Emergency Medical Services
Emergency medical services (EMS) use for older patients ranges between 100 and 167 per 1000 older adults per year. This rate exceeds for other age groups and has important implications for EMS operations. Patients 65 years and older are projected to compose 49% of all EMS transports by 2030. In the United States, EMS is generally provided by local communities and overseen by the state. However, the National Highway Traffic Safety Administration (NHTSA) created standard curricula, which have been adopted by many states. There are several levels of training for EMS providers. In the National Standard Curriculum for lower level providers (first responders and EMT-basic), there is a specific focus on children (who represent 4% of EMS patients), but no similar focus on older persons (who represent one-third of EMS patients). The curricula for higher-level providers (EMT-intermediate or EMT-paramedic) do have a specific focus on geriatrics. The curriculum for EMT-paramedic training includes comprehensive sections on physiology across the lifespan and geriatrics. Overall, this dedicated geriatrics training represents about 1% of the 1000- to 1200-hour curriculum.
The AGS and the National Council of State EMS Training Coordinators recognized the deficiency in geriatric training for EMTs and created a coalition of 13 national organizations, which developed a continuing education course, Geriatrics Education for EMS (www.gemssite.com). Future cooperation between the EMS community and geriatric professionals is essential to ensure that their training is appropriate and adequate.
EMS equipment and protocols must be adapted to the older patient. For instance, the standard approach to patients with potential neck injuries is to place them in a rigid cervical collar and a backboard with head immobilizing blocks. This approach may be difficult or impossible in older patients with kyphoscoliosis. Immobilization for prolonged periods can also lead to skin breakdown. An alternative is the use of long vacuum splints that can immobilize patients with kyphoscoliosis in a more comfortable position.
Providers of prehospital care have a rare opportunity among health care providers—the ability to assess patients in their homes during their acute illness. Programs have been developed to use EMTs to screen older adults for fall risk, social issues including abuse and neglect, and to assess the home environment. EMTs are trained to identify potential problems, refer at-risk patients to the appropriate agencies for assessment, and link the patient to community services. Evaluations of such programs have found a benefit to individual patients.
Geriatric EMS trauma triage protocols improve care for seniors. Adult EMS trauma triage guidelines were found to have poor sensitivity and specificity when applied to patients age 70 and older. Geriatric trauma triage guidelines use a higher systolic blood pressure and Glasgow Coma Scale (GCS) cutoffs, and contain anatomic and injury mechanisms that are not found on standard adult triage criteria. These include fall from any height with evidence of traumatic brain injury and motor vehicle crashes with fracture of a long bone (Table 17-5).
TABLE 17-5Geriatric Trauma Triage Guidelines |Favorite Table|Download (.pdf) TABLE 17-5 Geriatric Trauma Triage Guidelines
|Glasgow Coma Score ≤ 14 with evidence of traumatic brain injury |
|Systolic blood pressure < 100 mm Hg |
|Falls from any height with evidence of traumatic brain injury |
|Pedestrian struck by motor vehicle |
|Multiple body regions injured |
|Known or suspected long bone fracture from a motor vehicle crash |
There are not enough geriatricians for the present population and prospects for reducing this shortfall seem unlikely. Other specialists must develop sufficient geriatric expertise to attend to the special needs of the older patient. There is increasing growth in the number of emergency physicians who identify with geriatric emergency medicine. Part of this growth is a result of the AGS initiative to increase geriatric expertise among surgical and related medical specialists. Emergency medicine has been an active participant in this project from its outset. The project’s initial efforts were directed at increasing the geriatric content of residency education and improving the quantity and quality of research. This project, a collaboration between specialty societies developed a cadre of young leaders and improved the outlook for geriatric expertise in the surgical specialties, especially in emergency medicine.
Geriatricians can actively participate in increasing expertise among emergency physicians. They can contribute to the educational program for emergency physicians in training and in continuing education for board certified physicians. Geriatricians can participate in rounds and can give didactic material to those in training. The future of continuing education is likely to be in computer-based interactive educational modules. Geriatricians can participate in the development of these modules.
Geriatricians and advance practice nurses have been active and important consultants to emergency physicians. Emergency physicians appreciate the difficulty in diagnosis and management of older patients. A cooperative geriatric consulting service is of benefit to both the geriatrician and the emergency physician. Emergency physicians are responsive to service programs that will improve outcomes for their patients. Increasing interest in geriatric emergency care makes emergency physicians particularly amenable to programs that improve outcomes for older patients. Having a relationship of mutual respect further fosters willingness to cooperate. Geriatricians with an idea for a program that links the ED with a service, that is, a fall prevention or geriatric assessment, will find an ally if they wish to develop that program. Similarly, geriatricians should accept overtures from emergency physicians with ideas.
The Emergency Department’s Relationship With Long-Term Care
Nearly a quarter of nursing home residents are transported at least once each year to the ED. Compared to community-dwelling older adults, nursing home residents tend to present to the ED with less information and are more likely to have a nonspecific chief complaint. Thus they are most likely to require special adaptation in ED care. Two-thirds of nursing home residents who present to the ED are cognitively impaired and cannot provide a clear medical history. Often, families are not immediately available or are unaware of recent changes in the patient’s condition. For this reason, communication between the nursing home and ED is crucial. However, 10% of nursing home residents are transported to the ED without any written documentation and important patient information often is missing in the 90% who arrive with paperwork. If baseline cognitive and functional status is not reported, it is impossible to determine if changes have occurred. The ED is also often a poor communicator when older patients are discharged back to the nursing home. Nursing home personnel report that residents often return from the ED without notification, written documentation, or recommendations for care.
Nursing home to ED and ED to nursing home transfers are a frequent and important type of transition in care. Poor communication during these transitions increases the cost of care, leads to greater use of health care services, and jeopardizes the patient’s safety. The interaction between nursing homes and EDs is one area where geriatricians, nursing home personnel, and emergency physicians can interact to improve the care of the older patient.
Alternatives to Hospitalization
The ED is a gatekeeper between the community and the hospital. The decision to admit a patient to the hospital or to discharge a patient is made in the ED. As noted above, this difficult decision must take into account medical, functional, and social issues. There are several potential alternatives to hospitalization following an ED evaluation. One is the “Hospital at Home” concept. “Hospital at Home” programs have been evaluated for a variety of medical conditions including pneumonia, CHF, cellulitis, and chronic obstructive pulmonary disease (COPD). These programs have demonstrated improved satisfaction, lower rates of depression, and lower rates of nursing home admissions, without a difference in functional status or mortality. Another alternative is direct ED admission to skilled nursing facilities. Currently, Medicare requires a 3-day inpatient hospital stay to qualify for Medicare skilled nursing facility coverage. Thus a Medicare patient can only be covered for a direct admission from the ED to a nursing home if they have had a qualifying hospital stay in the prior 30 days. For patients with private insurance or who belong to a Medicare health maintenance organization (HMO), the requirement for prior hospitalization may not be applicable. The requirement for prior hospitalization was created decades ago, prior to the many changes in inpatient, ED, and skilled nursing facility care. A change in this rule might lead to improved transitions and more efficient use of health care.
The Centers for Medicare and Medicaid Services 2-midnight rule affects many older patients who are not well enough for discharge from the hospital. Patients placed in observation may have large out-of-pocket expenses since Medicare part A does not cover that stay. Hospitals may lose money if patients are admitted with short inpatient stays that do not meet criteria. Patients can be placed in observation and changed to inpatient status if their condition changes or diagnoses become obvious, but the time spent in observation does not count toward their three midnight inpatient criteria for skilled nursing facilities. Patients must be in observation for at least 8 hours with care provided hourly by a registered nurse.
Cooperation between emergency physicians, primary care physicians, and geriatricians is essential to create successful alternatives to hospitalization. Guidelines could help match care settings with appropriate subsets of acutely ill older adults and treatment protocols to ensure patient and caregiver satisfaction, cost-effectiveness, low mortality, and good functional outcomes. Transitional care coordinators, hospital discharge planners, or social workers may be able to help arrange outpatient follow-up, safety assessments, medical equipment, home health, activities of daily living resources, and access to medical transportation.
Older people are at increased risk and have unique needs in natural and human-made disasters. However, they often are not recognized as a vulnerable group during disaster planning and response. Recent disasters demonstrate their vulnerability. In the 2004 Indian Ocean tsunami, there were more deaths in people older than 60 years than in any other age group. Nearly half of those who died in hurricane Katrina were 75 years or older and 70% were older than 60 years. Even power outages can be a significant problem for older adults who need oxygen or nebulizers or who depend on motorized wheelchairs or other electric devices.
Older adults, especially those with disabilities or chronic medical conditions, do not have the functional reserve to respond to a disaster. Social isolation, impaired mobility, economic constraints, functional dependence, and the need for specialized medical treatments such as dialysis affect the ability of older persons to cope with disasters. Geriatric specialists can help those involved in disaster planning and response to understand the unique needs of the older population.
Standard disaster shelters often are unable to accommodate older adults who are not functionally independent. Special needs shelters can be created to help care for chronically ill or functionally impaired patients, though these shelters may require patients to be accompanied by a caregiver. Special needs patients often present to hospital EDs during a disaster, even without acute medical emergencies, because their needs cannot be met elsewhere. Unfortunately, they may spend considerable time in the ED or require hospitalization if no other location for care is identified. Since both EDs and hospitals may be functioning at or beyond capacity during a disaster, these limited resources are strained by the nonmedical demands of these special needs patients, and more appropriate settings are preferable for both the patient and the system.