Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: A qualitative study

Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, London, UK.
Emergency Medicine Journal (Impact Factor: 1.84). 01/2011; 28(1):44-50. DOI: 10.1136/emj.2009.079566
Source: PubMed


Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen.
During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out.
The interviews revealed a similar assessment and decision-making process among participants: Prearrival: forming an early opinion from information from the emergency call. Initial contact: assessing the need for any immediate action and establishing a rapport. Continuing assessment: gathering and assimilating medical and social information. Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct.
An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.

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    • "Dutch physicians define the situation 'medisch zinloos' [senseless], and the Netherlands was the first state to legislate on end-of-life situations, thus regulating the issue [8]. For some authors, the notion of treatment refusal should expand to additional practical issues and to cover non-professional staff, such as the case of paramedicals facing the refusal of a patient to be hospitalized [9]. In 2006 Austria promulgated a law regulating the issue of advance directives, mainly regarding the prolongation of the treatment, albeit the Dutch experience preceded the others' [10]. "
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    ABSTRACT: The Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices. The question of 'medically futile' interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions 'medisch zinloos' (senseless), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum. End-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of 'amanet', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.
    Full-text · Article · Jun 2011 · BMC Medical Ethics
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    ABSTRACT: Background and aim Falls are the leading cause of injury in older adults. Identifying people at risk before they experience a serious fall requiring hospitalisation allows an opportunity to intervene earlier and potentially reduce further falls and subsequent healthcare costs. The purpose of this project was to develop a referral pathway to a community falls-prevention team for older people who had experienced a fall attended by a paramedic service and who were not transported to hospital. It was also hypothesised that providing intervention to this group of clients would reduce future falls-related ambulance call-outs, emergency department presentations and hospital admissions. Methods An education package, referral pathway and follow-up procedures were developed. Both services had regular meetings, and work shadowing with the paramedics was also trialled to encourage more referrals. A range of demographic and other outcome measures were collected to compare people referred through the paramedic pathway and through traditional pathways. Results Internal data from the Queensland Ambulance Service indicated that there were approximately six falls per week by community-dwelling older persons in the eligible service catchment area (south west Brisbane metropolitan area) who were attended to by Queensland Ambulance Service paramedics, but not transported to hospital during the 2-year study period (2008–2009). Of the potential 638 eligible patients, only 17 (2.6%) were referred for a falls assessment. Conclusion Although this pilot programme had support from all levels of management as well as from the service providers, it did not translate into actual referrals. Several explanations are provided for these preliminary findings.
    Full-text · Article · Nov 2011 · Injury Prevention
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    ABSTRACT: Abstract Introduction. Responses for "lift assists" (LAs) are common in many emergency medical services (EMS) systems, and result when a person dials 9-1-1 because of an inability to get up, is subsequently determined to be uninjured, and is not transported for further medical attention. Although LAs often involve recurrent calls and are generally not reimbursable, little is known of their operational effects on EMS systems. We hypothesized that LAs present an opportunity for earlier treatment of subtle-onset medical conditions and injury prevention interventions in a population at high risk for falls. Objectives. To quantify LA calls in one community, describe EMS returns to the same address within 30 days following an index LA call, and characterize utilization of EMS by LA patients. Methods. Data from the computer-aided dispatch (CAD) system of a suburban fire-based EMS system were retrospectively reviewed. All LAs from 2004 to 2009 were identified using "exit codes" transmitted by paramedics after each call. The number and nature of return visits to the same address within 30 days were examined. Results. From 2004 through 2009, there were 1,087 LA responses (4.8% of EMS incidents) to 535 different addresses. Two-thirds of the LA calls (726; 66.8%) were to one-third of these addresses (174 addresses; 32.5%); 563 of the return calls to the same address occurred within 30 days after the index LA. For 214 of these return visits, it was possible to compare patient age and sex with those associated with the initial LA, revealing that 85% of return visits were likely for the same patients. Of these, 38.5% were for another LA/refusal of transport, 8.2% for falls and other injuries, and 47.3% for medical complaints. Hospital transport was required in 55.5% of these return visits. The EMS crews averaged 21.5 minutes out of service per LA call. Conclusion. Lift-assist calls are associated with substantial subsequent utilization of EMS, and should trigger fall prevention and other safety interventions. Based on our data, these calls may be early indicators of medical problems that require more aggressive evaluation.
    No preview · Article · Sep 2012 · Prehospital Emergency Care
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