Randomized Controlled Trial of a Prehospital Decision System by Emergency Medical Services to Ensure Optimal Treatment for Older Adults in Sweden
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1 Track 8: Clinical Geriatrics Randomized Controlled Trial of a Prehospital Decision System by Emergency Medical Services to Ensure Optimal Treatment for Older Adults in Sweden Veronica Vicente 27 oktober
2 Randomized Controlled Trial of a Prehospital Decision System by Emergency Medical Services to Ensure Optimal Treatment for Older Adults in Sweden Veronica Vicente PhD & Head of research and development department of the ambulance service in Stockholm Sweden Karolinska Institutet, Department of Clinical Science and Education and Stockholm Prehospital Centre, Södersjukhuset. Sophia hemmets University in Stockholm
3 Veronica Vicente 27 oktober
4 Veronica Vicente 27 oktober
5 Sweden, Stockholm Sweden ~ 9 million habitants Stockholm ~ 2 million habitants Old residents ( 65 years or older) are ~ estimated that the elderly population ( 65years or older) will increase by 56% Central Bureau of Statistics. Population statistics of different age groups in Sweden, Veronica Vicente 27 oktober
6 Health services in Stockholm visits to emergency departments (ED) (year 2012) Approximately 30% patients were admitted acute inpatient 20% of acute visits were patients 65 years or older Year 2006 almost 70% of the elderly population had been treated and hospitalized for at least 1 time Ambulanssjukvården i Stockholm (AISAB) - Kvalitetsmål2009. Samaras et al. Annals of Emergency Medicine Veronica Vicente 27 oktober
7 Emergency Medical Services (EMS) in Stockholm Today we have 70 ambulances to serve 2 million inhabitants ambulance assignments (year 2013) 52% of these assignments were patients from aged 65 years or older Central Bureau of Statistics. Population statistics of different age groups in Sweden, Ambulanssjukvården i Stockholm (AISAB) - Kvalitetsmål2009. Veronica Vicente 27 oktober
8 How does the ambulance work Before the Prehospital ambulance study almost all (98%) ambulance patients were transported directly to the ED Veronica Vicente 27 oktober
9 Consequences Low priority of geriatric patients Increased suffering For the patient Overcrowded ED is correlated to higher mortality Sprivulis et al. Medicine Journal Australia, Ross et al. Ann Emergency Medicine, Fatovich& Hirsch. Emergency Medicine Journal, Veronica Vicente 27 oktober
10 Problem When they don't get specific medical care adjust to there needs Veronica Vicente 27 oktober
11 Our solution Prehospital steering of elderly patient to optimal level of healthcare Veronica Vicente 27 oktober
12 Prehospital steering of elderly patient Limited ability to predict the patients medical need Unable to determine patients need of transport Poor agreement between predicted triage and actual disposition or diagnosis Levine et al. Journal Emergency Medicine, Pointer et al. Ann Emergency Medicine, Snookset al. Emergency Medicine Journal, Schumacher. American Journal Emergency Medicine, 2005 Veronica Vicente 27 oktober
13 Prehospital steering to optimal level of health care Higher education Guidelines (Decision system) Protocol (Decision support tool) Levine et al. Journal Emergency Medicine, Pointer et al. Ann Emergency Medicine, Snookset al. Emergency Medicine Journal, Schumacher. American Journal Emergency Medicine, 2005 Veronica Vicente 27 oktober
14 Prehospital Study Aim The aim of this study was to evaluate the feasibility and appropriateness of a pre-hospital decision system and an associated decision support tool that ambulance nurses use to triage older adults to optimal level of Healthcare. Method Randomized controlled trial Veronica Vicente 27 oktober
15 Appropriate patient categories to triage to alternative level of healthcare Urinary and/or with catheter disorders, Dizziness, Respiratory Disorders/Chronic Obstructive Pulmonary Disease COPD, Respiratory Disorders/Pneumonia, Diabetes (excluding hypoglycaemia), Fever, Hypotension, Frailty, Back pain/back contusion, Fall/injury and accident, Hip Trauma (without suspicion of femur fracture). Vicente et al. European Journal of Emergency Medicine, Veronica Vicente 27 oktober
16 Prehospital decision support tool (triage tool) Vicente et al. European Journal of Emergency Medicine, Veronica Vicente 27 oktober
17 Results Dispatch centre Randomized Intervention group Control group Alternative level of healthcare 20 % Emergency department Emergency department Subsequent transfer 6,7 %
18 Ambulance nurse adherence to the system Good compliance to the system Correctly identified patients' medical conditions in all patient cases Decisions system was followed in 93.3% (419 of 449) Veronica Vicente 27 oktober
19 The over all benefits of ambulance steering More adequate care for elderly patients Proper allocation of health care resources To better use the higher competence within the ambulance Vicente et al. Journal of the American geriatric society 2014 Vicente et al. International Journal of Qualitative Studies on Health and Well-being, Veronica Vicente 27 oktober
20 Conclusion Ambulance nurses are able to triage older adults to an alternative healthcare with the help of a pre-hospital decision support system This system optimize resources and improve emergency care of elderly adults Vicente et al. Journal of the American geriatric society 2014 Vicente et al. International Journal of Qualitative Studies on Health and Well-being, Veronica Vicente 27 oktober
21 or
22
23 Veronica Vicente 27 oktober
24 Intervention Control p-value (N=359) (N=198) Ambulance assignment time to Primary care 55 (16-98) Ambulance assignment time to Secondary care 57 (29-125) Ambulance assignment time to Tertiary care 54 (17-131) 55 (24-147) Patient time in ED: Arrival - Doctor 68 (0-621) 89 (0-624) Patient time in ED: Arrival- Discharge 262 (8-765) 288 ( ) The values presented are median minutes (min-max). P-values are from the Mann-Whitney U test. Veronica Vicente 27 oktober
25 Older adults Multi- and/or chronic disease Reduction of there spare capacity Multi users of healthcare services Melby et al. Journal of Clinical Nursing, Sawatzky et al. Health and Quality of Life Outcomes, Carretet al. BMC Health Services Research, Veronica Vicente 27 oktober
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