https://immattersacp.org/weekly/archives/2017/12/12/2.htm

PCP/EMS collaboration appeared to reduce ED visits for assisted-living residents who fall

In the intervention, paramedics responding to a fall followed a protocol that involved phone consultation with a physician and that assigned patients to one of three tiers based on their need for additional care.


Collaboration between primary care physicians (PCPs) and emergency medical services (EMS) personnel may reduce visits to the ED after falls for residents of assisted-living facilities, a new study has found.

Many assisted-living facilities have policies calling for transport to the ED after a fall regardless of the extent of injury. Researchers performed a prospective cohort study in Wake County, N.C., to examine whether unnecessary ED transport can be avoided in these situations. The study was a partnership between Doctors Making Housecalls, a practice of board-certified PCPs who make home visits throughout North Carolina, and Wake County Emergency Medical Services; both groups worked together to develop the study protocol. Patients were eligible for the study if they lived at one of 22 participating assisted-living facilities in Wake County and if their PCP was in the Doctors Making Housecalls network. Patients were included in the study if they had a ground-level fall at their facility and an advanced practice paramedic was dispatched by ambulance to provide an assessment.

In the intervention, paramedics responding to a fall followed a protocol that involved phone consultation with a physician and that assigned patients to one of three tiers based on their need for additional care. ED transport was recommended for patients in tier 1 and was not recommended for patients in tier 3. For patients in tier 2, who had no clear transport indication, the advanced practice paramedic could decide to transport to an ED or could contact a PCP to discuss the appropriate course of action. All patients who fell were transported to the ED or were scheduled for a PCP visit within 18 hours of the EMS call. Patients could decline transport regardless of the protocol's recommendation, and paramedics could contact the on-call PCP for patients in tiers 1 and 3 as well as tier 2.

The study's primary outcome measures were the number of ED transports after a fall and the number of time-sensitive conditions noted in patients who were not transported to the ED. The study results were published online Dec. 12 by Annals of Internal Medicine.

Of 1,473 assisted-living facility residents who were eligible for the study between November 2012 and May 2016, 953 consented to participate. The mean patient age was 86 years, and most (76%) were women. Eight hundred forty ground-level falls occurred in 359 patients over 43 months. The EMS protocol recommended that patients not be transported to the ED after 553 of the 840 falls; of these, 366 were tier 3 falls and 187 were tier 2 falls.

Among patients for whom transport was not recommended, 11 had a time-sensitive condition, and paramedics discussed nine of these cases with the on-call physician. Of these 11 patients, four requested to be transported to the ED regardless of the protocol, three had minor injuries successfully managed on site, three had fractures diagnosed by outpatient radiography, and one died 60 hours after the fall after developing vomiting and diarrhea and starting palliative care. The researchers judged that appropriate care was received by 549 of 553 patients (99.3%; 95% CI, 98.2% to 99.8%) for whom ED transport was not recommended according to the protocol.

The authors noted that they considered each fall as an independent event although some patients fell more than once; that hospital admission other than to the ICU, operating room, or cardiac catheterization laboratory was not included in their composite outcome; and that their results may not be generalizable to communities with different resources, among other limitations. However, they concluded that implementation of a protocol including paramedic assessment, primary care consultation, and timely follow-up substantially decreased ED transport in residents of assisted-living facilities after a fall.

“If successfully implemented on a widespread basis, this approach could potentially avoid large numbers of unnecessary ambulance transports to the emergency department for simple falls,” the authors wrote.

The authors of an accompanying editorial commended the researchers but said that their enthusiasm for the model was tempered by its methodological shortcomings, including probable lack of generalizability, possibility of selection bias, and potential costs. The editorial authors said that the study “heralds essential alterations in the health care system at large,” including financial realignment, better care coordination between sectors, and additional training in geriatrics.

“This study provides an important example of a much-needed innovation that pushes our health system toward the triple aim of improving patient experience of care, improving population health, and reducing costs of care,” the editorialists wrote.