducing number of falls and fall-related emergency service use by over 65s: a systematic review. Br Paramed J 2021; 6:46-52. [PMID: 34335100 PMCID: PMC8312361 DOI: 10.29045/14784726.2021.6.6.1.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Around 10–25% of emergency calls for adults aged over 65 are attributed to falls. Regardless of whether injuries are caused, quality of life is often affected by fear of falling, leading to reduced confidence and activity, negatively impacting mobility and risking depression and isolation. Ambulance service staff are well placed to identify falls risk factors so patients can be directed to falls prevention services. This article aims to determine how the referral by paramedics of uninjured falls patients to community falls services may reduce future falls and emergency services use. Methods: The CINAHL, MEDLINE and AMED electronic databases, grey literature sources and reference lists of relevant papers were systematically searched to identify primary research of an experimental design. Studies were eligible if they included elderly patients, aged over 65, who had received a paramedic response following a fall, were found to be uninjured and who were referred to local falls services rather than being transported to hospital. The study outcomes were required to include the rate of subsequent falls and emergency service use. Results: Four papers from three studies were included in the review following quality assessment. Results were not always statistically significant but showed a reduction in subsequent falls, particularly in the high-risk population, and in emergency service call-outs. A consistent positive effect was seen on the patients’ well-being and independence related to activities of daily living across the studies. Conclusions: The relationship between paramedics and local falls services has changed the pre-hospital management of these patients. Generally, access to a falls-specific care package has proved beneficial in supporting independence and reducing unnecessary transport to hospital. Further research into the uptake of this care pathway by paramedics now it is more established may be useful, as would research into barriers to adherence of the elderly to such an intervention.
Collapse
Affiliation(s)
- Mhairi Bonner
- West Midlands Ambulance Service University NHS Foundation Trust
| | - Matt Capsey
- Teesside University ORCID iD: https://orcid.org/0000-0003-3659-5344
| | - Jo Batey
- South Tees Hospitals NHS Foundation Trust
| |
Collapse
|
13
|
Alanazy ARM, Wark S, Fraser J, Nagle A. Nontransported Cases after Emergency Medical Service Callout in the Rural and Urban Areas of the Riyadh Region. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 9:38-44. [PMID: 33519342 PMCID: PMC7839576 DOI: 10.4103/sjmms.sjmms_560_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 11/04/2022]
Abstract
Background Callouts resulting in patient nontransportation can impact the overall quality of prehospital Emergency Medical Service (EMS), as resources in health care are finite. While some studies have investigated the causes of nontransportation, few have examined whether there are differences between urban and rural patients. Similarly, there has been limited research focused on rural EMS in locations such as the Middle East. Objectives This study investigated EMS cases that resulted in nontransportation in the urban and rural areas of the Riyadh region in the Kingdom of Saudi Arabia. Methods A cross-sectional study of 800 (400 rural and 400 urban) patient records was undertaken, using 12 months (January 1 to December 31, 2017) of data from the Saudi Red Crescent EMS. A random sampling method was used to select ambulance records from the 78 urban and rural EMS stations in the Riyadh region, with demographic data and reasons for patient nontransport analyzed comparatively. Results A total of 310 cases were nontransported (39%) (rural: 146; urban = 164). The highest rates of nontransportation cases were of medical and trauma callouts (44.6% and 39.6%, respectively), which was consistent in both areas. The most common reason for nontransportation in both urban and rural areas was refusal of treatment and transportation (66.5% and 59.9%, respectively). Further, 10 patients were treated on-scene and released by rural EMS, while no urban patients were treated and released. Overall, the case presentations of nontransported patients did not differ significantly between both areas, and it was found that gender, age, and geographic location were not predictors for nontransportation. Conclusions The high rate of nontransportation, particularly in medical and trauma callouts, indicates that a review of current EMS protocols may be required, along with consideration of relevant community education programs.
Collapse
Affiliation(s)
- Ahmed Ramdan M Alanazy
- School of Rural Medicine, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Stuart Wark
- School of Rural Medicine, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - John Fraser
- School of Rural Medicine, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Amanda Nagle
- School of Rural Medicine, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| |
Collapse
|
14
|
Infinger A, Dowbiggin P, Seymour R, Wally M, Karunakar M, Caprio A, Patt J, Studnek JR. Development of a Content Valid and Reliable Prehospital Environmental Falls Risk Assessment Tool for Older Adults. PREHOSP EMERG CARE 2020; 24:349-354. [PMID: 31237795 DOI: 10.1080/10903127.2019.1634777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing tools to assess environmental risk factors developed for consumers or home health providers, assessment of environmental falls risk by emergency medical services (EMS) providers represents a novel approach to primary and secondary prevention. The purpose of this study was to evaluate a content valid and reliable assessment of environmental fall risk to be performed in the prehospital setting. Methods: This was a mixed methods study, conducted from August, 2015 to September, 2017 in Mecklenburg County, NC, utilizing qualitative methodology to develop content valid items for an environmental falls risk assessment and quantitative methodology to assess those items for interrater reliability. Content validity was assessed using 2 expert panels. Expert Panel One was tasked with assessing validity of a construct to indicate an increased risk of an in-home fall for elderly individuals and expert Panel Two was responsible for assessing the likelihood of an EMS professional to identify a construct during their course of patient care. To assess reliability of the identified content valid items, 5 paramedics were recruited for interrater reliability (IRR) testing of the validated falls risk assessment tool. Each paramedic and their partner received education on documentation and deployment of the tool. Crews independently documented presence or absence of each item with pair agreement assessed using Cohen's kappa (κ). Results: A total of 87 items were identified for assessment through review of validated scales and relevant literature, with the content validation process reducing to 9 the number of items tested in the field for reliability. A total of 57 paired assessments were completed and included in analysis. One item returned almost perfect agreement (κ = 0.87), 5 items returned moderate agreement (κ = 0.41-0.54), with the remaining 3 items illustrating fair agreement (κ = 0.33-0.39). Conclusion: We developed a construct valid and reliable assessment of environmental falls risk to be performed in the prehospital setting. Further trials should be conducted using this tool to determine appropriate cut scores and deployment in the prehospital setting to help with primary and secondary fall prevention.
Collapse
|
15
|
O’Cathain A, Jacques R, Stone T, Turner J. Why do ambulance services have different non-transport rates? A national cross sectional study. PLoS One 2018; 13:e0204508. [PMID: 30240418 PMCID: PMC6150527 DOI: 10.1371/journal.pone.0204508] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/10/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Some patients calling ambulance services (known as Emergency Medical Services internationally) are not transported to hospital. In England, national ambulance quality indicators show considerable variation in non-transport rates between the ten large regional ambulance services. The aim of this study was to explain variation between ambulance services in two types of non-transport: discharge at scene and telephone advice. METHODS Mixed model logistic regressions using one month of data (November 2014) from the Computer Aided Despatch systems of the ten large regional ambulance services in England. RESULTS 41% (251 677/615 815) of patients calling ambulance services were not transported to hospital. Most were discharged at scene after attendance by an ambulance (29% n = 182 479) and a small percentage were given telephone advice (7% n = 40 679). Discharge at scene rates varied by patient-level factors e.g. they were higher for elderly patients, where the reason for calling was falls, and for patients attended by paramedics with extended skills. These patient-level factors did not explain variation between ambulance services. After adjustment for patient-level factors, the following ambulance service level factors explained variation in discharge at scene rates: proportion of patients attended by paramedics with extended skills (odds ratio 1.05 (95% CI 1.04, 1.07)), the perception of ambulance service staff that paramedics with extended skills were established and valued within the workforce (odds ratio 1.84 (1.45, 2.33), and the perception of ambulance service staff that senior management viewed non-transport as risky (odds ratio 0.78 (0.63, 0.98)). Variation in telephone advice rates could not be explained. CONCLUSIONS Variation in discharge at scene rates was explained by differences in workforce configuration and managerial motivation, factors that are largely modifiable by ambulance services.
Collapse
Affiliation(s)
- Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
- * E-mail:
| | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Tony Stone
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
16
|
Cox S, Roggenkamp R, Bernard S, Smith K. The epidemiology of elderly falls attended by emergency medical services in Victoria, Australia. Injury 2018; 49:1712-1719. [PMID: 30126534 DOI: 10.1016/j.injury.2018.06.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/06/2018] [Accepted: 06/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND With an increase in the proportion of older people in the community comes an increase in the demand on emergency medical services (EMS) by elderly patients who have fallen. OBJECTIVE To describe the epidemiology of elderly falls patients attended by EMS in Victoria, Australia and identify predictors of transport and repeat falls. METHODS A retrospective review included all elderly (age ≥ 65 years) falls patients attended by EMS between 2010 and 2017. Patient characteristics are described using descriptive statistics. Predictors of transport to hospital and repeat falls were identified using multivariable logistic regression analyses. RESULTS Between 2010 and 2017 EMS attended 324,060 elderly falls patients, which represents 9.7% of EMS attended workload in Victoria. The median age of patients was 83 years (IQR: 76-88) and 60.2% were female. Comorbidities and medication use were common, while private residence (64.3%) and nursing home (20.0%) were common scene locations. Overall, 78.8% of falls events resulted in transport to hospital by EMS. Predictors of transport to hospital included female gender, one or more pre-existing medical conditions or current medications and meeting the pre-hospital trauma triage criteria or hospital major trauma criteria. To investigate predictors of repeat falls, the follow-up period was restricted to 12-months post initial fall, which resulted in 30,997 patients and 42,873 (13.2%) repeat fall incidents. The median number of days between the initial fall and a second fall was 98 (IQR: 27-206). Predictors of repeat falls included living at a nursing home, one or more pre-existing medical conditions and one or more current medications. CONCLUSIONS Older falls patients place significant demand on EMS resources in Victoria, Australia, accounting for 9.7% of EMS attendances. Despite high demand, just 3.8% of elderly falls patients received a 'lights and sirens' emergency transport response to hospital. Furthermore, a large number of falls incidents recorded during the study period were repeat falls. Access to alternative pathways of care like GP referral, allied and community health services may benefit this patient group. Development and enrolment into such programs may improve patient outcomes by minimising falls risk and decrease demand on EMS and hospital resources.
Collapse
Affiliation(s)
- Shelley Cox
- Centre for Research & Evaluation, Medical Directorate, Ambulance Victoria, Victoria, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Victoria, Australia.
| | - Renee Roggenkamp
- Centre for Research & Evaluation, Medical Directorate, Ambulance Victoria, Victoria, Australia
| | - Stephen Bernard
- Centre for Research & Evaluation, Medical Directorate, Ambulance Victoria, Victoria, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Victoria, Australia; Intensive Care Unit, The Alfred Hospital, Victoria, Australia
| | - Karen Smith
- Centre for Research & Evaluation, Medical Directorate, Ambulance Victoria, Victoria, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia; School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Western Australia, Australia
| |
Collapse
|
17
|
Oosterwold J, Sagel D, Berben S, Roodbol P, Broekhuis M. Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review. BMJ Open 2018; 8:e021732. [PMID: 30166299 PMCID: PMC6119414 DOI: 10.1136/bmjopen-2018-021732] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital's emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest. OBJECTIVE To provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions. DATA SOURCES A mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included. STUDY ELIGIBILITY CRITERIA Only studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included. SETTING Prehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance. STUDY APPRAISAL AND SYNTHESIS METHODS The Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a 'best fit' framework synthesis approach. RESULTS ED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male-female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision's outcomes. CONCLUSION Many non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.
Collapse
Affiliation(s)
- Johan Oosterwold
- Department of Health Sciences - Nursing Research, UMC Groningen, Groningen, The Netherlands
- NHL Stenden, University of Applied Sciences, Leeuwarden, The Netherlands
| | - Dennis Sagel
- Ambulance Department, University Medical Center Groningen, Roden, The Netherlands
| | - Sivera Berben
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands
- Eastern Regional Emergency Healthcare Network, Radboud University Medical Centre, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Petrie Roodbol
- Department of Health Sciences - Nursing Research, UMC Groningen, Groningen, The Netherlands
| | - Manda Broekhuis
- Operations Department, Faculty of Economics and Business, Groningen, The Netherlands
| |
Collapse
|
18
|
Schierholtz T, Carter D, Kane A, Kemp O, Gallant C, Sheikh B, Johnston W, Zecevic A. Impact of Lift Assist Calls on Paramedic Services: A Descriptive Study. PREHOSP EMERG CARE 2018; 23:233-240. [PMID: 30118639 DOI: 10.1080/10903127.2018.1483454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The aging population in Canada is steadily increasing and is placing greater demand on paramedic services, especially through the growing number of non-emergent lift assist (LA) calls. A LA occurs when a person calls paramedic services and requests assistance to get up or mobilize, usually after experiencing a fall. The patient refuses transport to the emergency department for further medical attention. LA calls are time consuming and are non-reimbursable. The increase in number of this call type, specifically amongst older adults, is placing strain on paramedic services. OBJECTIVES The purpose of this study was to describe the characteristics of LA calls in patients aged 65 and older and determine their impact on paramedic services. METHODS A dataset of 1,121 LA calls of patients aged 65 and older was extracted from Middlesex-London Emergency Medical Services (MLEMS) database of electronic patient care reports collected over 1 year in 2015. Statistical and qualitative analyses were performed to describe LAs, perform time analysis, and extract dominant themes from the text in report notes written by paramedics. RESULTS The LA calls were generated from 611 individuals: 334 women (54.7%) and 275 men (45%), of which 192 (32%) individuals called more than one time. On average, a LA call lasted 43 minutes and ranged from 6 minutes to 2 hours and 23 minutes. In 2015, paramedics spent 801 hours, or the equivalent of 33 days (24 hours/day), solely conducting LAs for older adults. Text analysis determined that the bedroom (24.9%) and bathroom (17.0%) were the most common locations where LAs occurred. Most frequently, LAs were caused by a collapse or drop (28.7%), slide (25.7%), slip (16.7%), or trip (11.7%). CONCLUSION LAs consume the time of paramedics, preventing them from responding to more urgent emergency calls. Alternative solutions are needed to reduce the negative impact of LAs on paramedic services.
Collapse
|
19
|
Voss S, Brandling J, Taylor H, Black S, Buswell M, Cheston R, Cullum S, Foster T, Kirby K, Prothero L, Purdy S, Solway C, Benger JR. How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project. BMJ Open 2018; 8:e022549. [PMID: 30068624 PMCID: PMC6074617 DOI: 10.1136/bmjopen-2018-022549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital. METHODS We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure. RESULTS Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases. CONCLUSION Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene.
Collapse
Affiliation(s)
- Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Janet Brandling
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Hazel Taylor
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Black
- Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Plymouth, UK
| | - Marina Buswell
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - Richard Cheston
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Cullum
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Theresa Foster
- Research Support Services, East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Kim Kirby
- Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Plymouth, UK
| | - Larissa Prothero
- Research Support Services, East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Melbourn, UK
| | - Chris Solway
- Research Network, Alzheimer’s Society, London, UK
| | - Jonathan Richard Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
20
|
O’Cathain A, Knowles E, Bishop-Edwards L, Coster J, Crum A, Jacques R, James C, Lawson R, Marsh M, O’Hara R, Siriwardena AN, Stone T, Turner J, Williams J. Understanding variation in ambulance service non-conveyance rates: a mixed methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06190] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%.
Objective
To explain variation in non-conveyance rates between ambulance services.
Design
A sequential mixed methods study with five work packages.
Setting
Ten of the 11 ambulance services serving > 99% of the population of England.
Methods
(1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems.
Results
Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98).
Limitations
Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses.
Conclusions
Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Joanne Coster
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Annabel Crum
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cathryn James
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
- Association of Ambulance Chief Executives, London, UK
| | - Rod Lawson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Medical Humanities Sheffield, University of Sheffield, Sheffield, UK
| | | | - Rachel O’Hara
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Tony Stone
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Julia Williams
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| |
Collapse
|
21
|
Snooks HA, Anthony R, Chatters R, Dale J, Fothergill RT, Gaze S, Halter M, Humphreys I, Koniotou M, Logan P, Lyons RA, Mason S, Nicholl J, Peconi J, Phillips C, Porter A, Siriwardena AN, Wani M, Watkins A, Wilson L, Russell IT. Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial. Ann Emerg Med 2017; 70:495-505.e28. [DOI: 10.1016/j.annemergmed.2017.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/26/2016] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
|
22
|
Brown LH. Researching Lift-Assists: Nebulous Complexity. PREHOSP EMERG CARE 2017; 21:670-672. [PMID: 28880743 DOI: 10.1080/10903127.2017.1317893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
23
|
A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review. Scand J Trauma Resusc Emerg Med 2017; 25:71. [PMID: 28716132 PMCID: PMC5513207 DOI: 10.1186/s13049-017-0409-6] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process. METHODS We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction. RESULTS We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%-93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h-48 h after non-conveyance, 2.5%-6.1% of the patients have EMS representations, and 4.6-19.0% present themselves at the ED. Mortality rates vary from 0.2%-3.5% after 24 h, up to 0.3%-6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card). CONCLUSIONS Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety.
Collapse
|
24
|
Simpson P, Thomas R, Bendall J, Lord B, Lord S, Close J. 'Popping nana back into bed' - a qualitative exploration of paramedic decision making when caring for older people who have fallen. BMC Health Serv Res 2017; 17:299. [PMID: 28431536 PMCID: PMC5399835 DOI: 10.1186/s12913-017-2243-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older fallers constitute a large proportion of ambulance work, and as many as 25% are not transported to hospital following paramedic assessment. The objective of this study was to explore the decision making process used by paramedics when caring for older fallers. METHODS A qualitative study was conducted using constructivist grounded theory methodology. Purposive sampling was used to recruit paramedics to participate in semi-structured interviews and focus groups. Data analysis commenced with line-by-line coding, developing into formation of theoretical categories. Theoretical sampling was then used to clarify emerging theoretical concepts, with data collection and analysis continuing until theoretical saturation was achieved. RESULTS A total of 33 paramedics participated in 13 interviews and 4 focus groups. When caring for older fallers, paramedic decision making is profoundly affected by 'role perception', in which the individual paramedic's perception of what the role of a paramedic is determines the nature of the decision making process. Transport decisions are heavily influenced by a sense of 'personal protection', or their confidence in the ambulance service supporting their decisions. 'Education and training' impacts on decision making capacity, and the nature of that training subliminally contributes to role perception. Role perception influences the sense of legitimacy a paramedic attaches to cases involving older fallers, impacting on patient assessment routines and the quality of subsequent decisions. CONCLUSIONS Paramedic decision making processes when caring for older people who have fallen appear to be strongly influenced by their perception of what their role should be, and the perceived legitimacy of incidents involving older fallers as constituting 'real' paramedic work.
Collapse
Affiliation(s)
- Paul Simpson
- Western Sydney University, Locked Bag 1797, Penrith, 2750 NSW Australia
| | - Ric Thomas
- Western Sydney University, Locked Bag 1797, Penrith, 2750 NSW Australia
| | | | - Bill Lord
- University of Sunshine Coast, Queensland, Australia
| | - Stephen Lord
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW Australia
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW Australia
- Department of Geriatric Medicine, Prince of Wales Clinical School, Sydney, Australia
| |
Collapse
|
25
|
Leggatt L, Van Aarsen K, Columbus M, Dukelow A, Lewell M, Davis M, McLeod S. Morbidity and Mortality Associated with Prehospital “Lift-assist” Calls. PREHOSP EMERG CARE 2017; 21:556-562. [DOI: 10.1080/10903127.2017.1308607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
26
|
Snooks HA, Anthony R, Chatters R, Dale J, Fothergill R, Gaze S, Halter M, Humphreys I, Koniotou M, Logan P, Lyons R, Mason S, Nicholl J, Peconi J, Phillips C, Phillips J, Porter A, Siriwardena AN, Smith G, Toghill A, Wani M, Watkins A, Whitfield R, Wilson L, Russell IT. Support and Assessment for Fall Emergency Referrals (SAFER) 2: a cluster randomised trial and systematic review of clinical effectiveness and cost-effectiveness of new protocols for emergency ambulance paramedics to assess older people following a fall with referral to community-based care when appropriate. Health Technol Assess 2017; 21:1-218. [PMID: 28397649 PMCID: PMC5402213 DOI: 10.3310/hta21130] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Emergency calls are frequently made to ambulance services for older people who have fallen, but ambulance crews often leave patients at the scene without any ongoing care. We evaluated a new clinical protocol which allowed paramedics to assess older people who had fallen and, if appropriate, refer them to community-based falls services. OBJECTIVES To compare outcomes, processes and costs of care between intervention and control groups; and to understand factors which facilitate or hinder use. DESIGN Cluster randomised controlled trial. PARTICIPANTS Participating paramedics at three ambulance services in England and Wales were based at stations randomised to intervention or control arms. Participants were aged 65 years and over, attended by a study paramedic for a fall-related emergency service call, and resident in the trial catchment areas. INTERVENTIONS Intervention paramedics received a clinical protocol with referral pathway, training and support to change practice. Control paramedics continued practice as normal. OUTCOMES The primary outcome comprised subsequent emergency health-care contacts (emergency admissions, emergency department attendances, emergency service calls) or death at 1 month and 6 months. Secondary outcomes included pathway of care, ambulance service operational indicators, self-reported outcomes and costs of care. Those assessing outcomes remained blinded to group allocation. RESULTS Across sites, 3073 eligible patients attended by 105 paramedics from 14 ambulance stations were randomly allocated to the intervention group, and 2841 eligible patients attended by 110 paramedics from 11 stations were randomly allocated to the control group. After excluding dissenting and unmatched patients, 2391 intervention group patients and 2264 control group patients were included in primary outcome analyses. We did not find an effect on our overall primary outcome at 1 month or 6 months. However, further emergency service calls were reduced at both 1 month and 6 months; a smaller proportion of patients had made further emergency service calls at 1 month (18.5% vs. 21.8%) and the rate per patient-day at risk at 6 months was lower in the intervention group (0.013 vs. 0.017). Rate of conveyance to emergency department at index incident was similar between groups. Eight per cent of trial eligible patients in the intervention arm were referred to falls services by attending paramedics, compared with 1% in the control arm. The proportion of patients left at scene without further care was lower in the intervention group than in the control group (22.6% vs. 30.3%). We found no differences in duration of episode of care or job cycle. No adverse events were reported. Mean cost of the intervention was £17.30 per patient. There were no significant differences in mean resource utilisation, utilities at 1 month or 6 months or quality-adjusted life-years. In total, 58 patients, 25 paramedics and 31 stakeholders participated in focus groups or interviews. Patients were very satisfied with assessments carried out by paramedics. Paramedics reported that the intervention had increased their confidence to leave patients at home, but barriers to referral included patients' social situations and autonomy. CONCLUSIONS Findings indicate that this new pathway may be introduced by ambulance services at modest cost, without risk of harm and with some reductions in further emergency calls. However, we did not find evidence of improved health outcomes or reductions in overall NHS emergency workload. Further research is necessary to understand issues in implementation, the costs and benefits of e-trials and the performance of the modified Falls Efficacy Scale. TRIAL REGISTRATION Current Controlled Trials ISRCTN60481756 and PROSPERO CRD42013006418. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 13. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Helen A Snooks
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Rebecca Anthony
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Robin Chatters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachael Fothergill
- Clinical Audit and Research Unit, London Ambulance Service NHS Trust, London, UK
| | - Sarah Gaze
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Mary Halter
- Faculty of Health and Social Care Sciences, St George's University Hospital, London, UK
| | - Ioan Humphreys
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Marina Koniotou
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Phillipa Logan
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Ronan Lyons
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Suzanne Mason
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Julie Peconi
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Judith Phillips
- Centre for Innovative Ageing, Swansea University, Swansea, UK
| | - Alison Porter
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | | | | | | | - Mushtaq Wani
- Department of Geriatric and Stroke Medicine, Morriston Hospital, Swansea, UK
| | - Alan Watkins
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Richard Whitfield
- Pre-hospital Emergency Research Unit (PERU), Welsh Ambulance Services NHS Trust, Cardiff, UK
| | - Lynsey Wilson
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| | - Ian T Russell
- Patient and Population Health and Informatics, Swansea University Medical School, Swansea, UK
| |
Collapse
|
27
|
Faul M, Stevens JA, Sasser SM, Alee L, Deokar AJ, Kuhls DA, Burke PA. Older Adult Falls Seen by Emergency Medical Service Providers: A Prevention Opportunity. Am J Prev Med 2016; 50:719-726. [PMID: 26853845 PMCID: PMC4932831 DOI: 10.1016/j.amepre.2015.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/30/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Among people aged ≥65 years, falling is the leading cause of emergency department visits. Emergency medical services (EMS) are often called to help older adults who have fallen, with some requiring hospital transport. Chief aims were to determine where falls occurred and the circumstances under which patients were transported by EMS, and to identify future fall prevention opportunities. METHODS In 2012, a total of 42 states contributed ambulatory data to the National EMS Information System, which were analyzed in 2014 and 2015. Using EMS records from 911 call events, logistic regression examined patient and environmental factors associated with older adult transport. RESULTS Among people aged ≥65 years, falls accounted for 17% of all EMS calls. More than one in five (21%) of these emergency 911 calls did not result in a transport. Most falls occurred at home (60.2%) and residential institutions such as nursing homes (21.7%). Logistic regression showed AORs for transport were greatest among people aged ≥85 years (AOR=1.14, 95% CI=1.13, 1.16) and women (AOR=1.30, 95% CI=1.29, 1.32); for falls at residential institutions or nursing homes (AOR=3.52, 95% CI=3.46, 3.58) and in rural environments (AOR=1.15, 95% CI=1.13, 1.17); and where the EMS impression was a stroke (AOR=2.96, 95% CI=2.11, 4.10), followed by hypothermia (AOR=2.36, 95% CI=1.33, 4.43). CONCLUSIONS This study provides unique insight into fall circumstances and EMS transport activity. EMS personnel are in a prime position to provide interventions that can prevent future falls, or referrals to community-based fall prevention programs and services.
Collapse
Affiliation(s)
- Mark Faul
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia.
| | - Judy A Stevens
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | - Scott M Sasser
- Department of Emergency Medicine, Greenville Health System, Greenville, South Carolina
| | - Lisa Alee
- Section of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Angela J Deokar
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | - Deborah A Kuhls
- Division of Acute Care Surgery, University of Nevada, Las Vegas, Nevada
| | - Peter A Burke
- Section of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
28
|
Zozula A, Carpenter CR, Lipsey K, Stark S. Prehospital emergency services screening and referral to reduce falls in community-dwelling older adults: a systematic review. Emerg Med J 2016; 33:345-50. [DOI: 10.1136/emermed-2015-204815] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 11/29/2015] [Indexed: 11/04/2022]
|
29
|
Turner J, Coster J, Chambers D, Cantrell A, Phung VH, Knowles E, Bradbury D, Goyder E. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03430] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.
Collapse
Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Viet-Hai Phung
- College of Social Science, University of Lincoln, Lincoln, UK
| | - Emma Knowles
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
30
|
Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers S, Waring J. Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.ObjectivesTo identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.DesignMixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.ParticipantsSix study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.ResultsBetween 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.ConclusionsRising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.Future workResearch on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.Study registrationUK Clinical Reasearch Network 12960.Funding detailsThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - John Bankart
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ran Bhamra
- Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Simon Conroy
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stoyan Kurtev
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Stephen Rogers
- Department of Public Health, NHS Northamptonshire, Northampton, UK
| | - Justin Waring
- Business School, University of Nottingham, Nottingham, UK
| |
Collapse
|
31
|
Snooks HA, Carter B, Dale J, Foster T, Humphreys I, Logan PA, Lyons RA, Mason SM, Phillips CJ, Sanchez A, Wani M, Watkins A, Wells BE, Whitfield R, Russell IT. Support and Assessment for Fall Emergency Referrals (SAFER 1): cluster randomised trial of computerised clinical decision support for paramedics. PLoS One 2014; 9:e106436. [PMID: 25216281 PMCID: PMC4162545 DOI: 10.1371/journal.pone.0106436] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 08/05/2014] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design Cluster trial randomised by paramedic; modelling. Setting 13 ambulance stations in two UK emergency ambulance services. Participants 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture. Trial Registration ISRCTN Register ISRCTN10538608
Collapse
Affiliation(s)
- Helen Anne Snooks
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
- * E-mail:
| | - Ben Carter
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, United Kingdom
| | - Jeremy Dale
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, United Kingdom
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Milford Service Area, Fiveways Roundabout, Barton Mills, Suffolk, United Kingdom
| | - Ioan Humphreys
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Philippa Anne Logan
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Ronan Anthony Lyons
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Suzanne Margaret Mason
- School of Health and Related Research, Sheffield University, Regent Court, Sheffield, United Kingdom
| | - Ceri James Phillips
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Antonio Sanchez
- Department of Medicine, Cardiff University, Academic Building, Llandough Hospital, Penarth, United Kingdom
| | - Mushtaq Wani
- Abertawe Bro Morgannwg University Health Board, Department of Stroke Medicine, Morriston Hospital, Morriston, Swansea, United Kingdom
| | - Alan Watkins
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Bridget Elizabeth Wells
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Richard Whitfield
- Prehospital Emergency Research Unit, Welsh Ambulance Services NHS Trust, Lansdowne Hospital, Canton, Cardiff, United Kingdom
| | - Ian Trevor Russell
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| |
Collapse
|