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Abstract
Objectives To determine contentment with the performance of primary mission emergency care providers.
Methods A prospective cohort study was conducted using key informant interviews to assess quality of life and self-rated degree of contentment with care in geriatric emergencies.
Results Interviews concerning a total of 152 geriatric emergency cases in nursing homes were conducted with patients in 13 (8.6%) cases, geriatric nurses in 132 (86.8%) cases and emergency physicians in 116 (76.3%) cases within a 3-month period. All responding patients as well as the majority of nurses (96.2%) and physicians (79.4%) were content with the quality of emergency care, but showed less contentment with communication (57.6% of nurses; 22.4% of physicians) and with cooperation on-site (57.6% of nurses; 20.7% of physicians).
Conclusions Participants perceived a deficit in communication and cooperation on-site. There is a need for intensified education in managing geriatric emergency patients, especially with regard to communication and psychosocial issues.
- Emergency medical services
- geriatric emergency medicine
- nursing homes
- quality of life
- emergency ambulance systems
- emergency ambulance systems
- effectiveness
- nursing, pre-hospital
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- Emergency medical services
- geriatric emergency medicine
- nursing homes
- quality of life
- emergency ambulance systems
- emergency ambulance systems
- effectiveness
- nursing, pre-hospital
With the ageing of the population the emergency medical services (EMS) are confronted with an increasing number of geriatric emergencies.1 People exceeding age 65 years more frequently utilise EMS, driven in part by affective illness, increasing incidence of falls and depression of geriatric patients.2–5
Geriatric patients comprise a vulnerable subset of EMS users, and many cases present with various co-morbidities, as well as functional and cognitive impairment.6 Malnutrition risk, delirium and dependency were identified as deleterious prognostic factors in geriatric patients.7
The special care needs of older adults unfortunately may not be aligned with the priorities for how EMS care is rendered. In elderly patients acute illness often presents with subtle clinical signs and symptoms. Multiple drug prescriptions and compliance in drug intake can be problematic.8 Geriatric patients appreciate empathetic and comprehensible relief, but communication with older people may be time-consuming and gathering relevant case history information can be difficult. The social and personal concerns of the elderly are frequently not addressed, and targets may differ between EMS personnel, geriatric nurses and patients.9 10 While emergency physicians are trained to focus on vital impairment, nurses might have asked only for pain relief or supportive measures such as suction cleaning of airways. Abatement of discomfort rather than cure, the chance to remain at home and retain self-reliance, and the opportunity to grow old in dignity may be more important to the aged.
The purpose of our investigation was to evaluate prospects and contentment of geriatric patients, nursing staff and EMS physicians after emergency missions in nursing homes and to assess whether the performance of EMS teams meets the expectations and requirements of geriatric patients.
Methods
Setting
We prospectively evaluated emergencies of geriatric residents in 14 nursing homes in Innsbruck, Austria, treated by a university-affiliated, physician-staffed emergency medical service (EMS) between 1 January and 31 December 2008.
In emergency cases the dispatcher immediately sends an ambulance with rescue personnel able to provide basic life support including chest compression and bag ventilation with 100% oxygen. Simultaneously, he dispatches the emergency team, consisting of an emergency physician from the Department of Anesthesiology and Critical Care Medicine together with one emergency technician trained in advanced emergency care.
Study design
The level of contentment with the quality of emergency care was assessed in geriatric patients aged ≥65 years, involved nursing personnel and EMS physicians. EMS case data were obtained from the emergency documentation kept by EMS physicians. Patients, emergency physicians and geriatric nurses were contacted within 3 months following the EMS mission in a geriatric nursing home. Questionnaires were used to quantify data. Approval for this prospective investigation was obtained from the Regional Committee for Research and from the Committee for Ethics, Innsbruck Medical University. Explicit consent was obtained from nursing home administration and head nurses following being personally informed several weeks prior to onset of the study. Written consent was obtained from all participating patients, nurses and emergency physicians on the understanding that results would be published in medical journals. Eligibility criteria included nursing home patients aged ≥65 years having received recent emergency healthcare services within the last 3 months as well as geriatric nurses and emergency physicians assigned to the particular cases. Exclusion criteria were refused consent, severe dementia and inability to communicate in geriatric patients. Recognition of patient exclusion criteria was determined by the nursing personnel.
Instruments
Centers for Disease Control and Prevention Health-Related Quality-of-Life 14-Item Measure (CDC HRQOL-4)
The test comprises four core questions and 10 additional questions about health-related quality of life. The (CDC HRQOL-4) addresses three general schedules: Part 1: subjective health status; Part 2: activities and impairments; Part 3: symptoms and complaints. The questions focus on cause, duration and severity of current activity limitations. Participants indicate the number of days with pain, depression, anxiety, sleeplessness or vitality in the previous month, or respond on a selection of given answers.11
Questionnaire for the assessment of contentment following EMS operations (AC-EMS)
The AC-EMS was developed locally and includes 10 items operationalising the dimensions of: contentment (six items: overall contentment, justification of call, quality of care, cooperation on-site, communication on-site, hospital admission) and lasting impressions (four items: positive recall, unpleasant experiences, recovery since then, feeling of security for the case of future events). Participants respond either on a four-point scale ranging from 1 (very satisfied) to 4 (not satisfied) or on a selection of given answers, or may answer in their own words.
Scoring systems
National Advisory Committee for Aeronautics (NACA) scale
The seven-point NACA scale is used to categorise life-threatening conditions in trauma victims and severely ill patients. NACA scores correlate with morbidity and mortality, hospital admission and duration of hospital stay.12
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale is used to quantify level of consciousness and classify neurological deficiencies after severe brain injury. The GCS score between 3 and 15 represents the sum of the numeric scores for the best eye-opening response (four-point scale), the best verbal response (five-point scale), and the best motor response (six-point scale).13
Statistical analyses
Software used for analysis was SPSS V.16.0. The assumed null hypothesis was: quantifications of the quality of EMS care do not differ among patients, nursing personnel or emergency physicians. Ordinal data were computed with non-parametric tests (Mann–Whitney U test for n=2 and Kruskal–Wallis test for n>2) for analysis of differences between groups. Analysis of variance (ANOVA) was used to determine differences between groups regarding their mean; in this case the metric variables were tested for normal distribution before applying the ANOVA. To measure the correlation between ordinal and/or metric variables a correlation coefficient was computed according to Spearman's r or Pearson; p≤0.05 was considered significant.
Results
Patient responses
The catchment area of EMS Innsbruck has a population of 116 365; 20 143 (17.3%; 2006 census) are aged ≥65 years. During the one-year investigation period a total of 1094 patients (45.8%) aged ≥65 years were treated by EMS Innsbruck, including 152 nursing home residents (13.9%; 35 male, 117 female). EMS units were summoned from the emergency call centre by geriatric nurses on duty in all cases except two, in which relatives insisted on summoning the emergency physician. Mean NACA score for 152 geriatric emergency cases in nursing homes was 3 (range 1–7) and mean GCS was 12 (range 3–15) on arrival of the EMS team; 28 patients (18.4%) had no indication for hospitalisation, six (3.9%) died on-site and another 30 (19.7%) died within a 3-month period.
Nurses deemed overall communication with patients to be difficult in 36 cases (23.7%), whereas impaired verbal understanding and communication made responses impossible in 103 patients (67.7%). Ultimately, 13 patients participated in interviews (response rate 8.6%) (table 1). Patients' subjective assessment of health and quality of life showed a considerable reduction in activities due to impaired walking (nine patients), diseases of the locomotor system (four patients), and cardio-circulatory (three patients) and respiratory complaints (three patients). Depression (in five patients) and sleep disorders (in five patients) were common. Overall the 13 patients interviewed awarded good marks for the quality of emergency care, interval of arrival and treatment (table 2).
Demographic data and patient characteristics
Contentment with the quality of emergency care in geriatric nurses (132 cases) and emergency physicians (116 cases)
Health professional responses
In 152 geriatric emergencies 90 nurses participated in 132 cases (response rate 86.8%) and 31 EMS physicians participated in 116 cases (response rate 76.3%). EMS physicians questioned the rationale of the EMS call in nine cases; in four cases they complained that they were being asked to sub for a family physician who could not be contacted. In 92 cases (79.4%) EMS physicians were content with the circumstances of the emergency mission, in 26 cases (22.4%) with communication and in 24 cases (20.7%) with cooperation on-site. In EMS physicians satisfaction with the EMS operation correlated with the corresponding rating in the NACA scores (−0.243; p=0.009) but not with the corresponding rating in the GCS scores (0.056; p=0.562). Nurse contentment with EMS operations correlated neither with the corresponding rating in the NACA scores (−0.077; p=0.384) nor with the corresponding rating in the GCS scores (−0.093; p=0.301).
While in 127 cases (96.2%) nurses were satisfied with the quality of emergency care, they were content with communication and cooperation on-site in only 76 cases (57.6%). Nurses complained about attitude and conduct of EMS personnel in 12 cases and in four cases asserted that there are too many EMS personnel.
One nurse complained that cardiopulmonary resuscitation (CPR) was initiated despite the information that CPR attempts were not wanted. The quality of communication with the dispatch centre was criticised by nurses in five cases and by physicians in two cases. As compared to EMS physicians nurses more frequently viewed the EMS call as being justified (p=0.000). Accordingly, contentment with the EMS operation (p=0.000), quality of EMS care (p=0.009), cooperation (p=0.045) and communication on-site (p=0.002) was higher in nurses than in emergency physicians. In the event of future EMS indications 43.9% of the nurses would feel secure as opposed to 8.6% of the emergency physicians (p=0.000) (table 3).
Comparison of assumed emotional status for the case of future emergency missions in geriatric nurses (132 cases) and emergency physicians (116 cases)
Discussion
The results of our study revealed that geriatric emergency care appears to pose a specific challenge to both physicians and nursing personnel and that conflictive attitudes can collide during EMS operations in nursing homes.
Geriatric nurses and emergency physicians evaluated the indication and quality of care differently based on different expectations. Peterson et al observed that emergency physicians may regard emergencies in nursing homes as being of less importance and questionable indication, especially when there is little probability of cure or recovery.10 Training courses for EMS physicians in Austria do not focus specifically on geriatric emergency care, supportive care or care for the dying patient. Consequently, EMS physicians more frequently focus on curative medicine and may not be aware of the expectations held by patients, relatives and nursing staff with regard to relief and palliation. Difficulties in dealing with geriatric emergencies in nursing homes in Innsbruck arise from the fact that especially during the night shift when the number of qualified nurses is low and family doctors cannot be contacted by phone, nurses are forced to call for EMS assistance in order to get fast professional help for treatment or further decisions. Understandably, some EMS physicians complained that they felt like being asked to step in for a family doctor who could not be contacted.
Geriatric patients treated by EMS Innsbruck accounted for a threefold greater proportion of patients treated as compared to the general population of its catchment area. This is consistent with findings by Sander et al, who reported an increase in the overall number of geriatric patients, reflecting the fast-growing proportion of the elderly population. Elderly patients seeking emergency care were four times more likely to use ambulance services, five times more likely to be admitted to the hospital, five times more likely to be admitted to an intensive care bed, and six times more likely to receive comprehensive emergency services.9 In keeping with the higher life expectancy of females, the number of female geriatric patients needing emergency care was higher than that of males.2
Geriatric nurses and emergency physicians participating in our study perceived a deficit in communication and cooperation on-site. Compared to emergency physicians, nurses more frequently considered it justified to call the EMS and more frequently were content with the quality of care, cooperation and even communication during EMS operations. Education, age, work experience, care unit size and specialised training are associated with differences in attitudes.14 Kada et al reported that nurses with specialised training in geriatrics, psychiatry or dementia care had significantly higher hope attitudes, as compared with nurses without any special training.15 In our study nurses deemed overall communication with patients to be difficult in only 36 cases although verbal understanding and communication were impaired in 103 patients. Even in the case of patients suffering from dementia nurses did not necessarily report difficulties with communication. This implies that face-to-face interaction by facial expression and eye contact as well as non-verbal communication through gestures, touch and posture substitute and make impaired verbal expression less perturbing between nurses and patients.
Geriatric emergency patients have multiple health problems and consume more time and resources than do younger patients, and the elderly have high rates of co-morbidities. Delirium is a common occurrence and many older patients admitted to hospital in an emergency present with cognitive impairment.6 16 The cognitive deficits manifested by combined memory impairment and cognitive disturbances in executive functioning (ie, planning, organising, sequencing, abstracting) contribute to the development of disturbance of consciousness and delirium. These acute symptoms may be quickly avoided or improved by establishing a low-stimulus environment. A person of trust additionally establishes security and provides orientation. The disease-oriented model used for emergency care may not be appropriate for elderly patients.9 Nursing home emergencies are not always life-threatening and do not always need immediate attention.10 The terms ‘urgent’ and ‘life-threatening situation’ need to be defined differently in the aged as compensation mechanisms may be impaired and limited organ function and limited immune competence may lead to dramatic aggravation of medical conditions.17 On the one hand, EMS physicians focusing on current patient complaints may underestimate the degree of impairment. On the other hand, simply adding up multiple co-morbidities may cause an overestimation of the current illness.
Patients with decision-making capacity who wish to participate should guide important care decisions18 but precise and easily accessible information about patient preferences is rarely provided in geriatric nursing homes. In one case CPR was initiated despite the information that CPR attempts were not wanted. Unless ‘allow-natural-death’ (AND) orders are clearly documented in patients' records, decisions as to whether life-sustaining treatment is indicated or not are the responsibility of the EMS physicians.
Geriatric patients require specific skills, instruments and organisational models for emergency care, social and emotional competence and empathy in order to tend to their complex needs. Triage, clinical assessment and discharge were identified as critical moments during an emergency care process in order to reduce EMS physicians' difficulties and improve quality of care and outcome for elder patients.19 Identification of deleterious prognostic factors is needed to assign elderly patients to different mortality risk groups. Terrell et al identified quality indicators for cognitive assessment, pain management, and transitional care between nursing homes and hospitals to help researchers and clinicians target quality improvement efforts.20 Emergency physicians must be alert to more subtle atypical presentations of disease, account for underlying diseases and medication effects, and assess cognitive and functional deficits. Skills in communication and psychosocial issues need to be trained and implemented.19 21
Limitations of study design and results
The number of responding nursing home patients was very low, indicating that questionnaires are of limited use in the assessment of geriatric patients with cognitive impairment, communication disorders and neurological deficits.
Furthermore, investigations conducted up to 3 months after the emergency call were difficult to recall by some of the responders.
The specific domains of geriatric medicine, in which EMS providers need more training, and the modality through which continuing education is achievable, were not investigated in our study.
Conclusion
Although geriatric patients tend to be satisfied with the quality of care provided by EMS, there is a potential need to improve performance, especially in communication and cooperation between geriatric nursing staff and emergency physicians. Intensified training and continuing education for EMS providers is needed, mostly involving the communication and psychosocial issues of geriatric emergencies.
Acknowledgments
We express our gratitude to the geriatric nurses and to the emergency physicians of EMS Innsbruck for their conscientious participation.
References
Footnotes
Competing interest None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Committee for Ethics, Innsbruck Medical University.
Provenance and peer review Not commissioned; externally peer reviewed.