NEW YORK (Reuters Health) – Shared decision-making between paramedics and primary care physicians (PCPs) can reduce unnecessary transport to the emergency department (ED) for assisted living residents who fall, according to results from a prospective study.
“Your emergency medical services (EMS) colleagues can participate in the care of your patients, and that relationship (EMS and primary care) can really be a win-win-win for patients, paramedics, and physicians,” Dr. Jefferson G. Williams from Wake County Emergency Medical Services, Raleigh, North Carolina, told Reuters Health by email. “Getting the ‘right resource to the right patient at the right place at the right time’ is something that we as physicians should achieve for our patients, and EMS can really help with that. Paramedics are healthcare providers, not just a transport resource.”
From 2011 to 2014, more than 10 million adults age 65 or older were treated in U.S. EDs for falls. About 70% of these people were released from the ED. Many assisted living facilities, however, have policies requiring emergency medical transport to an ED for evaluation regardless of the fall’s severity or circumstances.
Dr. Williams and colleagues established a protocol for minimizing unnecessary transport of residents in assisted living facilities who had ground-level falls, hypothesizing that on-site evaluation and treatment by paramedics and a PCP would reduce the need for transport, improve patient outcomes, and limit healthcare costs.
They evaluated the protocol in 22 assisted living facilities in Wake County, North Carolina. Advanced practice paramedics were automatically sent when ambulances were dispatched to addresses known to be assisted living facilities with study patients. Patients who had ground-level falls were assigned, after the usual history and physical examination, to one of three tiers that determined whether PCP contact or transport was necessary.
During the study, 359 of 953 patients had 840 ground-level falls (median, 2 per patient; maximum, 17), according to the December 12 Annals of Internal Medicine report.
The protocol recommended no transport for 553 of the 840 falls. Eleven patients recommended for non-transport experienced a protocol-defined “time-sensitive condition” (a wound requiring repair, any fracture, admission to ICU, requirement for an operating room or cardiac catheterization laboratory, or death from any cause within 72 hours of the fall).
Nine of these 11 patients had been discussed with the PCP: four requested and received transport despite the protocol recommendation, and three had minor injuries that were successfully managed on-site by their PCP because of patient and physician preference. Overall, then, 549 of the 553 falls (99.3%) with a protocol recommendation for non-transport received appropriate care.
Nearly two-thirds of transports (528/840, 63%) were avoided because of the protocol. The median time to PCP follow-up for non-transported patients was 10 hours, and 95% of patients not transported had follow-up in fewer than 18 hours.
Three additional residents had fractures that were diagnosed by outpatient radiography after prompt follow-up visits with a PCP.
Absence of services like these in other catchment areas could limit the generalizability of these findings, and current reimbursement models for EMS pay only for transport, not assessment, which creates a disincentive against programs like this one, the researchers note.
“We certainly have a unique setup in Wake County with our ‘Advanced Practice Paramedic’ program and the Doctors Making Housecalls group, perhaps limiting generalizability of our specific protocol, but that is not to say that a very similar arrangement, with the key components, could not be implemented in most communities in the U.S.,” Dr. Williams said.
“We believe there is real potential here for healthcare cost savings, that we and others certainly need to look at more formally,” he added. “Part of that cost savings is EMS reimbursement reform. Allowing a wider range of reimbursement policy in the EMS/prehospital environment supports patient-centered, out-of-hospital care.”
Dr. Sharon K. Inouye from Harvard Medical School and Hebrew SeniorLife and Dr. Matthew E. Growdon from Brigham and Women’s Hospital and Harvard Medical School, Boston, who wrote a related editorial, told Reuters Health by email, “We were most impressed by the seamless integration of a group of primary care physicians serving an assisted living population and a provider of emergency medical services – a unique and powerful collaboration that yielded impressive results. While there were 11 patients who fell and ended up having time-sensitive conditions despite a protocol recommendation for non-transport, the fact that 98% of the non-transport recommendations were associated with relatively benign conditions that might be managed in-place, rather than in the ED, underscores the potential of their protocol to improve care for community-dwelling elderly patients who have fallen.”
“In our fragmented healthcare environment, very few communities would be able to implement such a protocol – likely less than 5% of communities,” they said. “There were a number of important factors that enabled their success. These included a supply of physicians well-versed in home care, an ability to guarantee expedited follow-up appointments within 18 hours, rigorously trained advanced paramedics who could implement the protocol safely and communicate with physicians, and, most important, physicians, EMS providers, and assisted living facilities that were motivated to collaborate in an innovative way to alter well-worn pathways of care for elders who have fallen.”
“Despite the fact that only a small minority of communities would be able to implement this exact protocol, the demonstration that many falls do not require evaluation in an ED or hospital should encourage more innovation in this important and costly area,” Dr. Inouye and Dr. Growdon conclude, adding the need for more research to assess reproducibility and cost-effectiveness.
Dr. Sharmila Dissanaike from Texas Tech University Health Sciences Center, Lubbock, who has examined the need for routine CT after a ground-level fall in older patients, told Reuters Health by email, “ED visits are a major source of healthcare costs in the U.S., and I congratulate the study authors on developing an innovative protocol to reduce unnecessary visits for a very common condition. We should be careful that this type of intervention does not prevent patients from getting transported to the ED when they need it; in the entire series, only 11 patients were inappropriately triaged with only one adverse consequence, which is a reasonable error rate given the size of the study – it is almost impossible for any intervention in medicine to have a zero rate of complications.”
“While this exact intervention may not be generalizable to every setting, it is reasonable to expect that their protocol could be used as a starting point to develop similar thoughtful strategies for addressing this problem in every community with a high proportion of elderly patients – which is almost every community in the developed world these days,” she said. “It is essential that we develop a systematic approach to this very common problem, since our current default practice of relying on EMS transport and ED assessments for every fall in an older patient is clearly not an optimal approach for the patient, their family, or society at large.”
SOURCES: http://bit.ly/2AalZLx and http://bit.ly/2AxeouH
Ann Intern Med 2017.
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