Joanne D Fisher

Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis.

Objective To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. Design Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis. Data sources Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews. Review methods Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. Data extraction Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. Results 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral. Conclusions Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults

The objective of this study was to summarize the evidence on the accuracy of screening tools for predicting falling risk in community-living older adults. This study was designed as a systematic review. Prospective studies of clinical fall risk prediction tools that provided data on the number of participants who sustained falls during follow-up were included. We searched six electronic databases and reference lists of studies and review articles. Data were extracted by two reviewers independently, and methodological quality assessment was performed with a modified version of the Quality Assessment of Diagnostic Accuracy Studies checklist. Twenty-five studies were included. These studies evaluated 29 different screening tools, but only 6 of the tools were evaluated by more than one study. Methodological quality was variable, and many studies were small. No meta-analyses were performed because of heterogeneity. Most tools discriminated poorly between fallers and nonfallers. We found that existing studies are methodologically variable and the results are inconsistent. Insufficient evidence exists that any screening instrument is adequate for predicting falls.

Breaking bad news : consultants' experience, previous education and views on educational format and timing

Context  Breaking bad news is a difficult task for health professionals. Senior hospital doctors acknowledge the importance of breaking bad news well, but previous surveys have found them to be sceptical of formal training and disinclined to seek courses in this area. We sought to ascertain if this view was still held.

Hospital consultants breaking bad news with simulated patients: An analysis of communication using the Roter Interaction Analysis System

OBJECTIVE To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. METHODS Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. RESULTS Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. CONCLUSION Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations. PRACTICE IMPLICATIONS It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.

A national survey of services for the prevention and management of falls in the UK

BackgroundThe National Health Service (NHS) was tasked in 2001 with developing service provision to prevent falls in older people. We carried out a national survey to provide a description of health and social care funded UK fallers services, and to benchmark progress against current practice guidelines.MethodsCascade approach to sampling, followed by telephone survey with senior member of the fall service. Characteristics of the service were assessed using an internationally agreed taxonomy. Reported service provision was compared against benchmarks set by the National Institute for Health and Clinical Excellence (NICE).ResultsWe identified 303 clinics across the UK. 231 (76%) were willing to participate. The majority of services were based in acute or community hospitals, with only a few in primary care or emergency departments. Access to services was, in the majority of cases, by health professional referral. Most services undertook a multi-factorial assessment. The content and quality of these assessments varied substantially. Services varied extensively in the way that interventions were delivered, and particular concern is raised about interventions for vision, home hazard modification, medication review and bone health.ConclusionThe most common type of service provision was a multi-factorial assessment and intervention. There were a wide range of service models, but for a substantial number of services, delivery appears to fall below recommended NICE guidance.

Does the use of dedicated dispatch criteria by Emergency Medical Services optimise appropriate allocation of advanced care resources in cases of high severity trauma? A systematic review.

BACKGROUND AND OBJECTIVES The deployment of Enhanced Care Teams (ECTs) capable of delivering advanced clinical interventions for patients at the scene of incidents is commonplace by Emergency Medical Services in most developed countries. It is unclear whether primary dispatch models for ECT resources are more efficient at targeting deployment to patients with severe trauma than secondary dispatch, following requests from EMS personnel at scene. The objective of this study was to review the evidence for primary and secondary models in the targeted dispatch of ECT resources to patients with severe traumatic injury. METHODS This review was completed in accordance with a protocol developed using the PRISMA guidelines. We conducted a search of the MEDLINE, EmBase, Web of Knowledge/Science databases and the Cochrane library, focussed on subject headings and keywords involving the dispatch of ECT resources by Emergency Medical Services. Design and results of each study were described. Heterogeneity in the design of the included studies precluded the completion of a meta-analysis. A narrative synthesis of the results therefore was performed. RESULTS Five hundred and forty-eight articles were screened, and 16 were included. Only one study compared the performance of the different models of dispatch. A non-statistically significant reduction in the length of time for HEMS resources to reach incident scenes of 4min was found when primary dispatch protocols were utilised compared to requests from EMS personnel at scene. No effect on mortality; severity of injury or proportion of patients admitted to intensive care was observed. The remaining studies examined the processes utilised within current primary dispatch models but did not perform any comparative analysis with existing secondary dispatch models. CONCLUSIONS This review identifies a lack of evidence supporting the role of primary dispatch models in targeting the deployment of Enhanced Care Teams to patients with severe injuries. It is therefore not possible to identify a model for ECT dispatch within pre-hospital systems that optimises resource utilisation. Further studies are required to assess the efficiency of systems utilised at each stage of the process used to dispatch Enhanced Care Team resources to incidents within regionalised pre-hospital trauma systems.

Good intentions, increased inequities: developing social care services in Emergency Departments in the UK.

Addressing the quality of services provided in Emergency Departments (EDs) has been a central area of development for UK government policy since 1997. Amongst other aspects of this concern has been the recognition that EDs constitute a critical boundary between the community and the hospital and a key point for the identification of social care needs. Consequently, EDs have become the focus for a variety of service developments which combine the provision of acute medical and nursing assessment and care with a range of activities in which social care is a prominent feature. One approach to this has been the establishment of multidisciplinary teams aiming to prevent re-attendance or admission, re-direct patients to other services, or speed patients through EDs with the aim of providing improved quality of care. This study, carried out between September 2007 and April 2008, was the first UK national survey of social care initiatives based in EDs and aimed to determine the objectives, organisation, extent, functions, funding and evidence on outcomes of such interventions. Eighty-three per cent of UK Type I and II EDs responded to the survey. Approximately, one-third of EDs had embedded social care teams, with two-thirds relying on referrals to external social care services. These teams varied in their focus, size and composition, leadership, availability, funding and permanence. As a result, the unintended effect has been to increase inequities in access to social care services through EDs. Three further conclusions are drawn about policy led, locally-based service development. This survey adds to international evidence pointing to the potential benefits of a variety of social care interventions being based in EDs and justifies the establishment of a research programme which can provide answers to key outstanding questions.

A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transfers by Paramedics

OBJECTIVE The aim of this study was to investigate if paramedics can safely transfer interfacility critically ill adult patients and to determine the prevalence and types of adverse events when paramedics lead interfacility critical care transfers. METHODS MEDLINE, Web of Science, Embase, and CINAHL databases were searched from 1990 up to February 2016. Eligibility criteria were adult patients (16 years and over), interfacility transfer (between two health care facilities), quantitative or qualitative description of adverse events, and a paramedic as the primary care provider or the sole health care provider. RESULTS Seven publications had paramedics as the sole health care provider conducting interfacility critical care transfers. All seven studies were observational studies published in the English language. The study duration ranged from 14 months to 10 years. The frequency of adverse events seen by paramedics in interfacility transfers ranges from 5.1% to 18%. CONCLUSION There is a gap in literature on the safety and adverse events in interfacility transfers by paramedics. The prevalence of in-transit adverse events is well established; however, because the published literature is lacking longitudinal monitoring of patients and only reporting in-transit events, we believe that further research in this area might provide the basis of paramedics safety in interfacility transfers.

222: Is There Enough Evidence to Support the Reversal of Standard Trauma Care for Patients Who Have Been Suspended?

The effects of being suspended motionless in an upright position is commonly termed suspension trauma. It has been reported that following rescue some patients are at risk of immediate sudden death from a cardiac arrest when they are laid flat. Although there is little evidence into the causes of this condition a number of authors have written guidelines for the care of these patients and whilst opinions differ, this quote from the UK Health and Safety Executive represents the majority view: “Important! The casuality must never be laid down after being rescued from the suspended position, not even in the recovery position.” This advice is clear, yet it is counter to the conventional approach to trauma care and creates difficulty for transportation and subsequent care if taken literately. It is hypothesised that lying patients down results in a sudden return of pooled blood to the heart resulting in a cardiac arrest, yet this could be explained by other mechanisms which are not related to lying patients down but could result in sudden death, for example, the release of potassium resulting from ischemic areas (e.g. after femoral vessel compression by a safety harness), similar to the mechanism in crush injury. The response of the UK ambulance service as to what guidance to issue to paramedics must be measured. In order to support this decision process a systematic review was undertaken.