Frailty and prehospital emergency care: implications for paramedic education

Le résumé fourni par la source

Editorial to accompany Prevalence and severity of frailty amongst middle-aged and older adults conveyed to hospital by ambulance between 2010 and 2017 in Wales [10]. The prevalence of frailty is high and increases with age amongst those conveyed to the hospital by ambulance. Frailty has significant implications for affected patients treated by emergency services. In addition to hospital conveyance, alternative care pathways may provide safe, patient-centred care. Paramedics should be trained not only to identify frailty but also to integrate their assessment into risk stratification, guiding prehospital management decisions, including whether hospitalisation is required, considering risks and benefits for frail individuals. Emergency medical services (EMS) were initially designed to treat acute conditions. However, as the global population continues to age, the role of EMS has been evolving to address a wider range of health issues, including those related to frailty. Frailty is a multidimensional syndrome characterised by an increased vulnerability to stressors and a functional decline. It is related to major outcome parameters such as reduced mobility, increased risk of falls, fractures, disability, and mortality [1]. Moreover loneliness, depression, cognitive dysfunction, and dementia are more prevalent in individuals with frailty [1]. Furthermore, quality of life is reduced [1]. Given these profound and widespread effects, it is unsurprising that frailty is a significant predictor of hospitalisation [2] and nursing home admission [3] amongst community-dwelling older adults. There is limited and heterogeneous evidence on frailty identification in prehospital care [4]. The relevance of frailty in daily preclinical care is known to paramedics, but there is scepticism about the value of formal frailty evaluation [5]. Frailty screening by paramedics is feasible using various methods, such as care partner Comprehensive Geriatric Assessment [6] or the Clinical Frailty Scale (CFS) [7, 8]. CFS shows a good interrater reliability (intraclass correlation coefficient = 0.87 [95%CI 0.81–0.93]), moderate accuracy (60.6% [95%CI 54.9–66.19]) and respectively high accuracy (94.8% [95%CI 92.0–96.7]) when accuracy is defined as a maximum of 1 point difference, based on clinical vignettes [8]. A minor comparative observational study found that paramedic CFS scores for 12 of 15 patients differed from hospital scores, mostly being lower [9]. It is conceivable that the impression gained in the patient's home environment better reflects the reality; on the other hand, it is also possible that the application of frailty screening needs further specific training. Data on the prevalence of frailty in the prehospital setting is limited. The largest observational study known to us so far demonstrated a growing prevalence of frailty with age in 3056 patients aged ≥50 years attended by an ambulance, with 58.7% of cases showing a CFS score of ≥5 [7]. The ambulances spent a median of 8.2 (95%CI:5.4–11.0) minutes longer with frail patients and transported them to the hospital less frequently (OR:0.75, 95%CI:0.60–0.94) [7]. The presented study provides new, compelling insights from a large cohort. In this retrospective cohort study, routinely collected Electronic Health Records were used to examine frailty prevalence in patients transported to hospitals by ambulance across Wales [10]. The study involved over 1 million patients, aged 50 and above, between 2010 and 2017, with frailty assessed using the electronic Frailty Index (eFI) [10]. Around 23.8% of the cohort (301.142 individuals) were taken to a hospital, resulting in 693.918 conveyances [10]. The eFI divides the cohort into four categories (fit, mildly frail, moderately frail, severely frail). Notably, 84.3% of the patients conveyed to the hospital were frail, with 61.6% being mildly to moderately frail [10]. Frailty prevalence of transported patients increased with age [10]. Amongst those aged 50–64, 62.7% had some level of frailty, whilst amongst those aged ≥85, 95.9% were frail [10]. Furthermore, prevalence of frailty was higher in transported patients living in residential homes (95.9%) and those diagnosed with dementia (96.9%) [10]. In total 55.2% of conveyances was amongst people aged 75 years or above, whilst these only compromised 22% of the cohort [10]. This highlights a disproportionate use of ambulance services by older adults, emphasising the increased healthcare needs of this age group, particularly those with frailty, and is in line with other studies demonstrating that most ambulance patients are being treated at an advanced age [11, 12]. Modern EMS play a critical role not only in responding to acute emergencies but also in providing care to individuals with chronic conditions and with complex healthcare needs, including medical, psychological and social needs. Given that individuals with frailty often present to EMS with multiple coexisting health burdens, which may initially manifest as social challenges, their care should be adapted early in the prehospital setting. Alongside an organ-specific assessment, a more comprehensive evaluation should be undertaken to ensure patient-centred care, with patients being actively involved in the decision-making process. Patient-centred outcome goals for frail individuals attending the emergency department focus on autonomy and functioning [13]. These patients strive for security both in their home and with their health issues [13]. Healthcare providers, including paramedics, should support this by offering clear information and functional support. Furthermore, the study revealed a steady increase in frailty prevalence over the study period [10]. In 2010, 43% of the cohort were frail (30% mild, 10% moderate, 3% severe), whilst by 2017, 51% were frail (33% mild, 13% moderate, 5% severe) [10], reflecting a growing need for medical attention in this vulnerable population and need for frailty training amongst paramedics. Paramedics, in accordance with their work in communities and in people’s homes, are able to assess the needs and living situation of individuals thoroughly. This holistic insight is difficult to assess in a hospital setting. However, paramedics must be trained to identify patients with frailty, consider frailty as a parameter for risk stratification and understand the risks and benefits of attending the emergency department for frail individuals. This improves care for many frail individuals contacting EMS, supports patient autonomy and helps to reduce emergency department visits and subsequent hospital admissions. It is conceivable that well-trained paramedics would continue to recognise high-risk situations and provide immediate assistance, whilst also initiating preventive measures in lower-risk situations. The authors highlight the lack of widespread offered alternative care pathways, such as home visits or multidisciplinary community-based services, and identify this as a contributing factor to the high number of conveyances for people with non-life-threatening conditions, 60% of whom had mild or moderate frailty [10]. These barriers were also frequently reported by paramedics who use the CFS and generally perceive its value positively [5]. However, effectiveness of established alternative pathways depends on paramedics having a comprehensive understanding of frailty and the healthcare structures available in the community, ensuring that patients are properly guided to these pathways to reduce preventable hospital conveyances. The article by Fogg C, England T et al. provides an important milestone in understanding the dimensions of frailty in prehospital care within a European emergency care system. Jan-Niklas Krohn: Received a research grant from the Dr. Ernst and Anita Bauer Foundation. The author declares no other conflicts of interest related to this funding. None.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.