What are four things that the emt should do when interviewing an older patient?

J Am Geriatr Soc. Author manuscript; available in PMC 2010 Mar 1.

Published in final edited form as:

PMCID: PMC2716724

NIHMSID: NIHMS76498

Abstract

Objectives

To understand the opinions of emergency medical service (EMS) providers regarding their ability to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which continuing education could be best delivered.

Design

Qualitative study using key informant interviews.

Setting

Prehospital EMS system in Rochester, New York.

Participants

EMS providers, EMS instructors and administrators, emergency physicians, and geriatricians.

Outcome Measures

Semi-structured interviews were conducted using an interview guide that addressed the following domains: 1)knowledge and skill deficiencies; 2)recommendations for improvement of geriatrics continuing education; 3)delivery methods of education.

Results

Participant responses were generally congruous despite the diverse backgrounds, and redundancy was achieved rapidly. All participants perceived a deficit in EMS education on the care of older adults, particularly related to communications with patients and skilled nursing facility staff. All desired more geriatric continuing education for EMS providers, especially in communications and psychosocial issues. Education was desired in various modalities.

Conclusion

Further geriatrics continuing education for EMS providers is needed. Some specific topics relate to medical issues, but a large proportion involve communications and psychosocial issues. Education should be delivered in a variety of modalities to meet the needs of the EMS community. Emerging online video technologies may bridge the gap between learners preferring classroom based modailities and those preferring self-study modules.

Keywords: emergency medical services, provider attitudes, continuing medical education, geriatrics

INTRODUCTION

Older adults (age≥65) comprise 38% of emergency medical services (EMS) patients and use EMS services almost four times more frequently than younger patients.1 In 2000 EMS treated almost 6 million older adult patients per year,1 and this number will increase as the older adult population in the United States is expected to double to over 70 million by 2030.2 Given the growth of this population and the large number of patients utilizing EMS, there is a compelling need to ensure that EMS providers have the proper interpersonal, cognitive, and procedural skills to address the unique medical and psychosocial needs of this group.

Unfortunately, most EMS providers get little geriatrics education during their initial training. 3 4 The national curriculum for emergency medical technician (EMT) training does not include any dedicated sections that specifically teach EMTs about physiological or psychological changes with aging or how to deliver quality care to older adults. The national curriculum for paramedics, EMTs who provide advanced and invasive care, does include some sections dedicated to caring for older adults, but they comprise a very small fraction of the two year curriculum. Some states, such as New York, attempt to address this deficiency by requiring EMS providers to obtain continuing education in geriatrics to renew their certification. A course has been developed by the American Geriatrics Society and a number of other groups, called Geriatrics Education for EMS, that is commercially available to provide continuing education in geriatrics.5

To our knowledge, only one study has evaluated EMS provider opinions regarding caring for older adults.6 That study surveyed EMS providers in the Geriatrics Education for EMS course as to their comfort in caring for older adults, and found a notable proportion of EMS providers who were uncomfortable caring for older adults before the training. Studies have not specifically evaluated EMS providers’ opinions regarding their abilities to care for these patients or their desires regarding further geriatric EMS education content or delivery.7

This study used qualitative research methods to explore the perceptions of EMS providers, EMS leaders, and leaders in geriatrics, regarding the ability of EMS providers to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which that continuing education could be best delivered.

METHODS

Design

We performed a qualitative research study that used key informant interviews to identify prevailing themes. This qualitative study design was chosen as it is considered an optimal approach to obtain broad knowledge about a relatively unexplored topic with little previous research.8 Qualitative studies are not only important as hypothesis-generating preliminary investigations into an unknown area, but they can be later integrated with subsequent quantitative work during systematic reviews of a topic.9 The institution's research subjects review board approved this study.

Setting and Population

This study took place in a Northeastern United States EMS region between June and August 2006. The region covers two counties and one urban, metropolitan area with a total population of approximately 800,000. There are four EMT training programs and one paramedic training program in the region. Geriatrics continuing medical education is provided through the Geriatrics Education for EMS, but that class has not been widely taken by EMS personnel.

Protocol

We used key informant interviews to identify prevailing themes to understand the perceptions of key stakeholders regarding the ability of EMS providers to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which the continuing education should be delivered.10 We used a purposive sampling technique, a selection method used in qualitative research to deliberately targeting subjects who are most likely to yield information. In contrast to quantitative studies, where eliminating selection bias is a concern, qualitative research actively pursues subjects with the most knowledge on a topic. In this study, this meant identifying major constituencies that interface with EMS care for older adults. The constituencies identified included EMS medical directors, geriatricians, EMS administrators, EMS educators, and EMS providers. Physicians, EMS administrators, and EMS educators were selected for interview based on the investigators’ perceptions of them as “thought leaders” within the EMS community or by referrals from EMS leaders within the community. All individuals within this category who were approached agreed to participate. EMS providers were recruited in person on predetermined days during visits to EMS bases and via flyers distributed in hospitals and EMS stations.

The study team developed and piloted a semi-structured interview guide (Figure 1) to initiate a discussion on the topics for investigation. The team also developed a demographics survey to understand the background of the participant. The survey queried the individual's degree and/or level of certification (either EMS or medical), their years of EMS and/or medical experience, any additional EMS agency roles they filled, and whether or not they had participated in continuing medical education (CME) focused on geriatric care.

Interview Guide

1. In your opinion and given your educational experience, what are the areas of geriatric EMS education that need improvement?

2. Of the areas you just identified, which do you consider the most pressing or important?

3. When responding to calls that involve geriatric patients, what are some of your worries?

4. How comfortable are you in assessing a geriatric patient?

5. How do you feel continuing education materials can best be provided to EMS responders?

6. Do you feel self study modules can be effective in EMS education?

7. How likely are you to use self-study materials if they were provided to you at your station?

8. Do you have any thoughts on geriatric EMS education that we have not explored?

One investigator (LKNP) performed the in-depth, semi-structured interviews with the identified key informants and EMS providers. This individual was chosen because he had no role in the local EMS system and no familiarity with the EMS providers, two factors which could have biased responses. Each interview began with obtaining consent and completing the demographics survey. The interviews were then performed following the semi-structured guide with use of follow-up probing questions where appropriate. Field notes were taken during the interviews and then transcribed immediately. No audio recordings were performed in order to minimize subject inhibition.

Sample size in a qualitative study is not determined by statistical power but rather by the number of interviews necessary to reach redundancy of responses.11 In this study, we interviewed subjects until redundancy was reached. For redundancy, we followed the National Institutes of Health definition, which states that redundancy exists when no new data emerge from additional interviews.12 All authors jointly decided that redundancy had been achieved on the various interview topics.

Data Analysis

Transcribed data were broken into discrete statements and initially coded by one investigator (LKNP). The coding was independently reviewed by the rest of the study team. Differences in coding were discussed as a group and resolved by consensus. The table of discreet statements consisted of columns containing the subject identification number, the survey guide domain, the main category the feedback addressed (training, patient care, etc.), and additional subcategories generated by the study team. In this way, the interview feedback could be sorted by subject, survey domain, and various subcategories (knowledge, attitudes, if the cited issue was medical or psychosocial, etc.).

The coded data were sorted by each category as described above, and after each sort the study team identified emerging themes. These themes were then combined into a smaller number of analytic domains.

RESULTS

We interviewed 30 participants, 20 EMS providers and ten area EMS leaders (EMS administrators, EMS educators, EMS medical directors, and geriatricians) who influence the region's geriatric education curriculum. Table 1 characterizes the subjects interviewed.

Table 1

Participant Demographic Data (N = 30)

The semi-structured interviews resulted in 435 discreet statements. We identified seven themes from these statements. These themes fit into four overall analytic domains (Figure 2). Our results will be presented in the context of each appropriate domain with representative quotes selected for illustration in Table 2.

Seven Basic Themes Sorted into Four Analytic Domains

Table 2

Exemplary Quotes from Participants

The Current State of Geriatric Care by EMTs

EMS providers and leaders identified communication difficulties in patient care handoffs, psychosocial issues, and distrust for skilled nursing facility staff as barriers to good care, but felt comfortable with their assessment skills.

Communication

EMS providers and leaders both expressed concern about communications barriers that impede timely gathering of patient information when they arrive at the patient. Our subjects described older adult patients as having complex medical histories, taking numerous medications, and having medical conditions that impede communication (Table 2, Quotes 1−2). Some participants felt that the communications barrier stemmed from the patients themselves (Table 2, Quotes 3−4). Interestingly, EMS providers also expressed these concerns for long-term care facilities, a location where communication challenges should not exist. A general distrust for skilled nursing facility staff was evident among participants (Table 2, Quotes 5−7).

Assessment

EMS providers expressed feeling comfortable with their skills in the medical assessment of geriatric patients. Participants stated this comfort resulted not from formal training, but from experience with older relatives, prior healthcare experience, or their own experience as an EMS provider. However, local EMS leaders had mixed opinions about the abilities of the providers. A geriatrician said the EMS providers were “mostly comfortable” but may not be aware of the subtleties of caring for the older adult, thus limiting their ability to evaluate their skills. An EMS educator stated the EMS community was “moderately comfortable” in assessing geriatric patients, with key deficiencies related to competing comorbidities, differentiating between pre-existing and new problems, and pharmacology. One paramedic-educator with 28 years experience said “Geriatric patients are the second most nerve-wracking group after pediatrics.”

Both leaders and providers both expressed concern about psychosocial issues such as the patient's social situation, mental health issues, decision-making capacity and end-of-life issues (Table 2, Quotes 8−9).

Desired Medical Topics for Continuing Education in Geriatric Care

EMS providers and EMS leaders identified many biomedical topics for geriatrics education. Specific and very common examples included evaluating a patient's medication history and compliance habits, improving knowledge related to pharmacology and particularly medications that could cause mental status changes, assessing falls and other trauma in the older adult, and understanding the role of chronic disease in the EMS setting, with diabetes being a particular concern. Some representative comments which were made in response to questions about what areas of education they feel they would benefit from are included in Table 2 (Quotes 10−12).

Desired Psychosocial Topics for Continuing Education in Geriatric Care

EMS providers and EMS leaders both identified a number of psychosocial educational topics that would benefit the EMS community. In fact, when asked to name a priority for geriatrics education, participants frequently cited psychosocial issues (Table 2, Quotes 13−15). Specific issues that were identified included mitigating communication impairment, increasing familiarity with end-of-life issues including advanced directives forms, acting as an entry point for social services, and improving interactions with other medical facility providers, especially skilled nursing facilities.

Desired Continuing Education Delivery Methods

With the requests for continuing education, discussion led to how the education should be delivered, the efficacy of self study methods, and the option of self-study modules. The issue of time was cited as a barrier to providing CME. Some participants felt they did not have enough time to participate in CME classes while others noted the difficulty of assembling EMS staff in the context of a 24-hour EMS agency. Participants noted that the nature of EMS dictates that not all members of a particular agency will be able to participate in a single CME session. Participants also stated CME should focus on “clinical pearls” and be delivered over a short duration.

When addressing the efficacy of self-study modules, participants were divided in opinion. Some felt that study modules would be effective for EMS providers, while others felt that a classroom based instruction modality would be better. Others felt that self-study modules required individual effort and focus to be useful, which may not be present in an individual learner (Table 2, Quotes 16−20).

DISCUSSION

This qualitative study allowed us to characterize the perceptions among EMS stakeholders regarding the state of geriatrics care by EMS, CME needs, and modalities through which the education might be delivered. The findings demonstrated that there are areas for improvement in geriatric EMS care. Overall, most providers felt comfortable with caring for older adult patients, although this view was not completely shared by EMS leaders and physicians who expressed concerns that EMS providers may miss the subtleties associated with caring for older adults, and therefore may overestimate their actual skills. All groups did agree that EMS providers are challenged by certain areas, such as communications issues (with both patients and health care facilities), age specific medical issues (such as dementia and polypharmacy), and psychosocial issues (such as advanced directives and accessing social services). These results were congruent with the one previous study that evaluated EMS providers comfort in caring for older adults.5

Specific areas of clinical weakness were linked directly to the desired medical and psychosocial topics for continuing education. The medical topics were quite broad, and likely reflected the limited previous older adult specific education the EMS participants had received. That the predominately cited psychosocial issues were communications and end of life issues were of particular interest. Most interesting was that psychosocial issues were mentioned frequently and felt to be a significant concern.

The state of geriatrics education is similar to the state of pediatrics education identified in a survey.13 Providers in that survey stated that they were comfortable caring for children, but additional continuing education was needed. They identified a broad range of topics for continuing education, including both medical and psychosocial issues.

This study has identified a perception that continuing education is needed on EMS care of older adults. The challenge now is to providing sufficient quantity and quality of continuing education to address this need and to change the care provided. However, there is a lack of data regarding EMS provider preference for the content and delivery mode of the CME. Previous studies have noted general obstacles to continuing education include cost, travel distance, and availability of the training.13 The diversity of opinion surrounding CME makes it evident that it is unlikely that a single solution will meet everyone's needs or preferences. However our study revealed support among EMS providers for the use of self-study modules, particularly those that could be accessed from a variety of locations and resources. Participants who were most interested in classroom style learning expressed a desire for engaging content and experienced teachers.

This dichotomy of learning styles may point to a future direction in CME: online video. Although not tested among EMS providers, on-line continuing education has been evaluated in physician continuing education and has been found to be potentially beneficial.14 With the increasing availability of high-speed Internet connections at base and while mobile, online video is easily distributed. Online video can be accessed by an individual at any time, removing the barrier created by the 24 hour schedules in EMS. Online video can capture dynamic and compelling demonstrations of techniques and reenactments favored by those who prefer classroom learning. By making geriatrics CME easily available, 24 hours a day online in an engaging format, EMS providers may be more likely to take advantage of the added education and thereby potentially improve the care of their geriatric patients. For instance, much of the Geriatrics Education for EMS curriculum can be converted to online video. This may make the course more accessible, a concern described in the one study that has evaluated the course.6

Successful educational programs require more than merely accessibility to result in an impact on knowledge, skills, and practice. Data exist in the physician continuing education literature that didactic programs do not improve the skills of the student. An online video educational program, whether presented in a classroom or individually accessed, may do little more than a didactic session. Interactive sessions that ensure active student participation and skills practice have been shown to change practice.15 16 17 However, creating an online system that can meet such levels of interaction will require significant development effort and cost. Instead, combining an online video education program with either an audit and feedback program or a focused educational outreach visit may have significant promise for EMS education, but it is not completely clear based on physician education research.18 19 From a practical standpoint, it is seems that the audit and feedback option would have more benefit, but future research is required to evaluate any such program to determine the impact on patient care.

This study has a number of limitations that should be recognized. First, the study was conducted in one mid-sized metropolitan area, and may lack generalizability to other practice environments such as rural EMS. However, this study does begin to explore the issues around prehospital care for older adults and methods through which we can provide EMS providers continuing education. Also, in our demographic survey, we did not distinguish between volunteer and paid / career EMS providers. If a difference of opinion about content or delivery method exists between these groups, our study was not constructed to identify that difference. Third, the interviewer (LKNP) had limited EMS experience, no role in the EMS system, and had been trained to interview by two of the investigators (RJF, MNS). This could have introduced inadvertent bias into the study. However, we feel his independence was a strength and the consistency of the responses make such a bias less likely.

This study begins to describe what EMS providers would like to learn in their geriatric care continuing education experiences and how those experiences may be delivered to the learner. Identifying and satisfying these needs is vital to create opportunities for geriatric care continuing education that EMS providers are likely to utilize in an educational environment with many other options.

CONCLUSION

EMS Providers, EMS leaders and physicians in this study perceive a deficit in EMS education content on the care of the older adult patient. There is a corresponding desire for more geriatric continuing education for EMS providers, particularly in communications and psychosocial issues. Education is desired in a variety of modalities. Emerging online video technologies may be able to bridge a significant gap between learners who prefer classroom based modalities and those who desire self study modules.

Acknowledgements

Mr. Peterson is supported by Offices for Medical Education Basic Science Summer Research Award, Center for Advocacy, Community Health, Education and Diversity, University of Rochester School of Medicine and Dentistry, Rochester, NY. Dr. Shah is supported by the Paul B. Beeson Career Development Award (NIA 1K23AG028942).

Footnotes

This study was presented in abstract form at the National Association of EMS Physicians, 2008 Annual Meeting in Phoenix, Arizona.

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