Objectives—To assess the degree of appropriate referral to the accident and emergency (A&E) department following the use of a community alarm where a mobile warden works in conjunction with the community alarm control centre.
Methods—611 consecutive calls using community alarms underwent assessment and the appropriateness of referral to the A&E department was considered.
Results—Of 542 requests for help 44 patients were transported to the A&E department (8.1%). Twenty nine patients were admitted (5.3%) and 15 patients (2.8%) discharged home from the A&E department after assessment or treatment, or both. Only three patients (0.55%) had been referred to the A&E department inappropriately.
Conclusions—This study shows that where a mobile warden works in conjunction with the community alarm control centre the number of inappropriate referrals to the A&E department should be minimal.
- community alarm
- social alarm
- personal emergency response system
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Home Accident Surveillance System (HASS) data show, among people aged 75 and over, falls account for 72% of home accidents for which hospital treatment was sought, and some 23% of accident and emergency (A&E) attendances by the over 75s involve a fracture.1 Many elderly people who live alone and fall at home are unable to reach a telephone and are often lying on the floor for hours until found by relatives. Apart from injuries sustained the person may also start to develop hypothermia and pressure sores.
Many local authorities encourage elderly and disabled people to rent community alarms to enable them to raise the alarm should they require help. Community alarms also help to delay institutionalisation, reduce admissions to hospitals, shorten hospital stays, and reduce the duration of home attendant services.2 The most favourable impact of community alarms has been its psychological value to the users and their families.3
Very little has been published in British medical journals about community alarms. Most studies have been undertaken in the USA where the alarms are known as personal emergency response systems. The healthcare system in the USA differs significantly to that of the UK and this study examines the emergency calls made by subscribers over a six month period and the appropriateness of subsequent referral to the A&E department.
A community alarm is a signalling device that summons help during an emergency. Although community alarms vary widely there are three components. The first component consists of a control console and sensors in the home. The second component is the control centre, which is either provider-based or manufacturer-based. The third component involves the sending of appropriate assistance to the alarm user.
The electronic hardware in the home consists of a personal radio transmitter and a receiver/telephone autodialler installed in the home of each vulnerable person. The telephone alarm unit can be used just like a normal telephone but it also includes an alarm button that automatically dials the control centre. The alarm button is large and illuminated, which makes location and dialling easy during day or night.
Each telephone alarm unit is supplied with a radio alarm trigger that can be attached to clothing or worn as a pendant. In an emergency if the client is unable to reach the phone (for example has fallen and unable to move) the alarm can be raised by pressing the button on the radio alarm trigger. Pressing this button puts out a call for help from the telephone alarm unit.
Table 1 lists the optional facilities with the Piper Lifeline 3000 telephone alarm unit (Tunstall Telecom Ltd, Whitley Bridge, Yorkshire) but there are other manufacturers with differing facilities. A ceiling mounted pull switch is available but an injured person may not be able to reach such alarms. An optical smoke detector is sensitive to smoke from fires and not only emits a shrill warning but it enables the control centre to alert the emergency services immediately. A pressure mat by the bed or in the bathroom allows the home unit to inform the control centre if the resident is inactive over a set period. A low temperature monitor is also available and when the dwelling temperature drops below a specified level the control centre is alerted and can send assistance before the onset of hypothermia. A domestic intruder alarm is another option that can be used.
The control centres in the UK are usually managed by local authorities or housing associations but there are some private organisations. The control centres keep details about their clients such as next of kin, keyholders, GP and medical history. When the alarm is raised whether from the telephone alarm unit or from the radio alarm trigger then the client's details are displayed on the computer screen at the control centre. The operator at the control centre will immediately ring the client. Occasionally there is a false alarm and no further action need be taken. In other cases the clients will request help and appropriate action taken by the operator. Frequently there are “silent calls” where the operator is unable to get a reply on the telephone. In such cases the client may be injured on the floor and unable to speak to the control centre. In the case of “silent calls” the operator will contact a keyholder or relative. If family or friends are not available then a mobile warden or the emergency services will be sent to the residence.
The study was undertaken at the Conquest Hospital, St Leonards on Sea in conjunction with the Ten Sixty Six (1066) Housing Association Ltd. This housing association covers the Hastings and St Leonards areas but has some subscribers in the Rother area. In July 1997 there were 2409 alarm subscribers with the 1066 Housing Association. A total of 1264 subscribers had a ceiling mounted pull switch and 1145 subscribers wore dispersed alarm users (pendants). This housing association employs mobile wardens who visit subscribers if key holders are unavailable.
For six months (May–October 1997) all calls to the control centre by alarm users were recorded. During this period any patient who was subsequently referred to the A&E department was assessed retrospectively as to whether such a referral to A&E was necessary. If patients were admitted to hospital then it was accepted that referral to A&E was appropriate.
Table 2 lists the results of the study. Excluding false alarms there were 542 requests for help during the six months. The mobile warden, keyholder or relatives were able to solve most problems but the GP was called on 38 occasions (7%). The ambulance service was called for assistance on 91 occasions (16.8%) and were able to solve the problem on a further 47 occasions (8.7%). Forty four patients (8.1%) were transported to the A&E department and 29 of these patients (5.4%) were admitted to hospital. Table 3 lists the patients that were admitted into hospital and table 4 lists the patients that were discharged from A&E.
In the majority of patients admitted to hospital the reasons were quite clear (table 3). In the eight patients who had fallen admission was because they were unable to weight bear or needed further social services input before they could return home.
In the 15 patients discharged from A&E seven patients needed suturing and one patient had a wrist fracture—all valid reasons for referral to A&E as is epistaxis in an elderly patient. One patient had initially claimed to have taken an overdose of drugs and was correctly brought to the A&E department. Another patient was intoxicated with alcohol and had fallen and it is very difficult for the ambulance service to leave such a patient at home alone. It could be argued that the two patients who had fallen and required no treatment and the patient who was depressed should not have come to A&E and could have been treated by the GP. Consequently, these three patients (0.55%) represent the only inappropriate referrals in the six month study.
Anecdotally there is an impression among some A&E doctors that when community alarms are used many patients are brought to A&E inappropriately. This study clearly indicates that in the Hastings and St Leonard's area the number of inappropriate referrals to A&E are minimal (0.55%).
During this study the ambulance service were called on 91 occasions and were able to solve the problem on 47 occasions, with only 44 patients being transported to hospital. It is possible that some of these 47 visits were inappropriate and the GP could have been called on some occasions rather than the ambulance service. However, the mobile warden or GP may be busy and in the absence of a relative or keyholder there is sometimes no option but to request an ambulance that subsequently proves to be inappropriate. In any further audit we will consider the appropriateness of ambulance use.
There have been no previous publications in British medical journals that have looked at attendances at A&E following the use of community alarms. This study investigated a community alarm control centre that worked in conjunction with a mobile warden. It is possible that in those areas without a mobile warden the number of inappropriate referrals to A&E may be much greater.
Elderly people living alone sometimes attend A&E after lying on the floor overnight. Such patients often have hypothermia and have started to develop pressure sores. Unfortunately people have to pay a rental to have an alarm and many pensioners are reluctant to pay for the service. At Hastings the cost is £3.47 per week (£1.74 a week for those on low income). However, if more people join then the cost to each subscriber will fall. A&E departments should actively promote community alarms to elderly and disabled patients and most local authorities run schemes that work in conjunction with mobile wardens.
In the near future there are likely to be social alarms that work from anywhere inside the home, using a neck worn speech pendant and outside the home making use of radio cellphone and global positioning technology.4
Ghassan Youssef initiated the research, participated in the design and execution of the study particularly data collection and data documentation, discussed core ideas, participated in the statistical analysis and edited the paper. Tim Underhill initiated the research, participated in the design of the study protocol, discussed core ideas, participated in the statistical analysis and edited the paper. Clive Tovey initiated and coordinated the formulation of the study hypothesis, discussed core ideas, collected some data, participated in the interpretation of the findings and writing of the paper. Clive Tovey and Ghassan Youssef act as guarantors.
Conflicts of interest: none.