Randomized Controlled Trial of a Prehospital Decision System by Emergency Medical Services to Ensure Optimal Treatment for Older Adults in Sweden

OBJECTIVES: To evaluate the feasibility and appropriateness of a prehospital system allowing ambulance nurses to transport older adults directly to geriatric care at a community-based hospital (CH) or to an emergency department (ED). DESIGN: Randomized controlled trial. SETTING: Emergency medical services in Stockholm, Sweden. PARTICIPANTS: Older adults who called the emergency number were randomized to an intervention group (n = 410) or a control group (n = 396). INTERVENTION: The dispatcher randomized the individuals. Those randomized to the intervention group were transported to several alternative destinations decided by a trained nurse performing a comprehensive assessment, using the new prehospital system. Those randomized to the control group were transported to the ED. MEASUREMENTS: Primary endpoint: number of individuals triaged directly to a CH (feasibility). Secondary endpoint: number of subsequent transfers (appropriateness) from CH to ED within 24 hours after initial admission. RESULTS: After exclusion and crossover, the control group consisted of 217 and the intervention group of 449 older adults. The nurse sent 20% of the intervention group (90/449) (95% confidence interval (CI) = 16.6-24.0) directly to the CH when using the prehospital system. Six of those individuals (6.7%) (95% CI = 3.1-13.8) were subsequently transferred from the CH to the ED. Overall, the nurse appropriately triaged 93.3% of the participants (84/90) and transferred them to the CH, avoiding an ED visit. CONCLUSION: Ambulance nurses are able to send older adults to an alternative healthcare facility with the help of a prehospital decision support system. In this geographical setting, this appears to be a promising method to optimize resources and improve emergency care of elderly adults.