The effect of the geriatrics education for emergency medical services training program in a rural community

The Geriatrics Education for Emergency Medical Service (EMS) (GEMS) course provides continuing education for EMS providers. This study evaluated the effect of the course on EMS providers in a rural county by performing a prospective cohort study using a pre-postsurvey design. The Geriatric Attitude Scale, the GEMS knowledge posttest, a class satisfaction survey, and a survey evaluating EMS providers' comfort in caring for older adults were used to measure the classes' effect. Eighty-eight EMS providers participated. All passed the course and were very satisfied with it. Follow-up was completed with 77 (80%). No significant change in attitude score was identified ( P =.09). Median comfort scores significantly increased for the domains of communications, medical care, abuse evaluation, and falls evaluation. Providing the GEMS course to EMS providers in a rural community resulted in students passing a posttest evaluating their knowledge regarding caring for older adults and resulted in an increase in their comfort level for the care of older adults. The effect of the training on patient outcomes needs to be identified.      

Reliability and Validity of Prehospital Case Finding for Depression and Cognitive Impairment

OBJECTIVES: To evaluate the test–retest reliability, the concurrent criterion validity, and the construct validity of prehospital, emergency medical service (EMS) case finding for depression and cognitive impairment in older adults.
DESIGN: Cross-sectional study.
SETTING: Prehospital EMS system and hospital emergency department.
PARTICIPANTS: EMS providers and community-dwelling older adult (aged ≥60) patients.
INTERVENTIONS: Case finding instruments for depression (Patient Health Questionnaire-2; PHQ-2) and cognitive impairment (Six-Item Screener).
MEASUREMENTS: The reliability and validity of these instruments.
RESULTS: Moderate test–retest reliability was found for prehospital application of the PHQ-2 (kappa=0.50) and Six-Item Screener (kappa=0.52), fair concurrent criterion validity for depression (kappa=0.36), and slight to fair concurrent criterion validity for cognitive impairment (kappa=0.11–0.23). Construct validity was demonstrated using the Multitrait-Multimethod Matrix.
CONCLUSION: Moderate test–retest reliability and construct validity were demonstrated for prehospital case finding by EMS providers for cognitive impairment and depression using these instruments. Slight to fair concurrent criterion validity was found, a result that methodological limitations could explain. These findings provide additional support for the concept of using EMS providers to detect older adults at risk for these conditions. Further work is needed to confirm the validity and effectiveness of prehospital screening before such programs are implemented.     

A novel emergency medical services-based program to identify and assist older adults in a rural community

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.     

Meeting the Need for Training in Geriatrics: The Geriatrics Education for Specialty Residents Program

The imperative created by increasing numbers of aging Americans coupled with increasing longevity has generated recognition and acceptance within american medicine that education, from medical school through postgraduate training through continuing medical education, must include appropriate knowledge and skills in aging and geriatrics to provide for effective care of older adults. Such education and training is necessary not only for traditional primary care providers, but also for specialty physicians, including those in most surgical specialties and in related fields such as anesthesiology, emergency medicine and physical medicine and rehabilitation. To fill this demand, the American Geriatrics Society Geriatrics for Specialist Initiative established the Geriatrics Education for Specialty Residents Program (GSR). This article reviews the process by which the GSR created a dynamic cohort of geriatric surgical educators and researchers who in turn created a vibrant body of educational tools and scientific works that continue to advance the cause of improving medical care of older adults.     

Emergency medicine management of the geriatric patient: an educational program for medical students

This article describes the experience of fourth-year medical students participating in a geriatric education program integrated into a 4-week emergency medicine student clerkship. Between July 2002 and April 2003, all students in this required clerkship participated in a geriatric educational program consisting of a small group discussion of medical and psychosocial issues of older adult emergency department (ED) patients. Students used learned skills to evaluate older adult ED patients for medical and psychosocial issues and later followed up with these patients by telephoning them at their homes or visiting them in the hospital. Students tracked their evaluations of the medical problems, functional abilities, and social supports of patients in the ED. Students also noted when their assessments resulted in the acquisition of new skills or knowledge and when their evaluation of geriatric syndromes resulted in a change of the patient care plan. Seventy-seven students evaluated 217 patients in the ED, of whom 167 (77%) received a follow-up visit or phone call. Students documented learning new skills while caring for 80 (48%) of the older adult patients. Qualitative survey responses from students indicated that students had increased understanding of the importance of assessing functional status and social supports and providing interdisciplinary care. Integrating geriatric education modules into existing emergency medicine clerkships is an effective method to expand the geriatric curriculum in medical schools and to emphasize the importance of geriatric assessment and syndromes in emergency care.     

The National Evaluation of Senior Mentor Programs: Older Adults in Medical Education

OBJECTIVES: To identify models for senior mentor programs (SMPs), critical factors in program development, achievement of goals and objectives, effect on medical school environment, and future of programs.
DESIGN: Ten SMPs were systematically selected to represent a variety of medical schools, geographic regions, and program types. The National Senior Mentor Program Evaluation relied upon archived data within the programs and new data collected during site visits. Archived data included internally conducted program evaluations, student course evaluations, and survey and focus group results. Site visit data were collected from key informant interviews with program staff and faculty, medical school leadership and students, and older adults serving as mentors.
SETTING: Ten U.S. medical schools with SMPs.
PARTICIPANTS: Evaluation participants at each site included program faculty, key medical school administrators, participating students, and mentors.
MEASUREMENTS: Program evaluation.
RESULTS: All 10 programs demonstrated a positive effect on student attitudes toward older adults. Student acceptance of the programs was strong, and mentor acceptance and support were extraordinary. Eight of the 10 programs were operating in 2008 and having considerable effect on medical school environments. Most of the operating programs expect to be continuing for 5 or more years into the future.
CONCLUSIONS: The findings of the national evaluation point toward continuation and likely growth of the senior mentor phenomenon in U.S. medical education.     

An emergency medical services program to promote the health of older adults

OBJECTIVES: To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs. DESIGN: A cluster sample design evaluation of an intervention conducted by EMS in one of two communities. SETTING: Two rural communities in upstate New York. PARTICIPANTS: Two hundred fifty-eight intervention-group and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005. INTERVENTION: EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients' physicians were notified of screening results to provide interventions. Control group patients were provided usual care. MEASUREMENTS: Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs. RESULTS: Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found. CONCLUSION: EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients' needs.     

Geriatric emergency medicine: a survey of practicing emergency physicians.

STUDY OBJECTIVES: To evaluate the current status of clinical, educational, social, ethical, and resource issues related to the care of the elderly among practitioners of emergency medicine. DESIGN: A mailed survey instrument. SETTING: None. TYPE OF PARTICIPANTS: Practicing emergency physicians randomly drawn from the membership list of the American College of Emergency Physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 971 surveys were mailed, with 433 usable surveys among the 485 (50%) respondents. The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages. For each of seven clinical presentations (abdominal pain, altered mental status, chest pain, dizziness/vertigo, fever without a source, headache, multisystem trauma), 45% or more of the emergency physicians have more difficulty in the management of older compared with younger patients. Most respondents reported that each of these presentations required more time and resources for older patients. The majority believed research, the availability of continuing medical education, and time spent during residency training regarding geriatric emergency medicine was inadequate. CONCLUSION: Practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and continuing education in geriatric emergency medicine.     

Reliability of the hierarchical assessment of balance and mobility in frail older adults

OBJECTIVES: To study the test–retest and interrater reliability of the Hierarchical Assessment of Balance and Mobility (HABAM) in frail older adults.
DESIGN: Convenience sample of 167 frail older adults seen as part of routine care by an academic geriatrician at a tertiary care teaching hospital.
SETTING: Inpatient medical and geriatric wards, geriatric ambulatory care clinic, emergency department, home visits.
PARTICIPANTS: The interrater reliability sample consisted of 98 inpatients and 69 outpatients. The test–retest reliability sample tracked 63 of the inpatients over the first 2 days of their hospital stay.
MEASUREMENTS: Mobility and balance were assessed using the HABAM. Frailty was assessed using a frailty index based on a standardized Comprehensive Geriatric Assessment. Reliability was assessed using Pearson correlations and the intraclass correlation coefficients.
RESULTS: The interrater reliability of the HABAM was 0.92 and ranged from 0.88 to 0.96 across settings for the various components (balance, transfers, mobility). Test–retest reliability was 0.91 (range 0.85–0.92).
CONCLUSION: The HABAM appears to be a reliable means of assessing mobility and balance in frail older adults.     

Continuing Medical Education: March 2008

Early life risk factors that contribute to irritable bowel syndrome in adults: a systematic review.
Accreditation and Designation Statement: Blackwell Futura Media Services designates this educational activity for a maximum of 1 category 1 credit toward the AMA Physician's Recognition Award^TM. Each physician should claim only those credits that he/she actually spent in the activity.
Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.     

Workforce training and education gaps in gerontology and geriatrics: what we found in New York State

This article summarizes data from the 2008 Symposium Charting the Future for New York State Workforce Training and Education in Aging: The Stakeholder Perspective and the 2009 report Workforce Training and Education: The Challenge for Academic Institutions. This research is the outcome of a collaborative State Society on Aging of New York and New York State Office for the Aging study on New York State's workforce training and education needs. Eight Listening Sessions were held across New York State to obtain input on topics including training, gerontology education, and credentialing and certification. Individual sessions highlighted the needs of urban, rural, and suburban communities. Key themes identified through content analysis included the need for education about aging in agencies serving older adults, education on human development, positive aspects of aging, disabilities, developmental disabilities, and greater opportunities for training and education for service providers. Lack of incentives was identified as a barrier to credentialing or certification. Education about growing older beginning in grade school was recommended. Lack of funding was identified as a barrier that limited support for employee education/training. Disconnects were identified between employers and academic institutions and state government and providers regarding gerontology/geriatric training and education. Consideration to how these themes may be addressed by the Association of Gerontology in Higher Education is offered.     

Workforce Training and Education Gaps in Gerontology and Geriatrics: What We Found in New York State

This article summarizes data from the 2008 Symposium Charting the Future for New York State Workforce Training and Education in Aging: The Stakeholder Perspective and the 2009 report Workforce Training and Education: The Challenge for Academic Institutions. This research is the outcome of a collaborative State Society on Aging of New York and New York State Office for the Aging study on New York State's workforce training and education needs. Eight Listening Sessions were held across New York State to obtain input on topics including training, gerontology education, and credentialing and certification. Individual sessions highlighted the needs of urban, rural, and suburban communities. Key themes identified through content analysis included the need for education about aging in agencies serving older adults, education on human development, positive aspects of aging, disabilities, developmental disabilities, and greater opportunities for training and education for service providers. Lack of incentives was identified as a barrier to credentialing or certification. Education about growing older beginning in grade school was recommended. Lack of funding was identified as a barrier that limited support for employee education/training. Disconnects were identified between employers and academic institutions and state government and providers regarding gerontology/geriatric training and education. Consideration to how these themes may be addressed by the Association of Gerontology in Higher Education is offered.     

An Assisted Living Facility Curriculum to Introduce Geriatrics to First-Year Medical Students

Many U.S. medical schools have developed curricula in geriatric medicine to address the growing older adult population. At our university, the authors have integrated an assisted living facility (ALF) program into a required first-year clinical skills course. During the 2011 to 2012 academic year, an electronic survey was distributed to 109 first-year medical students prior to and after the program. Eighty-eight percent and 85% of students completed the pre- and postintervention survey, respectively. Students reported a positive attitude toward caring for older adults (92.5% post- vs. 80.2% preintervention), an understanding of the medical and social needs of older adults (89.2% post- vs. 38.5% preintervention), an acquisition of the skills to assess the health of older adults (71% post- vs. 14.5% preintervention), and an understanding of ALFs as nonmedical supportive housing (92.5% post- vs. 70.8% preintervention). The authors’ curriculum offers an innovative method to integrate geriatrics education early in medical education and to involve medical students in their community.     

The Co-Occurrence of Chronic Diseases and Geriatric Syndromes: The Health and Retirement Study

OBJECTIVES: To analyze the co-occurrence, in adults aged 65 and older, of five conditions that are highly prevalent, lead to substantial morbidity, and have evidence-based guidelines for management and well-developed measures of medical care quality.
DESIGN: Secondary data analysis of the 2004 wave of the Health and Retirement Study (HRS).
SETTING: Nationally representative health interview survey.
PARTICIPANTS: Respondents in the 2004 wave of the HRS aged 65 and older.
MEASUREMENTS: Self-reported presence of five index conditions (three chronic diseases (coronary artery disease, congestive heart failure, and diabetes mellitus) and two geriatric syndromes (urinary incontinence and injurious falls)) and demographic information (age, sex, race, living situation, net worth, and education).
RESULTS: Eleven thousand one hundred thirteen adults, representing 37.1 million Americans aged 65 and older, were interviewed. Forty-five percent were aged 76 and older, 58% were female, 8% were African American, and 4% resided in a nursing home. Respondents with more conditions were older and more likely to be female, single, and residing in a nursing home (all P <.001). Fifty-six percent had at least one of the five index conditions, and 23% had two or more. Of respondents with one condition, 20% to 55% (depending on the index condition) had two or more additional conditions.
CONCLUSION: Five common conditions (3 chronic diseases, 2 geriatric syndromes) often co-occur in older adults, suggesting that coordinated management of comorbid conditions, both diseases and geriatric syndromes, is important. Care guidelines and quality indicators, rather than considering one condition at a time, should be developed to address comprehensive and coordinated management of co-occurring diseases and geriatric syndromes.     

The use of clinical decision-support tools to facilitate geriatric education

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.     

An Analysis of End-of-Life Content in Aging Network Conference Proceedings

Important home and community-based issues in the lives of older adults and caregivers relate to end of life. It is well documented that education on end of life, including curricula and textbook content for health and human service professionals, is lacking. This study analyzed another aspect of education: continuing education sessions offered at three major annual conferences for members of the Aging Network. Conference proceedings were reviewed for end-of-life–related content for the years 1999 through 2006. Only four sessions out of 960 addressed end-of-life issues. The implications in the rise of the number of aging consumers accessing end-of-life services depict a need for end-of-life service providers and Aging Network service providers to support opportunities to conduct educational outreach through national conferences. Additional research is recommended to analyze opportunities at the local level for education on end-of-life issues for the Aging Network.     

Survey of nationally registered emergency medical services providers: pediatric education

STUDY OBJECTIVE: To survey emergency medical services (EMS) providers on a national level to determine and describe their perspective regarding their initial and continuing education (CE) needs in pediatrics. METHODS: A 10-question survey was developed, pilot-tested, and sent to EMS providers as a part of their National Registry of Emergency Medical Technicians reregistration materials. RESULTS: Surveys were completed by 18,218 EMS providers, a response rate of 67%. During a typical month, 60% of emergency medical technician-paramedics (EMT-Ps), 84% of EMT-intermediates (EMT-Is), and 87% of basic EMTs (EMT-Bs) care for 0 to 3 pediatric patients. CE was identified by all provider levels as the main source of their pediatric knowledge and skills. A state or national mandate for required CE in pediatrics was supported by 76% of surveyed providers. More than 70% of all providers responded they were comfortable to some degree with their own ability and their EMS system's ability when confronted with a critical pediatric call. Cost, availability, and travel distance were identified by all levels as the primary barriers to obtaining pediatric CE. All levels identified infants as the age of greatest concern if the provider was called to manage a critical case. CONCLUSION: Surveyed practicing nationally registered EMS providers have infrequent contact with pediatric patients and have acquired most of their pediatric knowledge and skills from CE. In general, these providers are comfortable with their personal and their system's ability to care for children, but clearly support the need for required pediatric CE and identify the birth to 3-year age range as the priority for an educational focus. Cost, travel distance, and availability of pediatric CE are barriers that should be considered if pediatric CE is to be required of EMS providers.     

Against all advice: an analysis of out-of-hospital refusals of care

STUDY OBJECTIVE: We examine the characteristics of patients involved in out-of-hospital emergency medical services (EMS) incidents that result in refusal of care and determine the rates of subsequent EMS, emergency department (ED), and inpatient care, as well as death within 7 days. METHODS: Utah statewide EMS data identifying refusals of care were probabilistically linked to Utah statewide ED, inpatient, and death certificate data within 7 days of the initial EMS refusals for 1996 to 1998. Refusals were defined as incidents in which field treatment or transport was refused and did not include incidents in which EMS providers deemed care or transport unnecessary. RESULTS: Of 277244 EMS incidents, 14109 (5.1%) resulted in refusals of care. For all age groups, motor vehicle crash dispatches resulted in the highest rate of refusal of care, ranging from 8.0% to 11.7%. Slightly more than 3% of patients involved in a refusal of care incident had a subsequent EMS dispatch within a week. One fifth of the patients involved in EMS refusals of care had a subsequent ED visit. Less than 2% of the EMS refusal patients were hospitalized; hospitalization was highest among children younger than 3 years and adults older than 64 years. Twenty-five adults died within a week of refusing EMS care, of whom 19 (76.0%) were older than 64 years. CONCLUSION: Refusal of care incidents are a small segment of all EMS incidents. They arise from a variety of situations, and the risk for missed intervention may be minimal.     

Medical Students' Recognition and Application of Geriatrics Principles in a New Curriculum

Given the aging U.S. population, it is imperative that medical students recognize and apply geriatrics principles. To address this need, in 2006, the Warren Alpert Medical School of Brown University integrated geriatrics content into a new medical school curriculum. Preclinical and clinical medical students submitted written reflective journals in response to prompts regarding the geriatrics content of the new medical school curriculum, including their didactic and clinical experiences. An interdisciplinary team used a structured qualitative approach to identify themes, including the recognition and application of geriatrics principles. Thirty medical student journalers submitted 405 journal entries. Themes regarding students' emerging understanding of geriatrics principles included a growing understanding of geriatrics principles, recognition of the importance of psychosocial factors and patient preferences in caring for older adults, recognition of the complexities of treating older adults and application of geriatric principles to clinical situations, and understanding of physicians' roles in managing the care of older adults. Medical student reflective journaling allows medical educators to obtain timely feedback on curricular innovations and helps illuminate the process by which medical students learn to recognize and apply core geriatrics principles.     

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older.
DESIGN: Randomized, controlled trial.
SETTING: Two primary care clinics in the Seattle, Washington, area.
PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older.
INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care.
MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2—Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed.
RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P =.03).
CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.