Judah Goldstein

Frailty in Older Adults Using Pre-hospital Care and the Emergency Department: A Narrative Review.

Background Older adults use more health-care services per capita than younger age groups and the older adult population varies greatly in its needs. Evidence suggests that there is a critical distinction between relative frailty and fitness in older adults. Here, we review how frailty is described in the pre-hospital literature and in the broader emergency medicine literature. Methods PubMed was used as the primary database, but was augmented by searches of CINAHL and EMBASE. Articles were included if they focused on patients 60 years and older and implemented a definition of frailty or risk screening tool in the Emergency Medical Services (EMS) or Emergency Department setting. Results In the broad clinical literature, three types of measures can be identified: frailty index measures, frailty scales, and a phenotypic definition. Each offers advantages and disadvantages for the EMS stakeholder. We identified no EMS literature on frailty conceptualization or management, although some risk measures from emergency medicine use terms that overlap with the frailty literature. Conclusions There is a paucity of research on frailty in the Emergency Medical Services literature. No research was identified that specifically addressed frailty conceptualization or management in EMS patients. There is a compelling need for further research in this area.

The validation of a care partner-derived frailty index based upon comprehensive geriatric assessment (CP-FI-CGA) in emergency medical services and geriatric ambulatory care

BACKGROUND The derivation of a frailty index (FI) based on deficit accumulation from a Comprehensive Geriatric Assessment (CGA) has been criticised as cumbersome. To improve feasibility, we developed a questionnaire based on a CGA that can be completed by care partners (CP-FI-CGA) and assessed its validity. METHODS We enrolled a convenience sample of patients aged 70 or older (n=203) presenting to emergency medical services (EMS) or geriatric ambulatory care (GAC). To test construct validity, we evaluated the shape of the CP-FI-CGA distribution, including its maximum value, relationship with age and gender. Criterion validity was evaluated by survival analysis and by the correlation between the CP-FI-CGA and specialist-completed FI-CGA. RESULTS The mean age was 82.2±5.9 years. Most patients were women (62.1%), unmarried (widowed, divorced and single) (59.6%) and lived in their own home or apartment (78.3%). The mean CP-FI-CGA was 0.41±0.15 and was higher in the EMS group (0.45±0.15) than in GAC (0.37±0.14) (P<0.001). The CP-FI-CGA correlated well with the specialist-completed FI-CGA (0.7; P<0.05). People who died had a higher CP-FI-CGA than did survivors (0.48±0.13 versus 0.38±0.15). Each 0.01 increase in the FI was associated with a higher risk of death (HR 1.04; 95% CI 1.02-1.06). CONCLUSION The CP-FI-CGA has properties that resemble other published FIs and may be useful in busy clinical practice for grading degrees of frailty. It efficiently integrates information from care partners so that it can help guide decision-making.

The Epidemiology of Prehospital Emergency Responses for Older Adults in a Provincial EMS System

OBJECTIVES Societal aging is expected to impact the use of emergency medical services (EMS). Older adults are known as high users of EMS. Our primary objective was to quantify the rate of EMS use by older adults in a Canadian provincial EMS system. Our secondary objective was to compare those transported to those not transported. METHODS We analysed data from a provincial EMS database for emergency responses between January 1, 2010 and December 31, 2010 and included all older adults (≥65 years) requesting EMS for an emergency call. We described EMS use in relation to age, sex, and resources. RESULTS There were 30,653 emergency responses for older adults in 2010, representing close to 50% of the emergency call volume and an overall response rate of 202.8 responses per 1,000 population 65 years and older. The mean age was 79.9±8.5 years for those 57.3% who were female. The median paramedic-determined Canadian Triage and Acuity Scale (CTAS) score was 3 and the mean on-scene time was 24.2 minutes. Non-transported calls (12.3%) for the elderly involved predominantly (54.9%) female patients of similar mean age (78.3 years) but lower acuity (CTAS 5) and longer average on-scene times (32.6 minutes). CONCLUSIONS We confirmed the increasingly high rate of EMS use with age to be consistent with other industrialized populations. The low-priority and non-transport calls by older adults consumed considerable resources in this provincial system and might be the areas most malleable to meet the challenges facing EMS systems.

Assessment of older adults by emergency medical services: methodology and feasibility of a care partner Comprehensive Geriatric Assessment (CP-CGA)

OBJECTIVES The Comprehensive Geriatric Assessment (CGA) is used in geriatric medicine as a means to manage the health care needs of older adults and to grade frailty. We modified the CGA so that it could be completed independently by care partners (usually family) and be used to grade frailty. Our objective was to examine the feasibility of a care partner completing the CGA at the time of the first prehospital encounter. METHODS A prospective, observational study was conducted with a convenience sample of patients ≥ 70 years accompanied by a knowledgeable care partner. Feasibility was measured by the time required and percent completeness of items on the form based on completion by the care partner and by paramedic perception of utility. RESULTS Subjects (N  =  104) were enrolled with three postenrolment exclusions due to ineligibility. Most participants were older women living in their own home. The mean time to complete the questionnaire was 18.7 minutes (SD 11.3; median 15 minutes; interquartile range 12-20 minutes). Only 64% of the care partners recorded the time it took. Nineteen percent of paramedics completed a follow-up survey, and all felt screening for frailty was worthwhile and most (> 70%) thought that the CP-CGA may be a useful approach. The study was limited by recruitment bias of potentially eligible patients, a high level of missingness in the outcome measures of interest, and low paramedic participation rates. CONCLUSION We observed a high rate of item completeness of questionnaires with a mean time to complete of 18.7 minutes in a convenience sample of older patients. A small sample of paramedics universally endorsed the utility of screening for frailty in the prehospital setting, and many thought the CP-CGA was a helpful tool.

Feasibility of Using Information Derived from a Care Partner to Develop a Frailty Index Based on Comprehensive Geriatric Assessment.

BACKGROUND Frailty is a state of increasing vulnerability that places an individual at high risk for adverse health outcomes. The best approach for frailty measurement in clinical practice has not been resolved. Frailty can be measured by deficit accumulation and be derived from a comprehensive geriatric assessment (CGA). In busy clinical practice, it may not be feasible to gather this information entirely from patients, particularly from those with cognitive decline. OBJECTIVE We describe the feasibility of a frailty index based upon a care partner derived CGA (CP-CGA). In addition, we sought to establish the acceptability of the questionnaire and explore whether care partners felt that the provided information contribute to patient assessment. DESIGN AND SETTING A cross-sectional data analysis of 99 community dwelling older adults attending geriatric ambulatory care clinics at a single tertiary care center. MEASUREMENTS Care partners completed the CP-CGA and a Clinical Frailty Scale (CFS; Range 1 -Very fit- to 9 -Terminally ill). We evaluated the time to complete and item completeness. RESULTS The mean age of patients was 81.3±5.7 years. Most were women (n=54), widowed, lived in their own home, with a median CFS of 5 (Mildly Frail). The care partner respondent was usually an offspring. Item completeness was 95% with a mean time to complete of 15.5±8.6 minutes. CONCLUSION The CP-CGA seems feasible for gathering information that would be integral towards determining frailty by deficit accumulation. Future inquiries will evaluate its feasibility in other settings and validity as a form of frailty assessment.

Burden of Emergency Medical Services Usage by Dialysis Patients

Abstract Background: Patients receiving chronic dialysis often require emergent and inpatient care; however, only a minimal amount is known about their out-of-hospital/inter-hospital use of Emergency Medical Services (EMS). The purpose of this study was to describe the utilization of EMS in a cohort of dialysis patients. Methods: We analyzed a cohort of adult (≥18 years) chronic dialysis patients within the Nova Scotia Health Authority Central Zone Renal Program who initiated chronic dialysis between January 1, 2009 and June 30, 2013 (last follow up July 1, 2015). Dialysis patient data was linked to regional EMS data. Requests for EMS, including encounter type, day of the week, and patient characteristics were described. Results: The cohort consisted of 468 patients of whom 79% (N = 361) had an EMS encounter. There were a total of 8,774 EMS encounters for the entire cohort. Patients who had an EMS encounter tended to be older (64 ± 14 years), compared to those without an encounter (55 ± 16 years, P < 0.001) and also had a higher burden of comorbidity. Transfers (including those between facilities) accounted for 89% of all encounters (N = 7,826), followed by emergency department (ED) transports (N = 749, 9%). Overall, 79% of all non-transfers underwent transport to the ED. For patients receiving thrice weekly in-center hemodialysis, the highest EMS utilization for ED transport occurred on the first hemodialysis day after the long dialysis break (22%, P < 0.01). The lowest proportion of ED transports occurred on the day after hemodialysis day 3. Conclusion: Utilization of EMS services by dialysis patients is considerable, particularly for transfers. This highlights a potential area to be targeted for reducing resource utilization. Calls requiring transport to the ED occurred most often on Mondays and Tuesdays, the day after the long-dialysis break, and may represent a time of heightened risk for in-center hemodialysis patients.

State of the Evidence for Emergency Medical Services (EMS) Care: The Evolution and Current Methodology of the Prehospital Evidence-Based Practice (PEP) Program

Background: Emergency medical services (EMS) leaders and clinicians need to incorporate evidence into safe and effective clinical practice. Access to high-quality evidence, and the time to synthesize it, can be barriers to evidence-based practice. The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, repository of critically appraised evidence specific to EMS. This paper describes the evolution and current methodology of the PEP program. Methods/design: The purpose of PEP is to identify, catalog and critically appraise relevant studies. Following regular systematic searches, two trained appraisers critically appraise included studies and assign a score on three-point level of evidence (LOE) and direction of evidence (DOE) scales. Each clinical intervention is plotted on a 3 × 3 (LOE × DOE) evidence matrix, which provides a summary recommendation. Discussion: The PEP program is a unique knowledge translation tool, specific to EMS. End-users can easily identify which clinical interventions are, or are not, supported by evidence.

Methodology of a Cross-sectional Study Evaluating the Impact of a Novel Mobile Care Team on the Prevalence of Ambulatory Care Sensitive Conditions Presenting to Emergency Medical Services

Introduction Hospitalization due to ambulatory care sensitive conditions (ACSC) is often used as a proxy measure for access to primary care. The prevalence of ACSC has not been measured in the prehospital setting. Emergency medical services (EMS) are being used by patients who lack access to primary care for ACSC. Many novel models of care have been implemented within Canada and internationally, utilizing paramedics to ease the burden of poor primary care access. Recently, a mobile care team (MCT) consisting of a paramedic/nurse configuration has been deployed in the community of New Waterford, Nova Scotia. The team responds to low acuity 911 calls and follow-up appointments booked by primary care clinicians. This study will identify the prevalence of patients with ACSC presenting to EMS before and after the implementation of MCT and the differences after the implementation of the MCT. Methods Secondary data will be collected from the centralized EMS electronic patient care report (ePCR) database. All patients presenting to the ground ambulance with ACSC during the year prior to MCT implementation, all patients presenting to the ground ambulance with ACSC during the year post-MCT implementation, and all patients presenting to the MCT with ACSC will be included for analysis, allowing for a calculation of ACSC prevalence. Descriptive methods will be used for age, sex, primary care practitioner, and ASCS complaints. Prevalence data will be compared via the chi-squared test. A subgroup analysis of age, sex, and individual presenting conditions will also be analyzed using the chi-squared test. Confounding will be dealt with via multivariate logistic regression. Results The study results are pending; however, a literature review reveals a paucity of data on ACSC in EMS. Conclusions Due to the paucity of literature surrounding ACSC prevalence in EMS, the methodology developed to study these prevalence rates is a novel protocol of importance to prehospital research and the epidemiology of ACSC more broadly.

The novel role of paramedics in collaborative emergency centres aligns with their professional identity: A qualitative analysis

OBJECTIVE The Collaborative Emergency Centre (CEC) model of care was implemented in Nova Scotia without an identifiable, directly comparable precedent. It features interprofessional teams working towards the goal of providing improved access to primary health care, and appropriate access to 24/7 emergency care. One important component of CEC functioning is overnight staffing by a paramedic and registered nurse (RN) team consulting with an off-site physician. Our objective was to ascertain the attitudes, feelings and experiences of paramedics working within Nova Scotia’s CECs. METHODS We conducted a qualitative study informed by the principles of grounded theory. Semi-structured telephone interviews were conducted with paramedics with experience working in a CEC. Analysis involved an inductive grounded approach using constant comparative analysis. Data collection and analysis continued until thematic saturation was reached. RESULTS Fourteen paramedics participated in the study. The majority were male (n=10, 71%) with a mean age of 44 years and mean paramedic experience of 14 years. Four major themes were identified: 1) interprofessional relationships, 2) leadership support, 3) value to community and 4) paramedic identity. CONCLUSIONS Paramedics report largely positive interprofessional relationships in Nova Scotia’s CECs. They expressed enjoyment working in these centres and believe this work aligns with their professional identity. High levels of patient and community satisfaction were reported. Paramedics believe future expansion of the model would benefit from development of continuing education and improved communication between leadership and front-line workers.