Project title:
Research into Older people with Dementia and their carers use of Emergency ambulance Services (RODES).
Type of research:
Complex evaluation: development grant to progressively refine the design before embarking on a full scale intervention design and evaluation.
Background & strength of scientific evidence:
Care for older people with dementia (OPWD) is a major concern across all care settings and the Prime Minister’s Challenge on Dementia both reflects and has contributed to a growing awareness of the issues bringing dementia up the political agenda. Ambulance services are also in the spotlight, as crucial players in the many interlinked care settings. Pressures on emergency services and calls for admissions avoidance have hit the headlines and prompted last year’s Urgent and Emergency Care Review. One of the ‘Opportunities for meeting people’s urgent care needs closer to home’ identified in the Nov 13 interim report was for ambulances to be ‘seen as a community-based mobile urgent treatment service, rather than solely a means of transportation.’ Currently, in England, 28.6% of patients are treated at the scene only (i.e. do not require onward transportation) following arrival of an emergency response vehicle at the scene of the incident (1). A previous study on non-transported patients found this group to be made up of predominantly elderly people (i.e. over 65 years old), but did not report on the type of residence (i.e. a home or a care home) of non-transported patients (2) and information is not available on these patients’ cognitive status. Research on use of emergency ambulance services has tended to focus on characteristics and needs of OPWD on arrival at the Emergency Department (ED) and the appropriateness of admission (3, 4). As noted in recent guidance from the British Geriatrics Society, ‘The Silver Book’ “There is an embarrassing paucity of research into the needs of frail older people in general, and hardly any directly relevant research addressing urgent care (5).
The Research into Older People with Dementia and their Carers’ use Emergency Ambulance Services (RODES) study was directly informed by findings from two studies on use of emergency services by OPWD, one that focused on care home residents and another that took a broader view across the community.
Study aim
The RODES study aimed to inform the selection and development of interventions to support a more efficient use of emergency ambulance services by OPWD.
Study objectives
- To establish the feasibility of using routine data collected by the East of England Ambulance Service Trust (EEAST) to identify OPWD.
- To examine existing patterns of service use by this population including (i) how many OPWD use the East of England Ambulance Service (EEAST) and what proportion is people living at home or in care homes and (ii) the proportion of call-outs to OPWD living at home and in care homes that do not result in conveyance to the Emergency Department.
- To evaluate and quantify the potential to reduce total costs of OPWD accessing urgent and emergency care via the ambulance service.
- To identify factors associated with emergency ambulance use by OPWD in care homes and at home and the decision to convey to hospital.
- To develop testable hypotheses of what kind of interventions work in what circumstances to support appropriate and efficient use of emergency ambulance services by OPWD.
- To define OPWD sensitive outcomes that recognises opportunities for intervention at organisational, service and patient level of care.
Study design
The study employed a mixed-methods approach (see Figure 1) including evidence review, audit of routinely collected data (i.e. patient care records and computer-aided dispatch records), critical incident review and a case study of a targeted service, followed by review of these work-stream findings with key stakeholders in order to develop testable hypotheses or propositions of what kind of interventions work in what circumstances to support a more efficient use of emergency ambulance services by OPWD. Learning from this was also used to inform planning of dementia-specific educational programmes for emergency ambulance staff.
References
- Ambulance Services, England 2012-13: Health and Social Care Information Centre, 2013.
- Marks PJ, Daniel TD, Afolabi O, Spiers G, Nguyen-Van-Tam JS. Emergency (999) calls to the ambulance service that do not result in the patient being transported to hospital: an epidemiological study. Emergency Medicine Journal 2002;19(5):449-52.
- Konetzka RT, Spector W, Limcangco MR. Reducing Hospitalizations From Long-Term Care Settings. Medical Care Research and Review 2008;65(1):40-66.
- Clevenger K, Chu A, Yang Z, Hepburn W. Clinical care of persons with dementia in the emergency department: A review of the literature and agenda for research. Journal of the American Geriatrics Society 2012;60(9):1742-48.
- The Silver Book: Quality care for older people with urgent and emergency care needs, 2011.
Key findings and outputs:
Publications:
Buswell M, Lumbard P, Prothero L, Lee C, Martin S, Fleming J, and Goodman C. Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence. Emergency Medicine Journal 2014 Dec 2. doi: 10.1136/emermed-2014-203941.(Abstract).
Buswell M, Fleming J, Lumbard P, Prothero LS, Amador S, and Goodman C. Difference between how ambulance service personnel use paper and electronic patient care records when attending older people at home. European Journal of Emergency medicine 2015; 22(2): 147 – 148. (Abstract).
Download a poster summarising this study
For further information on this project, contact Dr Marina Buswell at mb934@medschl.cam.ac.uk
