Symptoms of depression and risk of emergency department visits among people aged 70 years and over.

BACKGROUND: Older people experiencing depression and anxiety have higher rates of health service utilisation than others, but little is known about whether these influence their seeking of emergency care. The aim was to examine the associations between symptoms of depression and the use of emergency health care, in an Australian context, among a population of people aged 70 years and over initially free of cardiovascular disease, dementia or major physical disability. METHODS: We undertook secondary analyses of data from a large cohort of community-dwelling Australians aged [Formula: see text]70 years. Multivariable logistic regression was used to compare the association of symptoms of depression (measured using the Center for Epidemiological Studies Depression Scale 10 question version, CESD at baseline) with subsequent episodes of emergency care, adjusting for physical and social factors of clinical interest. Marginal adjusted odds ratios were calculated from the logistic regression. RESULTS: Data were available for 10,837 Australian participants aged at least 70 years. In a follow-up assessment three years after the baseline assessment, 17.6% of people self-reported an episode of emergency care (attended an ED of called an emergency ambulance) in the last 12 months. Use of emergency healthcare was similar for men and women (17.8% vs. 17.4% p = 0.61). A score above the cut-off on the CESD at baseline was associated with greater use of emergency health care (OR = 1.35, 95% CI 1.11,1.64). When modelled separately, there was a greater association between a score above the cut-off on the CESD and emergency healthcare for women compared with men. CONCLUSIONS: This study is unique in demonstrating how depressive symptoms among healthy older persons are associated with subsequent increased use of emergency healthcare. Improved understanding and monitoring of mental health in primary care is essential to undertake effective healthcare planning including prevention of needing emergency care.

Emergency ambulance demand by older adults from rural and regional Victoria, Australia.

OBJECTIVE: To describe the demographic profile and clinical case mix of older adults following calls for an emergency ambulance in rural Victoria, Australia. METHODS: Retrospective cohort study using ambulance electronic patient care records from rural-dwelling older adults (≥65 years old) who requested emergency ambulance attendance during 2017. RESULTS: A total of 84 785 older adults requested emergency ambulance attendance, representing a rate of 278 per 1000 population aged ≥65 years. More than 10% of calls were to residential aged care homes. Medical complaints and trauma accounted for 69% and 18% of attendances, respectively. The predominant cause of trauma was ground-level falls. Common reasons for call-outs were for pain (17.5%), respiratory problems (9.7%) and cardiovascular problems (8.5%). Increased demand was associated with increasing age and winter months. CONCLUSIONS: Older adults from rural Victoria have high rates of emergency ambulance attendance and transportation to an emergency department, particularly with increasing age.

Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes.

OBJECTIVE: To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. METHODS: Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. RESULTS: The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. CONCLUSION: This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.

Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study.

BACKGROUND: Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches. OBJECTIVES: To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch. DESIGN: A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted. SETTING: The secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period. PARTICIPANTS: There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses. MAIN OUTCOME MEASURES: Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients. RESULTS: The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005). CONCLUSION: Secondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.

Predictors of transport to hospital after emergency ambulance call-out for older people living in residential aged care.

OBJECTIVES: People living in residential aged care (RAC) frequently experience ambulance call-out. These episodes may have unintended consequences, yet remain under-investigated. Our aim was to examine clinical and sociodemographic features associated with transfer to hospital for this population. METHODS: Retrospective cohort study using 6 years of clinical data from Ambulance Victoria (AV). Data analysis included multilevel multivariable logistic regression analysis of factors associated with transport to hospital. RESULTS: Odds of transfer were greater for people in rural areas, those with a history of depression, cardiovascular disease and osteoporosis, and residents prescribed antipsychotic and antidepressant medication. Ambulance call-out for trauma (commonly low-level fall) was less frequently transferred to hospital than that for a medical complaint. CONCLUSION: These results will improve prediction of call-outs likely to require transfer. Findings include identification of clinical features to be targeted by community and preventative health programs to reduce risk of acute health deterioration and requirement for emergency hospital transfer.

Unplanned Transfer to Emergency Departments for Frail Elderly Residents of Aged Care Facilities: A Review of Patient and Organizational Factors.

BACKGROUND: With an aging population, a growing number of older adults experience physical or cognitive decline that necessitates admission to residential aged care facilities (RACF). Each year a considerable proportion of these residents has at least 1 emergency transfer to hospital, which may result in a number of adverse outcomes. Rates of transfer from RACF to hospital can vary considerably between different RACFs suggesting the presence of potentially modifiable risk factors for emergency department (ED) transfer. METHODS: A systematic and comprehensive search of the peer-reviewed literature using 4 electronic databases was conducted. Included papers were those reporting on determinants of unplanned transfer to hospital for elderly people (aged 65 years and above) living in RACFs. Studies were assessed for quality and key concepts and themes extracted. RESULTS: There are both individual patient factors and health system factors, which influence rates of transfer to hospital for elderly RACF residents. For individuals, increased risk of ED transfer has been associated with presence of particular comorbidities such as chronic airways disease, congestive cardiac failure, and diabetes; presence of indwelling devices; absence of an advance care plan; and reduced functional ability. For organizations, "for profit" facilities and those with poorer staff to patient ratios also have higher rates of transfer to hospital, compared with those owned by not-for-profit organizations and those with improved registered nurse and medical practitioner staffing. CONCLUSIONS: This review has identified a number of potentially modifiable patient and organizational factors that should reduce the need for burdensome transfer to the ED and improve the quality of both acute care and end-of-life care for this population of frail, elderly individuals. A number of these determinants, including facility staffing, the role of specialist geriatricians, and advance directives, should be further examined, ideally through interventional trials to evaluate their impact on the pre-hospital and emergency management of these patients.

A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities.

BACKGROUND: residential aged care facility (RACF) resident numbers are increasing. Residents are frequently frail with substantial co-morbidity, functional and cognitive impairment with high susceptibility to acute illness. Despite living in facilities staffed by health professionals, a considerable proportion of residents are transferred to hospital for management of acute deteriorations in health. This model of emergency care may have unintended consequences for patients and the healthcare system. This review describes available evidence about the consequences of transfers from RACF to hospital. METHODS: a comprehensive search of the peer-reviewed literature using four electronic databases. Inclusion criteria were participants lived in nursing homes, care homes or long-term care, aged at least 65 years, and studies reported outcomes of acute ED transfer or hospital admission. Findings were synthesized and key factors identified. RESULTS: residents of RACF frequently presented severely unwell with multi-system disease. In-hospital complications included pressure ulcers and delirium, in 19 and 38% of residents, respectively; and up to 80% experienced potentially invasive interventions. Despite specialist emergency care, mortality was high with up to 34% dying in hospital. Furthermore, there was extensive use of healthcare resources with large proportions of residents undergoing emergency ambulance transport (up to 95%), and inpatient admission (up to 81%). CONCLUSIONS: acute emergency department (ED) transfer is a considerable burden for residents of RACF. From available evidence, it is not clear if benefits of in-hospital emergency care outweigh potential adverse complications of transfer. Future research is needed to better understand patient-centred outcomes of transfer and to explore alternative models of emergency healthcare.