In the emergency geriatric guidelines, there is a whole component on transition of care. One important actor of this aspect one that is often forgotten is the EMS system.
They answer the 911 call, they assess patients and most of the time they transfer them to the emergency department. What is their specific role in transition of care for elderly? Could they extend their scope of practice?
We met two interesting persons today. They have some answers to these questions but most importantly, they have great ideas!
But first, lets see what is out there.
In the United States, they are always ahead of Canada in terms of EMS care. The NAEMT, which is their national organization for EMS, have a special education on geriatric care called GEMS (The Geriatric Education for Emergency Medical Services). According to their website, this program trains emergency and mobile healthcare practitioners to deliver state-of-the-art care to geriatric patients. The medical director is Manish Shah who has a few publications on the subject. A recent paper that he was involved with on alternative care for EMS showed a positive association with patient satisfaction (1). I was able to find a few other papers on patient satisfaction, all of them with positive conclusion towards alternative care.
There is no big surprise here; patients love being taking care of as a whole special person instead of having to visit the ED.
Alternative care delivered by professional EMS provider seems to be a brilliant idea. But does it worth the effort? The literature to answer this question is more limited.
In the BMJ in 2007 (so, relatively recent concept!) evaluated the effect of alternative care on ED attendance, hospital admission and on the time from call to discharge. Turns out that each outcome was significantly reduced by providing alternative care to elderly (2). This was for minor medical condition though. Another interesting study evaluated the effect on emergency department admission of a strong program of telemedicine (3). It showed that the more engaged the senior homes are with telemedicine, the more they tend to avoid a transfer to the emergency department (27% reduction). I was not able to find more precise studies about the real clinical impact (defined by what?) of EMS practitioners for alternative care. There is a major knowledge’s gap here. But in my opinion, it is far from being a barrier to implement alternative care by EMS.
Here are a few advantages that I can see of this innovative way to practice care for the elderly:
- Reduction of emergency department transfers;
- Reduction of hospital admission;
- Improving level of care;
- A great opportunity for prevention (assess falls risk, on site evaluation, even frailty assessment!);
- EMS does not have a specific “ordre” nor “college” to regulate their scope of action. They act under a physician order which is a great advantage for implementing new ways of practice easily;
- Not evaluated but I would say that this is cost effective;
- Enforce the concept of “maintien à domicile”.
There is probably more.
Is there any disadvantage? I will have to think about it.
Another question on the subject is what is the core content that an EMS practitioner should know about elderly?
The GEMS offers an 8 or 16 hours course, + video, + online lecture, + a book to read (I need to have that book!). Is that enough? Unfortunately, I was not able to find another specific training on geriatric although in 2009, a study showed with a survey among EMS provider that they have needs for further geriatric training .
Back to the two gentlemen I met today, Walter and Christ, watch them; they are going to change the face of geriatric EMS care and by proxy the face of geriatric emergency medicine in the next few years with a Canadian perspective. If I want to be a part of that? You bet !
- Munjal KG, Shastry S, Loo GT, Reid D, Grudzen C, Shah MN, et al. Patient Perspectives on EMS Alternate Destination Models. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2016 May 27:1-7. PubMed PMID: 27232532.
- Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, et al. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. Bmj. 2007 Nov 3;335(7626):919. PubMed PMID: 17916813. Pubmed Central PMCID: 2048868.
- Gillespie SM, Shah MN, Wasserman EB, Wood NE, Wang H, Noyes K, et al. Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2016 Jun;22(6):489-96. PubMed PMID: 26741194.