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Abstract
The increase in the size and age of the UK older population has had a major effect on emergency services. Many older people will visit the emergency department but not necessarily require significant clinical intervention. The Paramedic Practitioner in Older People's Support (PPOPS) scheme was set up to provide community-based clinical assessment of older patients contacting the emergency services with minor acute conditions as an alternative approach to emergency department transfer. Patient carers were followed-up to evaluate the impact of this scheme when compared with standard transfer to the emergency department. Postal questionnaires, including items on the level of care provided, satisfaction with care received and carer impact, were administered to 561 carers. The overall response rate was 71.5% (401/561). The carers were predominantly female, approximately 60 years of age and family members, with more than three-quarters providing some form of physical care before the patient episode. Overall, carers did report an increase in the level of care provided before episode, significantly more so in the emergency department group (p=0.003). These increases related to more input needed in supporting physical activities. The carers in the PPOPS group were more likely to report greater satisfaction with their impression of care and staff attitude and would prefer treatment at home for the patient than those in the emergency department group (p<0.001). A minor health event does impact on the life of a carer. However, community-based schemes, such as PPOPS, do not increase the burden on carers and have high levels of satisfaction among this important group of the community.
- Carer
- emergency care
- older people
- burden
- carer satisfaction
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Background
In recent decades, there has been a considerable shift surrounding the provision of care for older people from institutional to more community-based care, and over the coming decades, it is likely that there will be an increasing reliance on the provision of informal care to help keep older people in the community. Being an informal carer for an older person can be both physically and emotionally demanding and can disrupt aspects of the carers' lives such as social and family life.1
It is well known that the older population in the UK is growing.2 This increase in the size and the age of the older population has had a major effect on emergency services within the UK, and this may provide even greater pressure in the future. Many older people will have illness or injury that will necessitate calling the emergency services, resulting in a visit to the emergency department (ED), but which require very little clinical intervention. A systematic review of older adults in the ED found that older adults constitute between 12% and 21% of visits to the ED; they are more likely to arrive at the ED by ambulance, when compared with younger people, and more likely to be admitted to hospital from the ED,3 adding more pressure to already strained healthcare resources. Increasing demand for emergency healthcare has prompted policy makers and healthcare organisations to look at ensuring that services are delivered in an efficient manner and have looked to alternative ways of delivering services closer to home.4 5 Studies suggest that an alternative approach to a standard emergency ambulance response would have the greatest chance of improving the patient experience and potentially reducing workload on EDs and hospitals if targeted at older patients with minor conditions.6 7
Increasing demands on emergency healthcare in the UK were a factor in the redesigning of emergency healthcare provision such as the Paramedic Practitioner in Older People's Support (PPOPS) scheme developed by the South Yorkshire Ambulance Service.8 The scheme used seven experienced paramedics who completed a training course to enable them to provide community-based clinical assessment of older people contacting the emergency services with minor acute conditions. Initial assessment and, where appropriate, treatment were delivered within the patients' residence by a paramedic practitioner (PP) who responded to these calls in a single-manned vehicle. Where the PP deemed it necessary, patients were transported to the ED for further assessment or treatment. Operational between the hours of 0800 and 2000 each day, the service was activated by a ‘999’ or a general practitioner urgent call to the ambulance control room or by an ambulance crew attending a suitable patient. Referral pathways open to the PPs included the ED, the ear, nose and throat department and community social services. It was unclear how this scheme would impact on the carers of patients being treated by PPs.
The new service was evaluated as a cluster randomised controlled trial.9 As part of this study, we aimed to describe the impact that a minor acute health episode has on a carer in addition to evaluating the impact on carers of the new PPOPS service (intervention) compared with the standard service of 999 ambulance response and transfer to the local ED (control).
Methods
In this study, a carer was defined as someone who provided physical or emotional support to the patient and was present at the time of the episode. Carers were eligible to participate in the study if the study inclusion criteria were met (box 1). Written consent was obtained after recruitment at the scene of assessment/treatment (intervention) or in the ED (control). Healthcare professionals employed within nursing or residential homes were excluded from this study. The study was approved by the local research ethics committee.
Study inclusion criteria
Care recipient presented to the ambulance service
between 1 September 2003 and 26 September 2004;
between the hours of 0800 and 2000;
aged ≥60 years;
with a call originating from a Sheffield postcode;
with a presenting complaint that fell within the scope of practice of the PP.
Survey instruments
During the development of the questionnaire, interviews were undertaken using the questionnaire as a guide, with carers of patients who had recently been assessed by a PP and/or in the ED. This approach was used to ensure that the questionnaire was relevant to carers and their experiences and was straightforward for comprehension and completion. The questionnaire asked carers about the level of care provided by them both before and after the patient episode and about satisfaction with the care received from health services during the episode. Carers were also asked about the impact that the patient episode had had on them, regarding both physical and non-physical aspects of care.
Postal questionnaires were administered to the carer 7 days after the initial patient episode, accompanied by a covering letter and business reply envelope. Non-responders were sent a postal reminder approximately 14 days after the initial mailing.
Analysis
Data were entered into an Access database and exported to SPSS V.12.0 for statistical analysis. The χ2 test and independent samples t test were used to detect differences between respondents in the intervention versus the control group. Levels of significance were taken as p<0.05.
Results
Response rate
Five hundred and sixty-nine carers were identified as eligible and consented to take part in the study. Carers who withdrew consent or notified us of their care recipient's death were not contacted for follow-up. Of 569 carers, 561 (98.6%) were sent a questionnaire (n=329/561, 58.6% intervention group vs n=232/561, 41.4% control group). The overall response rate was n=401/561 (71.5%): n=234/401, 58.4% in the intervention group versus n=167/401, 41.6% in the control group.
Table 1 describes the carers and the care recipients in each group.
Description of carers and care recipients
Overall, care recipients in both groups were similar in terms of age, sex and presenting condition. Carers were predominantly female, approximately 60 years of age and family members, with more than 75% providing some form of care before the initial health episode. Significant differences between the two groups were found in relation to the proportion who received care from a family member (p=0.001) and the proportion of patients who were subsequently admitted to hospital after their initial health episode (p<0.001): in the intervention group, fewer carers were family members, and fewer recipients of care were admitted to hospital after their care episode.
Carer satisfaction
Carers in the intervention group experienced assessment by a PP in the home. Carers in the control group experienced care that may have been provided by clinical and non-clinical staff in the ED. Carers were asked to report their satisfaction with the care given at the time of the health episode using a scale that included the responses ‘good’, ‘satisfactory’ or ‘poor’. These results are shown in table 2.
Satisfaction with care
Where care recipients had received their care at home with a PP, carers were more likely to report greater satisfaction with their impression of care and staff attitude towards the carer than those receiving assessment in the ED (p<0.001). Forty-two per cent (42/100) of the carers in the control group reported that carer facilities in the ED were ‘good’, with fewer (21%, 21/102) reporting that they were happy with the waiting time in the ED. Another indicator of satisfaction was where carers would prefer care recipients to receive care. The carers were asked if they had a preference for at-home versus at-hospital care. Carers in the intervention group were more likely to express a preference for care to be delivered in the patients' home (p<0.001).
Impact of the healthcare episode on carers
The carers were asked about the overall impact of the health episode on themselves. They were asked to omit responding to questions on changes in physical care provided if care recipients were in hospital at the time the questionnaire was being completed. Table 3 shows these results.
Change in level and nature of care provided after health episode
Overall, the carers did report an increase in the level of care provided after episode, more so if the care recipient had received their initial assessment in the ED (p=0.003). These differences related to increased input needed in supporting physical activities such as bathing patients (p<0.001), cooking for patients (p=0.003) and dressing patients (p=0.003) among carers in the control group.
Although not statistically significant, more than half of the carers in both groups reported that they had felt anxious about providing care and that there had been a restriction of their work/leisure time since the episode, with a significant minority also reporting that the episode had a negative impact on other family members.
Discussion
The impact of caring for people with chronic illness and cognitive decline are documented.10 This study has enabled some insight to be gained into the impact that a minor health episode has on the life of a carer for an older person and provides evidence to suggest that community schemes such as PPOPS, which reduce the requirement for transfer to the ED, do not have a detrimental effect on the lives of carers.
Overall, care recipients in intervention and control groups were similar in terms of age, sex and presenting condition. Most of the care recipients were not admitted to hospital, and so it is likely that their carers took responsibility for providing any post-episode care, with family members at the centre of this.
There is increasing evidence of a policy drive towards the development of new types of responses by emergency care services to provide a more flexible approach to service delivery and using extended practitioner skills.11 Ambulance services within the UK have investigated the use of alternative responses for non-life-threatening 999 calls through numerous different schemes.12 An evaluation of the PPOPS scheme found it to be beneficial to patients for shorter episode times, fewer ED attendances and increased patient satisfaction.9 In addition, the study suggested that appropriately trained paramedics with extended skills treating older people with minor acute conditions in the community are as safe as standard ambulance transfer and treatment within the ED.13
One of the risks of increasing the amount of care provided at home for patients is that those responsible for caring for them will bear an increased burden of care as a result of patients being treated and left at home. However, patients experiencing and carers observing clinical assessment in a familiar environment (the home, with a sole practitioner) may feel more confident in asking questions and obtaining advice and influential in decision making, which may be beneficial when providing aftercare. Evidence suggests that some carers report feelings of satisfaction because they themselves are able to provide care and avoid any adverse consequences for the people they are caring for.14 Findings from a hospital at home study also suggests that caring at home avoids difficulties with hospital visits and that a patient's own satisfaction with home care may positively influence carer perceptions of burden,15 which may ring true in our study.
Interestingly, the patients who were reported by carers to require increased care after their episode received their treatment in the ED and were more likely to be admitted to hospital. For the care recipient, being treated at home rather than in the ED may help keep the healthcare episode in perspective. It may be the case that they do not perceive the episode as serious and are also able to maintain the level of functioning and, therefore, care received before the health episode rather than placing extra demands on the carer. The increased disruption caused by an older person attending the ED may, in turn, place an increased burden on the carer.
Carers experiencing at-home assessment reported that they preferred this type of patient assessment compared with those receiving care in the ED. This may imply that the carers of those receiving care in the ED were satisfied with their ED experience. However, when asked specifically about their experience, carers of the ED patients were less enthusiastic regarding their impressions of care and the attitude of staff compared with those who experienced care in the home by PPs. Carers in this study were approximately 60 years of age, and evidence suggests that older age groups are more likely to use established and familiar forms of healthcare, such as a general practitioner, rather than more recent additions, such as NHS Direct.16 This may be because of habit or a sense of security and familiarity in using services that they already have experience of. This is supported by the fact that the carers in the ED group, having had no experience of at-home assessment, were less likely to report this as a favourable option in the future.
The priority of the PPOPS scheme was to improve the care experience of the older person having a minor illness or injury. However, the carer's emotional and physical well-being and acceptance of such schemes must also be considered if they are to continue to play an increasingly crucial role in keeping older people out of the ED and in the community.
Study limitations
The data presented in this paper were collected during a randomised controlled trial and was not the primary research objective. This was an opportunistic study based on convenience sampling; hence, no comment can be made on whether the findings are subject to type 2 error owing to the study being inadequately powered. Not all carers were present at the time of the patient episode or chose to take part in the study. We are unclear of how many carers declined to take part and the characteristics of these carers. It is also not clear if the carers who took part were the main carers of the patients, although most of the respondents reported providing some physical care to the patient before the episode, indicating that those who considered themselves as a carer were included.
Carers of nursing/residential home patients were excluded from the analysis because it was felt that the carer burden faced by formal carers was different from that of an informal carer.
Although we highlight these limitations, the statistical significance associated with many of the results reported here suggests that we can be confident in our findings.
References
Footnotes
Funding PPP Foundation.
Competing interests None.
Ethics approval This study was conducted with the approval of the Sheffield local research ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.