Respect Your Elders

Special considerations for EMS response to geriatric patients

 

 
 
 

Keith Widmeier, NREMT-P, CCEMT-P, EMS-I | From the August 2013 Issue | Tuesday, August 20, 2013


Now that the baby boomer generation has reached age 65, the number of geriatric patients EMS may encounter will increase dramatically. In fact, geriatric patients are almost three times more likely to be transported to an emergency department by ambulance and three times more likely to be admitted to the hospital. They’re also more than twice as likely to be triaged as critical in the emergency department.1 With the maturity of the large baby boomer generation, it’s imperative that EMS providers are familiar with complications that may occur with geriatric patients, including transport challenges and communication issues.

Scene Considerations

A scene size-up is a basic, fundamental skill of prehospital medicine. However, EMS providers should take this assessment tool further when dealing with the geriatric population. Two components that providers must add to their scene size-up for geriatric patients include an environmental and a social assessment. 

Environmental assessment: This should include a careful evaluation of the condition of the residence. If the provider notes general care issues, such as dirty dishes being piled up, they should consider that the patient may have issues performing activities of daily living (ADL).

ADL assessments are common in gerontology. However, EMS providers are in a unique position to help because they see patients living in their environment, which means they may be the first to notice patient safety  issues. This allows them to look at the entire area, evaluate for safety hazards and educate the patient to help prevent injuries. A good way to perform an ADL assessment is to look at the entire residence as they manage their scene.

Beyond the ADL assessment, providers should take the time to note hazards. This type of public education could help reduce injuries and, therefore, call volume. Some issues common to the geriatric population may include loose rugs in high traffic areas, lack of handrails in the bathroom or other fall risks, as well as urban hypothermia from maintaining colder temperatures in the residence. Fixing these health and safety hazards can prevent a catastrophic fall and its consequences, such as a hip fracture that results in the patient not ever being able to return to normal unassisted life in their own home.

Are handrails available for entry into the house, and are they in good operating condition? Are all walkways clear from fall hazards, such as wires or other chords, small area rugs or torn carpet? Is assistance readily available in the event of a fall?

Providers should make patients aware of injury alert indicators that can allow the patient who lives alone to contact an emergency line in the event that they fall and are unable to get to a phone. These tools may also provide a patient history and notify family depending on the complexity of the product used.

If a medical history isn’t available, providers should look for and educate patients on the benefits of medical alert bracelets and stickers from such programs as Vial of Life. This program, for example, provides stickers for patients to put on the outside of the door and a medication list that can to be put in a labeled bag.

Social assessment: This should also be conducted on arrival. Providers should inquire about whom, if anyone other then the patient, notified dispatch. They should find out how often the patient receives general wellness checks from family or friends. If providers find out patients don’t have regular visits, they should stress the importance of an injury alert program to ensure that help will be sought in a timely manner. And although the physical safety component is important, it’s also imperative that patients have regular interactions with others to help prevent feelings of loneliness and associated depression. 

Patient Movement

Extrication of a frail, injured geriatric patient from a residence can often be complex. It’s important to plan a path of egress before securing the patient. After evaluating the amount of room to maneuver in, providers may opt to use another piece of equipment, such as a stair chair, flexible stretcher or other transport device.

It may be necessary to move furniture or rugs to clear a safe and effective path. Some residences have automatic chairs that assist patients up and down steps or other equipment unique to the geriatric population that EMS can use to move patients effectively, particularly down tight stairwells. If providers are unfamiliar with this equipment, attempt to find a family member, friend or neighbor who is familiar with the device or attempt to work around it. 

Assisted living and long-term care facilities present unique scene considerations of their own. Assessments can be enhanced by talking to a variety of people who interact with the patient on different levels. Certified nursing aids (CNAs) are often overlooked. Yet they may have the most interaction with the patient. The role of the CNA requires them to interact regularly with the patients and assist with various advanced directives. CNAs may be able to help develop an accurate baseline for your patient—perhaps better then the nurse assigned to the unit—because of their special relationship with the patient. 

Patients in long-term care facilities may also have isolation precautions to consider. It’s imperative to read any signs that are listed on the doorway. If the provider notices a tray of gloves, masks or gowns, inquire why they’re there and if donning the available personal protective equipment (PPE) is important to safety. It’s important to discover if the precaution is contact, airborne or both. This will play a role in scene management as well as transport. While transporting these patients, ensure the removal of PPE prior to entering the driving compartment and apply PPE again prior to moving the patient out of the ambulance.

Abuse & Neglect

The 1985 Elder Abuse Prevention, Identification and Treatment Act defines abuse as the “willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish, or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.”

Neglect is defined as “the refusal or failure to fulfill any part of a person, obligations, or duties to an elder.” A consensus conference of the National Center on Elder Abuse (NCEA) and the National Elder Abuse Incidence Study (NEAIS) has standardized definitions on the various types of abuse and neglect that may be seen in the geriatric community. 

Statistically, abusers tend to be the male adult children and primary caregiver. These caregivers are usually financially dependent on the patient and will suffer a loss of income if the patient isn’t at home with them. Red flags for abuse include alcohol abuse, drug abuse, and history of abuse or domestic violence.2 Issues may arise from caregiver stress and poor coping mechanisms depending on the complexity of the patient’s condition.

It’s important that providers ensure that the stories of the patient and the caregiver match. Providers should be concerned if patients appear to be shut down and become silent or timid around caregivers, hesitate to make eye contact or look at caretakers for approval of statements. 

If EMS providers suspect elder abuse, they should attempt to talk to patients without the presence of the caregivers. They can attempt to separate the two by asking the family member or caregiver to do a task that takes them away from the patient, such as locate medications, past medical histories or insurance cards. Many states have a hotline affiliated with protection and permanency that can be used to report possible elder abuse. Providers should notify the receiving hospital, so hospital staff can investigate further and alert a social worker if needed.

In suspected abuse cases involving long-term care facilities, EMS providers should attempt to follow the appropriate chain of command. Providers should report issues to the receiving facility but also follow up with the long-term care facility at a supervisory level. If the issue appears to become common and your concerns aren’t being addressed, providers can choose to contact the state Ombudsman. The Ombudsman is an advocate for patients and there’s a specific Ombudsman for long-term care facilities. The key is to start low to attempt to resolve the issue and work up the chain of command if that doesn’t work.

Communication Considerations

Due to body changes associated with aging, communicating with the elderly may be difficult and occasionally frustrating. Older patients may have issues seeing, hearing or speaking with providers. Although some corrective measures may be available, it’s important for providers to understand the problem and appropriate ways to handle specific communication issues that may arise. Shouting at a patient will do little good if they have significant hearing loss. Instead, providers should get close to the patient and speak in a normal tone and level.

Patients who are hearing impaired are generally familiar with the best techniques to compensate for their impairment. They may tell providers to speak into their “good ear,” or providers may need to wait until they put in their hearing aid. Hearing aids, which must be on and in the ear canal to be effective, are a valuable tool for communication and should be used if they don’t impede an injury. If hearing aids are unavailable it’s important that providers use low tones while speaking. Frequency of pitch plays a bigger role in communicating with the hearing impaired compared to increasing volume. Other solutions to compensate for hearing loss may be to write questions out on paper and allow them to respond. This may be problematic depending on the literacy level in your service area. 

Patients may have developed a variety of ophthalmic and optometric issues. This may or may not have a direct impact on communication. A patient’s inability to see appropriately may increase their anxiety. In addition, patients with sight issues may have decreased cooperation due to increased suspicion. Some disorders may be able to be rectified with corrective lenses. If that’s the case, ensure that the patient’s glasses travel with them. 

Previous strokes may have caused patients to develop aphasia. This means that although the patient may be able to understand every word a provider is saying, they may not be able to answer clearly due to previous damage. If the patient’s words are coherent but it takes them time to complete their thoughts, be patient and don’t finish their sentences. This tactic can be demeaning. If a patient's words are incoherent, see if a caregiver can understand what they’re saying. Sometimes caregivers may be able to understand what is being said because of repeated communication that may have occurred in the weeks, months, or years since the patient's stroke. 

Polypharmacy

Polypharmacy, which is sometimes referred to as pill burden, is when patients are prescribed multiple medications—often from multiple physicians. This can be detrimental and can be caused because of issues in healthcare deployment, healthcare cost or patient falsification. 

Many elderly patients suffer from a variety of chronic disorders. Their multiple pathologies often require multiple specialties, and communication between specialists can be minimal. If the patient uses a single pharmacy, then medication interactions may be discovered by the pharmacist. However, this isn't always the case, and research shows that large numbers of prescription medications have a correlation to poor health outcomes.3

A large percentage of senior citizens live on a fixed incomes. With the rising cost of medications, patients may be put in a position where they have to decide between paying for food or medications. This may lead to patients sharing medications with friends and family. For example, if a patient’s friend has a spouse who died, the friend may offer the spouse’s blood pressure medication.

Since patients don’t have the medical knowledge to differentiate between an ACE inhibitor or a beta-blocker, they often don’t understand the differences in response to these medications. And even though the drug the friend offers is different from their own prescription, the patient may choose to take the friend’s medication because it is free and it helps regulate blood pressure. 

Considering Comfort

It can be a challenge to transport elderly patients comfortably without exacerbating their current injury and illness, as well as not causing any new injuries. This is particularly true if they have frail skin or osteoporosis. The provider must always consider chronic conditions as well as the physiology of aging when transporting geriatric patients. 

It can be difficult for them to get comfortable on an ambulance stretcher. They may need help moving from one side to another, flexing legs or just finding their sweet spot. Pillows and blankets are valuable tools providers can use to adjust elderly patients. Usually, the patient will inform providers if they would like a pillow behind their head, or under their lumbar spine or legs, but they will sometimes try to suffer through the pain to be polite. Providers may not be able to relieve all of their pain but should always offer to help make them more comfortable if at all possible.

Patient transfers are the fifth-leading cause of skin tears in the geriatric population. Providers can help prevent this by using caution when handling limbs during any point of the transfer process, as well as keeping a patient's arms and legs covered if possible while transferring them.4 According to a report published in Advanced Skin Wound Care, one of the most important factors in preventing skin tears is educating healthcare staff on prevention techniques.

A large portion of the techniques  recommended in the report involve primary care measures, such as making dietary changes in conjunction with a nutritionist and lubricating skin with moisturizers. However, some equipment and techniques apply to providers during transport, such as using scoop stretchers and padding voids with blankets. Doing so limits movement of patients and reduces the likelihood of skin tears. Specialty equipment that EMS may use to facilitate transfer of geriatric patients include a scoop stretcher, which must be used carefully, and slide boards in conjunction with sheets. By using this equipment properly EMS providers minimize movement and minimize the risk of and skin tears.

Spinal immobilization is often more difficult in elderly patients than in their younger counterparts. Obvious concerns are kyphosis and other abnormal curvatures of the spine. However, decubitus ulcers are devastating in the elderly population, and the length of time on a long backboard increases the risk of developing decubitus ulcers.5 When performing spinal immobilization, providers should take any and all actions possible to help prevent these wounds.

Some solutions include padding the board and using commercial products that exist specifically for long backboard. Kyphosis must be addressed by padding all voids as necessary. This may require a significant number of sheets, towels and blankets—anything that may fill the large voids. Remember: The most important thing is that the patient’s spine isn’t moving.

Some geriatric patients have medical equipment that must be considered during transport. Some equipment that may be transported include insulin pumps, wound vacuums and Foley catheters. Newer insulin pumps are fairly self-regulating and require minimal oversight. With the variety of insulin pump models available, the provider shouldn’t alter it without being familiar with that model and having the appropriate protocols to do so.

Wound vacuum assisted closure (VACs) devices usually have a fixed unit and a disposable circuit. The fixed unit will generally be set prior to your arrival and will require little oversight. The major responsibility of the providers will be to watch the disposable tubing to ensure that it doesn’t become disconnected from the wound VAC—a common issue that will cause a low-pressure alarm to sound—or becoming disconnected from the wound dressing. In addition, field providers should protect the wound dressing to ensure that it maintains a negative pressure seal.

Urinary catheters, commonly referred to as Foley catheters, are a valuable assessment tool to monitor urine output. If at all possible, have the Foley catheter emptied prior to transport to help prevent the bag from bursting. Place the catheter bag underneath blankets while walking in public to help protect the patient’s privacy.

Thermoregulation can be difficult with geriatric patients because of the thinning of subcutaneous fat. Providers should do everything possible to help compensate for this, including suffering through a cold or hot environment. Increasing the temperature of the patient compartment may be uncomfortable for EMS personnel, but it can drastically improve the patient’s comfort. Providers should also ensure that they have blankets available for transfers that occur outside so they can always keep their patients warm.

Unlike transporting younger adults without chronic issues, elderly patients may like to be transported to the facility where their primary care physician practices. It may take slightly longer to transport them to the facility of their choosing, but it will ultimately expedite the patient’s care if their physician is available. This will save the facilities from having to complete all of the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements and transfer time between facilities.

Ageism

EMS, like a large portion of healthcare fields, has ageism ingrained into its culture. This can be seen when providers are managing what they might deem “routine transports.” “Geezers,” “taters,” “lizards,” “gramps” and many other disrespectful terms are sometimes heard throughout the EMS transport industry. Although it’s rare that these comments are made in front of older patients or their family members, it’s unacceptable to use them at all while on the job. Geriatric patients, like all patients, deserve to be treated with the utmost respect. It’s important for providers to remember that they are public servants and are here to serve the entire population.

Providers often complain about “frequent flyers”—patients who frequently use or abuse the system or who are transported regularly for non-emergent transports. Dialysis patients, for example, must often be transported twice a day for three days each week. Chemotherapy and radiation patients may be transported twice a day for five days or for a few weeks, depending on the treatment regimen.

Although providers may see these patients regularly, it’s important to remember that their job is to provide safe and comfortable transport to each patient every time. These transports are relevant and necessary. They're no less honorable then emergency transports although they may be less exciting. Nonetheless, these transports save lives. A patient who needs dialysis will die without it.

As professionals it’s imperative to always display a positive attitude and appropriate demeanor in front of our patients and their families An attitude is a representation of professionalism, and EMS field providers must act as professionals to be seen as professionals. Even though geriatric transport may not be as exciting or communication with the patient may be difficult, providers must remain professional and welcoming. Patient satisfaction is so important that often times, patients would prefer a provider who is compassionate, caring and less competent over one who is competent and rude.

Summary

A variety of chronic pathologies often come along with the aging process and are experienced by many patients in late adulthood. EMS providers must be aware of the various challenges of transporting the geriatric population. And although an emphasis is often placed on the physical and medical issues associated with this population, it’s also imperative to look at the whole picture to help prevent issues before they become an emegent problem. This includes being vigilant for elder abuse and neglect, as well as potential home hazards—including fall potentials and maintaining colder home temperatures—and dangerous cost-cutting measures, such as sharing medications.

Prevention is key to helping older patients avoid potentially devastating situations, such as falls, medication errors and urban hyperthermia. But when those situations happen and providers are called to care for an older patient, compassion and demeanor are necessary to make this more vulnerable patient population comfortable and safe. jems

 

References

1. Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: A review. Ann Emerg Med. 2010;56(3):261–269.

2. Geriatric Medical Society. Geriatric education. Jones & Bartlett Publishing: Sudbury, Mass., 2003.

3. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–351.

4. LeBlanc K, Baranoski S, Skin Tear Consensus Panel Members. Skin tears: State of the science: Consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9 Supp):2–15.

5. Walker J. Pressure ulcers in cervical spine immobilisation: A retrospective analysis. J Wound Care. 2012;21(7):323–326.

Resources

Gorbien MJ, Einstein AR. Elder abuse and neglect: An overview. Clin Geriatr Med.  2005;21:279–292.

Yim VW, Graham CA, Rainer TH. A comparison of emergency department utilization by elderly and younger adult patients presenting to three hospitals in Hong Kong. Int J Emerg Med. 2009;2(1):19–24.

 
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Related Topics: Patient Care, Special Patients, Jems Features

 

Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, is the training officer for Wayne County EMS in Monticello, Ky. He’s responsible for all initial, continuing and community education for Wayne County. .

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