An Emergency Medical Services Program to Promote the Health of Older Adults Manish N. Shah, MD, w Lindsay Clarkson, BS, E. Brooke Lerner, PhD, w Rollin J. Fairbanks, MD, NREMT-P, Robert McCann, MD, z and Sandra M. Schneider, MD
OBJECTIVES: To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs. DESIGN: A cluster sample design evaluation of an intervention conducted by EMS in one of two communities. SETTING: Two rural communities in upstate New York. PARTICIPANTS: Two hundred fifty-eight interventiongroup and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005. INTERVENTION: EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients’ physicians were notified of screening results to provide interventions. Control group patients were provided usual care. MEASUREMENTS: Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs. RESULTS: Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found.
From the Departments of Emergency Medicine, wCommunity and Preventive Medicine, and zMedicine, School of Medicine and Dentistry, University of Rochester, Rochester, New York. Portions of this work were presented in abstract at the 2004 Annual Meeting of the Society for Academic Emergency Medicine and the 2006 National Association of Emergency Medical Services Physicians Annual Meeting. Address correspondence to Manish N. Shah, MD, Department of Emergency Medicine, 601 Elmwood Avenue, Box 655, Rochester, NY 14642. E-mail:
[email protected] DOI: 10.1111/j.1532-5415.2006.00736.x
JAGS 54:956–962, 2006 r 2006, Copyright the Authors Journal compilation r 2006, The American Geriatrics Society
CONCLUSION: EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients’ needs. J Am Geriatr Soc 54:956–962, 2006. Key words: emergency medical services; geriatrics; prevention
O
lder adults ( 65) constitute a large segment of the U.S. population.1 Healthcare providers are encouraged to identify older adults’ needs and to intervene to promote ‘‘successful aging,’’ prevent disability, and maximize patients’ quality of life.2,3 Unfortunately, the healthcare system often falls short in identifying and addressing needs of older adults, particularly in underserved populations.4 Older adults’ failure to receive needed interventions is particularly perplexing, because they have frequent contacts with healthcare providers.5 The emergency medical services (EMS) system is one potential nontraditional resource to identify and address the needs of older adults.6 The concept of EMS-based prevention is based upon the notion that emergency medical technicians (EMTs) have unique opportunities to screen and educate patients during emergency medical responses and then refer those patients for interventions. For instance, EMTs are able to provide services to all patients throughout a community without regard to financial or physical limitations, to evaluate the home environment, and to provide services to the patients who refuse transport to an emergency department (ED), which may total up to 17% of older adults requesting EMS assistance.7,8 Additionally, EMTs frequently care for older adults who are in need of medical or psychosocial assistance but who are not critically ill.9,10 This group may particularly benefit from screening and interventions, because the lack of immediate need for medical intervention gives EMTs time to perform these tasks. Limited attempts have been made to implement and rigorously evaluate EMS-based health promotion pro-
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grams.11–13 One cohort study evaluated the feasibility of screening older adults to identify those needing the influenza vaccine and found that EMTs successfully screened only 61% of patients.14 Little work has been done to implement programs throughout entire EMS systems and evaluate those programs. Furthermore, the authors are not aware of any studies that have examined EMS-based health promotion programs in a rural community. This study aimed to evaluate the feasibility and effect of an EMS program in a rural community to promote the health of older adults. Specifically, the study evaluated whether EMTs could successfully screen at least 80% of communitydwelling older adults to identify those at risk for falls, influenza, and pneumococcal disease. The study also evaluated whether notifying patients’ primary care physicians (PCPs) to intervene in identified deficiencies had an effect on risk status. It was hypothesized that this program would be feasible, with EMTs screening at least 80% of patients, and would alter the proportion of at risk older adults.
METHODS Design This study used a cluster sample design to evaluate an intervention conducted by EMS in one of two communities. It took place between February 2004 and June 2005 and was approved by the University of Rochester Research Subjects Review Board. Patients cared for by the Geneseo Fire Department Ambulance (GFDA) formed the intervention group, and patients cared for by the Livonia Fire Department Ambulance (LFDA) formed the control group. These two EMS agencies operate in separate areas within Livingston County, New York. All patients received follow-up at least 14 days after EMS contact to assess the effect of this program. Patients were included in the intervention group if they were aged 65 and older, residents of Livingston County, New York, and cared for by GFDA. Patients were included in the usual-care control group if they were aged 65 and older, residents of Livingston County, and cared for by LFDA. Patients were excluded if they could not speak English, if they had been previously included in the study, or if they were institutionalized (group home, nursing home, jail). Setting Livingston County is a rural county in upstate New York with 64,328 residents. GFDA provides service to Geneseo and Groveland, New York, which together had 1,011 residents aged 65 and older in 2000. Of the older adult population, 409 (40%) were male and 602 (60%) were female, 712 (70%) had at least a high school diploma, and 985 (97%) were white.15 LFDA provides service to Livonia, New York, which had 720 residents aged 65 and older. Of the older adult population, 312 (43%) were male and 408 were female (57%), 544 (76%) had at least a high school diploma, and 715 (99%) were white.15 Thus, these two areas are similar in terms of resident demographics. LFDA and GFDA are volunteer EMS agencies staffed by EMTs trained at least to the basic life support level. Requests for assistance are processed by a county-operated emergency services call center that triages patients and dispatches EMS
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assistance from the proper agencies based upon the call location. A mutual aid system is also used. EMS agencies respond outside their primary service areas if another area’s EMS resources are unavailable. Thus, patients included in the control group or the intervention group may not reside in GFDA’s or LFDA’s primary service areas.
Program Methods Before initiating the program, EMTs and PCPs received general and program-specific education. PCPs were introduced to the study via written materials and notification during staff meetings. EMTs in both agencies participated in a 90-minute case-based discussion on caring for older adults. The GFDA EMTs were also provided training on the screening program, which included training on how to ask the screening questions and evaluate the home environment. This training was reinforced at monthly EMT training sessions. GFDA EMTs were instructed to screen communitydwelling patients aged 65 and older during emergency responses to evaluate risk of falling, need for pneumococcal vaccine, and need for the influenza vaccine. Screening questions were listed on the EMS medical record, and EMTs recorded answers on the medical record. Specifically, patients were asked about their history of falls during the past year. If they were cared for in their home, the environment was assessed for hazards such as throw rugs.16 Patients were asked if they had ever received the pneumococcal vaccine. Patients were considered to be at risk if they had never been vaccinated. Patients were asked if they had received the influenza vaccination between October 1, 2004, and February 28, 2005. Individuals denying prior vaccination were considered to be at risk. After screening, EMTs gave all patients informational materials produced by the Centers for Disease Control and Prevention regarding these three conditions. Upon the completion of EMS care, the GFDA EMTs faxed copies of subjects’ medical records to the study staff. A research assistant reviewed the results and faxed information on at-risk patients and patients who did not know their risk status to patients’ PCPs within 96 hours. Thus, physicians were not notified of patients who were not at risk for any items or who were not screened for any items. For patients without PCPs, no report was faxed, but patients were offered a referral during the telephone follow-up. EMTs from LFDA, the usual-care control group, notified eligible patients that they would be receiving a telephone follow-up call regarding their EMS care but did not explain the explicit reason for the telephone follow-up, so as to not bias the study. The LFDA EMTs did not perform any screening during their contact with the patients because of the potential contamination of the control group that could have resulted. The LFDA medical records were sent to the study staff for follow-up. Study staff abstracted the EMS medical records from both agencies for demographic, clinical, and administrative information. Standard medical record abstraction methods were used to maximize data quality.17 Two weeks after EMS care, study staff attempted to follow-up patients from the intervention and control groups. Follow-up calls were attempted for up to 4 weeks
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or until contact was made. If communication with the patient was not possible, a proxy could answer questions. The follow-up interview was performed using a structured survey that was pilot tested and revised before the start of the study. During the follow-up survey, patient demographic characteristics and clinical experiences were elicited. Patients’ risk status upon initial EMS contact was confirmed for the intervention group and measured for the control group. Finally, the effect of the intervention was measured, including recollection of educational materials, recollection of discussions with physicians’ regarding risks, and receipt of vaccinations and changes to the home environment. Control-group risk status was also assessed during telephone follow-up to minimize contamination of the control group. For the intervention group, risk status was assessed during EMS care and then confirmed during telephone follow-up. Patients’ self-report provided during follow-up was used in the analysis to perform an equivalent comparison between the two groups.
Data Management and Analysis All data were managed using Microsoft Excel (Microsoft Corp., Redmond, WA). Intention-to-treat analysis was used in data analysis. Continuous data were compared using a t test, and categorical data were compared using the chisquare test. A P-value of .05 was considered statistically significant. All data were analyzed using Stata 8.0 (Stata Corp., College Station, TX). Sample-size calculations were based upon the primary objective of this study: to determine the feasibility of EMS screening of older adults to identify those with unmet needs. Sufficient numbers of patients are needed to achieve narrow
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confidence intervals (CIs) round screening estimates. Therefore, it was estimated that a sample of 250 individuals eligible for screening (in the intervention group) would be needed to achieve a 95% CI no wider than 5% on either side of the point estimate of 80%.
RESULTS During the study period, 669 patients aged 65 and older were eligible from the intervention group, and 272 were eligible from the control group. After exclusions (Figure 1), 258 intervention-group and 143 control-group patients remained for follow-up. PCP identities were known for 234 (91%) patients in the intervention group. Follow-up was successful in 245 (61%) patients overall. As depicted in Table 1, control-group patients who received follow-up were comparable to intervention-group patients who received follow-up. No statistical or clinically significant differences were identified for characteristics collected at the time of EMS care. No difference was noted in pneumococcal vaccination status, influenza vaccination status, or history of falls within 1 year, as measured retrospectively by telephone survey 2 weeks after EMS care. Environmental risks could only be assessed in interventiongroup patients, and a notable number of patients had risk identified. Feasibility was primarily assessed according to the success in EMT screening of intervention patients. Screening was successful for pneumococcal vaccination status in 204 of 258 patients (79%, 95% CI 5 74–84%), for influenza vaccination status in 63 of 83 patients (76%, 95% CI 5 65– 85%), for falls history in 210 of 258 patients (81%, 95% CI 5 76–86%), and for environmental hazards in 163 of 188 patients (87%, 95% CI 5 81–91%). The EMTs indi-
941 patients eligible for participation
272 in control group
129 excluded 42 group home/skilled nursing facility 52 duplicate patients 35 other reasons (lived outside Livingston County, non-EMS patient, primary care provided by other EMS agency, dead on arrival)
143 included for follow-up
47 lost to follow-up
96 completed follow-up
Figure 1. Flow diagram of study. EMS 5 emergency medical services.
669 in intervention group
411 excluded 211 group home/skilled nursing facility 128 duplicate patients 70 other reasons (lived outside Livingston County, non-EMS patient, primary care provided by other EMS agency, dead on arrival) 2 requested to be excluded
258 included for follow-up
109 lost to follow-up
149 completed follow-up
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Table 1. Characteristics of Study Population Who Completed Follow-Up by Study-Group Enrollment (N 5 245)
Characteristic Age, mean Female, n (%) Race, n (%) White Black Other Unknown Ethnicity, n (%) Hispanic Not Hispanic Unknown Education, n (%) oHigh school graduate High school graduate to some college College graduate Unknown Overall health, n (%) Excellent Very good Good Fair Poor Unknown Transport to emergency department after EMS care, n (%) Admitted to hospital, n (%) Yes No Unknown Contact with primary care physician, n (%) Yes No Unknown Contact with any physicians, n (%) Patient chief complaint (most common listed), n (%) Trauma/injury Cardiac related Respiratory Pain General illness Syncope
Intervention Group (n 5 149)
Control Group (n 5 96)
79 80 (54)
77 56 (58)
138 (93) 2 (1) 2 (1) 7 (5)
91 (95) 1 (1) 0 (0) 4 (4)
0 (0) 144 (97) 5 (3)
1 (1) 90 (94) 5 (5)
25 (17)
23 (24)
73 (49)
48 (50)
27 (18)
10 (10)
24 (16)
15 (16)
14 (9) 34 (23) 72 (48) 17 (11) 10 (7) 2 (1) 139 (93)
9 (9) 22 (23) 39 (41) 21 (22) 4 (4) 1 (1) 85 (89)
Characteristic
.13 .48 .71
Pneumococcal vaccination status, n (%)w Vaccinated Needing vaccine Unknown Influenza vaccination status (only influenza season, n 5 45 intervention group, n 5 33 control group), n (%)w Vaccinated Needing vaccine Unknown History of falls in previous year, n (%)w Yes No Unknown Environmental fall risk identified by EMS, n (%) Yes No Not cared for at home Unknown
.28
.35
.20
.82 86 (58) 51 (34) 12 (8)
Table 1. (Contd.)
P-value
.35
54 (56) 32 (33) 10 (10)
959
Intervention Group (n 5 149)
Control Group (n 5 96)
P-value .68
102 (68) 29 (19)
63 (66) 23 (24)
18 (12)
10 (10) .58
29 (64) 14 (31)
18 (55) 14 (42)
2 (4)
1 (3) .18
60 (38) 90 (57) 7 (4)
36 (34) 68 (65) 1 (1) N/A
26 (17) 70 (47) 45 (30)
N/A N/A N/A
8 (5)
N/A
Contact with any physician outside of emergency department, including primary care physician or admitting hospital physician. w Upon emergency medical services (EMS) contact, as reported by patients during telephone follow-up.
.47
82 (55) 62 (42) 5 (3) 119 (80)
57 (59) 38 (40) 1 (1) 77 (80)
.54 .44
30 (20) 28 (19) 23 (15) 13 (9) 6 (4) 9 (6)
18 (18) 14 (15) 9 (9) 12 (13) 9 (9) 4 (4)
cated that approximately half of patients not screened could not be screened because of the acuity of their illness; the other half had no results recorded on the EMS medical record. Table 2 shows the effect of this study on patients with needs identified by EMS, which was defined as those patients at risk or those that did not know their risk status. This program resulted in statistically and clinically significantly greater pneumococcal vaccination rates than in the control group, although no differences were noted in influenza vaccination rates or changes made to prevent falls. Secondary outcome results show poor recollection of receipt of educational materials and infrequent discussions with PCPs regarding risk, as determined by self-report. The follow-up rate of 61% leads to concerns regarding bias in follow-up. A comparison of subjects with successful follow-up with those without shows no clinically
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Table 2. Effect of Emergency Medical Services (EMS) Screening, Education, and Referral Program on At-Risk Patients Intervention Group Characteristic Pneumococcal vaccination status on follow-up Vaccinated Needing vaccine Unknown Influenza vaccination status on follow-up Vaccinated Needing vaccine Unknown Changes to prevent falls since EMS contact Yes No Unknown Recollection of educational materials (all patients) Pneumococcal vaccine brochure (n 5 47) Influenza vaccine brochure (n 5 16) Falls brochure (n 5 82) Discussion with PCP regarding pneumococcal vaccine Yes No Unknown Not applicable (no PCP visit) Discussion with PCP regarding influenza vaccine Yes No Unknown Not applicable (no PCP visit) Discussion with PCP regarding falls Yes No Unknown Not applicable (no PCP visit)
Control Group
n (%)
P-value
n 5 47
n 5 33
10 (21) 19 (40) 18 (38) n 5 16
1 (3) 22 (67) 10 (30) n 5 15
4 (25) 10 (62) 2 (12) n 5 82
5 (33) 9 (60) 1 (7) n 5 37
12 (15) 67 (82) 3 (4)
4 (11) 32 (86) 1 (3)
.02
1.0
.91
N/A
11 (23)
N/A
7 (44)
N/A
17 (21)
N/A
n 5 47
n 5 33
5 (11) 16 (34) 8 (17) 18 (38)
2 (6) 16 (48) 4 (12) 11 (33)
n 5 16
n 5 15
4 (25) 5 (31) 1 (6) 6 (38)
6 (40) 4 (27) 2 (13) 3 (20)
n 5 82
n 5 37
8 (10) 35 (43) 10 (12) 29 (35)
1 (3) 12 (32) 7 (19) 17 (46)
.63
.69
.30
Includes individuals who stated that they had fallen and those with identified environmental risks. PCP 5 primary care physician.
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significant differences in characteristics measured upon EMS care. These characteristics, which include age (78 in those with follow-up vs 79 in those without), sex (56% female vs 54% female), transport to ED (91% for both), and patient chief complaint. A comparison of EMS screening results, which could only be made for the intervention group, identified a greater frequency of EMTs marking ‘‘Not asked due to clinical condition’’ (1–10% for those with follow-up vs 0–16% for those without) or not recording any result (4–5% for those with follow-up vs 16–21% for those without).
DISCUSSION EMS-based public health promotion programs that use EMTs to screen, educate, and refer older adults with preventable injuries and illnesses are a recent development. They represent a shift from the traditional concept of EMTs focusing only on acute disease processes to a more global public health view.18–20 To the authors’ knowledge, this is the first study that formally implements and evaluates an EMS-based screening, education, and referral program for an EMS agency that serves a rural community. The primary goal of this study was to confirm the feasibility of a screening program for older adults in a volunteer EMS agency. The identified high screening rate exceeds previously described rates. It clearly demonstrates feasibility of using EMTs to screen older adults when implemented as standard practice in a volunteer EMS agency serving a rural community.14 Before this study, the extent of risk for falls, pneumococcal disease, and influenza present in the EMS patient population was unclear. One study showed significant unmet needs, whereas a second showed minimal needs of any type.12,14 Residents screened by the EMTs in this study had significant deficiencies that needed to be addressed. Patients reported suboptimal pneumococcal and influenza immunization rates during the EMS encounter and during the telephone follow-up, leaving them at unnecessary risk.21,22 The risk of falls, as shown by the commonly reported history of falls and the frequency of identified home environmental hazards, is significant in this population and has potential for morbidity and loss of quality of life.23,24 Providing EMS patients with educational materials regarding the three conditions was intended to reinforce the risks associated with these three conditions and remind patients and their families to discuss their risk status with their physicians. Conceptually, providing EMS patients with written materials may not be productive. The chaos surrounding the acute disease process and the ED visit could result in the materials being lost or ignored. This may have been the case in this study, because few patients remembered receiving the materials. Because of this lack of effect, future programs should not unnecessarily expend effort to distribute educational materials to patients during emergency responses. Reducing the proportion of older adults at risk is an important endpoint, and for this study it was a secondary objective. A significant reduction was found only in the number of older adults at risk for pneumococcal disease, and the magnitude of the reduction was small. A number of factors may explain the failure of this program
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to reduce the proportion of older adults at risk by a clinically significant amount. If EMTs were unable to screen all patients and identify patients’ PCPs, then interventions could not be delivered. If patients refused the interventions, then they would appear still to be at risk. Additionally, if patients incorrectly reported their risk status or the presence of any interventions, then they would still appear to be at risk.25 Physicians may not have remembered to provide necessary interventions to remedy identified risks because of the paper-based referral process used in this program. Paper-based reminder systems have a mild effect in prompting actions, with a meta-analysis finding the adjusted odds ratios of the effect of provider reminders ranging up to 3.80.26 As a result, a more-intensive referral and intervention process may be needed, potentially using case managers. PCPs may have also elected not to provide necessary interventions to remedy identified risks, because the interventions may not have been available (influenza vaccine or falls prevention clinics) or may not be felt to be effective (pneumococcal vaccine).21,27–29 In conditions with greater needs and with more-intensive interventions that address these issues, it is possible that a greater effect can be identified, although the results of this study suggest that faxed notifications to PCPs are insufficient to address unmet needs in older adults. A number of limitations existed in this study. First, because this study did not evaluate the accuracy of patients’ self-report, it is possible that patients may have misrepresented their risk status and interventions received, although the bias should have affected the intervention and control groups equally. Second, this study did not directly ascertain the reasons that patients did not receive the interventions. Third, the 14-day follow-up was likely too rapid to allow patients to receive necessary interventions. Future studies should increase the time between EMS care and follow-up. Fourth, a Hawthorne effect may be present in this study, with EMTs successfully screening patients, because they were participating in the program. Fifth, study staff were not blinded to the study hypothesis, potentially creating a bias. Finally, only 61% of enrolled patients received followup, which is less than ideal. Patients who were too sick to answer questions were particularly at risk of being lost to follow-up, because they would be less likely to be at home for follow-up 14 days after EMS care. The next step in developing this program of EMS screening and referral is to evaluate the validity of the screening. It is unclear whether the patient self-report or EMT assessment is accurate; this must be ascertained if an EMS screening program is to be successful. An additional step is to strengthen the intervention process to ensure that at-risk patients receive the appropriate services. Case managers, home health nurses, and social workers should be considered as possible participants or coordinators of a rigorous intervention program.
ACKNOWLEDGMENTS We would like to acknowledge the assistance of the GFDA, particularly Karen Dewar, RN, EMT, and the LFDA, particularly Marc Connolly, EMT-P, and all of their volunteer members who helped successfully complete this study. We would also like to acknowledge the assistance of Joan Elli-
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son, RN, MPH, the Livingston County Director of Public Health, and William D. Sheahan, EMT-P, the Livingston County EMS Coordinator, for their assistance. Financial Disclosure: This work was supported in part by an award from the Dennis W. Jahnigen Career Development Scholars Awards Program (Dr. Shah), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York and the Atlantic Philanthropies. Author Contributions: Manish N. Shah designed the study, developed the methods; collected, analyzed, and interpreted the data; and wrote the manuscript. Lindsay Clarkson collected the data, assisted with data analysis, and edited the manuscript. E. Brooke Lerner, Robert McCann, and Sandra M. Schneider assisted with study design, assisted with methods development, assisted with data interpretation, and edited the manuscript. Rollin J. Fairbanks assisted with study design and data interpretation and edited the manuscript. Sponsor’s Role: The study sponsor had no direct role in the design, methods, subject recruitment, data collection, analysis, or preparation of the paper.
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