21st December 2021 Paul Bernard, Grace Corcoran, Lawrence Kenna, Claire O’Brien, Peter Ward, William Howard, Laura Hogan, Rebecca Mooney, Siobhan Masterson
A new service is safely keeping a high proportion of older people, who have phoned 112/999, in their own home rather than transporting them to the Emergency Department (ED) for assessment.
Pathfinder is a collaborative service between the National Ambulance Service (NAS) and Beaumont Hospital Occupational Therapy and Physiotherapy Departments. The service consists of an Advanced Paramedic and Occupational Therapist (OT) or Physiotherapist (PT) responding to 112/999 calls. It also has a Follow-Up Team consisting of OTs and PTs doing immediate follow-up visits as necessary. Older people are particularly vulnerable to adverse events while attending the ED. Pathfinder is improving outcomes for older people by minimising unnecessary ED attendances and offering safe alternative care pathways for older people in their own homes rather than in hospital.
A study of 527 callers directed to the service in North Dublin found that 69% of them were supported to remain at home for assessment and intervention and didn’t have to travel to Beaumont Hospital ED. Traditionally in Ireland all 112/999 callers are transported to ED, unless they decline to go.
Lawrence Kenna, NAS Lead for Pathfinder, said:
“The Pathfinder Model demonstrates that Pre-Hospital Services can help to safely keep older people, who have phoned 112/999, in their own home rather than transporting them to a hospital ED for assessment. In North Dublin, Pathfinder is available to patients 65 years or older who have called 112/999 with a non-serious or non-life threatening concerns. In addition to being a first response to patients whose emergency care needs have been triaged at a lower level, Pathfinder also accepts ambulance crew referrals for patients whose emergency care needs have been initially triaged at a higher level. The North Dublin Pathfinder service operates from Monday to Friday from 8am to 8pm.”
Mr Kenna discussed the results from a research paper published by the team: “The average caller was 80 years of age and the average Rockwood Clinical Frailty Scale score was 6 (moderately frail). All patients, who were not transported to ED following initial Pathfinder visit, remained at home at 24 hours, while 90% remained at home at 7 days. Patients with a diagnosis of dementia and/or a high frailty level were no more likely to be transported to hospital, or to re-present to ED following the initial Pathfinder decision not to transport”.
Reasons for calls
The most common reasons for the initial 112/999 call were; falls, generally unwell, non-traumatic back pain and minor trauma. The average response time to a caller was 25 minutes, and the average time spent completing a comprehensive joint assessment of the older person in their own home was 61 minutes. Approximately one third of callers had a diagnosis of cognitive impairment or dementia.
If an older person is deemed clinically well and safe to remain at home by the Pathfinder team on the initial 112/999 response, the Pathfinder Follow-Up Team can respond immediately and over subsequent days to provide a short period of intensive intervention at home. This role of the Follow-Up Team includes case management, rehabilitation and equipment provision. This input typically lasts for up to one week, with the aim of stabilising the situation and connecting the older person to alternative hospital and community based services for longer-term intervention where required.
Bridget Clarke, NAS Lead, Out of Hospital Cardiac Arrest Strategy and Associated Specialist Programmes, said:
“Pathfinder not only offers an alternative to assessment in the ED, but also acts as a connector and integrator of the person at home with the services and agencies in the acute, community, and voluntary setting that can most appropriately meet their needs. In terms of outcomes, it has demonstrated that it can keep patients safely and appropriately at home, at rates comparable with established UK pre- hospital services.”
When it is necessary for the patient to travel to hospital Pathfinder can manage a more planned interaction with the ED which benefits both the patient and those working at the hospital.
Ms Clarke said:
“In the case of patients who do require transport to the ED and who may need to be admitted to an in-patient bed, hospital therapists and teams benefit from receiving a handover of a comprehensive assessment of the patient in their home prior to transfer to hospital. Pathfinder helps to reduce congestion in busy EDs and improves the environment for patients and staff on the floor, and improves overall flow through and performance of the ED. The service enables increased ED capacity to care for other patients, by supporting this cohort of complex, frail patients at home.”
Paul Bernard, OT with the Pathfinder Service, said the service is also helping to reduce unnecessary patient journeys to the ED. “Our research has shown that most older patients can be safely and appropriately managed in their own home rather than being transported to the ED when they dial 112/999 with low acuity complaints”.
“Older people can be particularly vulnerable to adverse events and poor outcomes during ED attendances and hospitalisation. The service has developed alternatives to ED transportation through a whole network of hospital and community health resources working together to ensure patients are managed safely at home.”
“Pathfinder is a good example of organisations working in an integrated way to improve outcomes for patients. To do this it has required the formation of a joint team from two organisations, as well as close collaboration with a wide variety of other organisations and teams including Dublin Fire Brigade, Primary Care, the Integrated Care Team, the Community Intervention Team and the NAS Community Paramedics. Patient feedback has been overwhelmingly positive and strongly confirms that older people hugely value the Pathfinder model”.
Sláintecare Integration Fund 2020
The service received funding from the Sláintecare Integration Fund 2020 to test the model, and has been operational since May 2020. It is now in the process of being mainstreamed and it is intended to expand the model to other parts of the country so that older people who dial 112/99 with low acuity complaints in other areas of Ireland will also benefit from this model of care.