Extending Continuum of Care for Older People: A Role for Emergency Medical Services Personnel

To the Editor: We read with great enthusiasm the two studies in the October 2001 issue of the Journal of the American Geriatrics Society focusing on emergency care of older people. 1, 2 Although both studies were of great interest and long awaited, we would like to comment on the study by Mion et al. As the authors pointed out, the emergency room is becoming a setting where community-based at-risk frail older people can be identified. Previous studies support the finding that, although people who are aged 65 and older represent approximately 13% of the U.S. population, they account for up to 36% of all ambulance transportation to the emergency room. 3 In addition, older patients often require accompaniment by paramedics, the highest-trained prehospital provider. 4 The Systematic Intervention for a Geriatric Network of Evaluation and Treatment (SIGNET) model used by Mion et al. introduces and reinforces the need for busy emergency room personnel to “think differently” and incorporate a psychosocial model while medically assessing older patients. The Triage Risk Screening Tool is an excellent example of an instrument for use by emergency room staff to evaluate ill patients who are potentially at high risk of continued loss of functional independence. We propose that, for those older people who arrive at the emergency room via ambulance, more can be done to assess premorbid conditions and functional independence. We surveyed more than 500 randomly assigned licensed emergency medical personnel in Oklahoma as part of our Oklahoma Emergency Medical Services (EMS) Geriatric Studies.5 Preliminary data suggest that EMS personnel, in general, understand the importance of communicating to emergency room staff observations about an older patient's home environment made while responding to a 911 call. Despite the limited amount of geriatric care training that EMS personnel currently receive, these intuitive observations could be purposeful in identifying high-risk community-dwelling older people. We believe that these “front-line” personnel can provide valuable information to enhance the effectiveness of the likes of a SIGNET model. The results of our initial study suggest that EMS personnel can play an important role and serve as a vital link between community-dwelling older people and emergency rooms. EMS personnel have a natural role in identifying frail at-risk older people while responding to 911 calls in a home setting. We are developing a Geriatric Emergency Risk Index scale, a rapid and easy to use prehospital screening tool that someday may be used in the out-of-hospital setting, and, like Mion et al., we will continue to explore the value of integrating a psychosocial model into the provision of emergency room care for older patients.