Jefferson G. Williams, MD, MPH; Michael W. Bachman, MHS, EMT-P; Michael D. Lyons, BA, EMT-P; Benjamin B. Currie, EMT-P; Lawrence H. Brown, PhD; A. Wooten Jones, MPH, EMT-P; Jose G. Cabanas, MD, MPH; Alan K. Kronhaus, MD; J. Brent Myers, MD, MPH
Presented in part at the National Association of EMS Physicians' Annual Meeting in New Orleans, Louisiana, on 24 January 2017.
Disclaimer: Dr. Williams takes responsibility for the study as a whole. The authors alone are responsible for the content and writing of the paper.
Acknowledgment: The authors thank all of the health care providers from Wake County Emergency Medical Services and Doctors Making Housecalls who evaluated and treated study patients. This study would not have been possible without this hard-working team of paramedics and physicians.
Disclosures: Dr. Brown reports personal fees from Wake County Emergency Medical Services during the conduct of the study. Dr. Kronhaus reports that clinicians (physicians, physician assistants, and nurse practitioners) employed by Doctors Making Housecalls were compensated by Medicare or other insurers for providing services to patients who were included in the study. Dr. Myers reports a salary from Envision Healthcare outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0969.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See Supplement. Statistical code and data set: Available through written agreements with the authors (e-mail, firstname.lastname@example.org).
Corresponding Author: Jefferson G. Williams, MD, MPH, Wake County Emergency Medical Services, 331 South McDowell Street, Raleigh, NC 27601; e-mail, email@example.com.
Current Author Addresses: Drs. Williams, Cabanas, and Myers; Mr. Bachman; Mr. Lyons; and Mr. Currie: Wake County Emergency Medical Services, 331 South McDowell Street, Raleigh, NC 27601.
Dr. Brown: Emergency Medicine Program, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, 1400 North I-35, Suite 2.230, Austin, TX 78754.
Mr. Jones: 406 Lancelot Drive, Greenville, NC 27858.
Dr. Kronhaus: 2511 Old Cornwallis Road, Suite 200, Durham, NC 27713.
Author Contributions: Conception and design: J.G. Williams, M.W. Bachman, J.G. Cabanas, A.K. Kronhaus, J.B. Myers.
Analysis and interpretation of the data: J.G. Williams, M.W. Bachman, B.B. Currie, L.H. Brown, A.W. Jones, J.G. Cabanas, J.B. Myers.
Drafting of the article: J.G. Williams, M.W. Bachman, L.H. Brown, J.G. Cabanas, J.B. Myers.
Critical revision of the article for important intellectual content: J.G. Williams, M.W. Bachman, L.H. Brown, J.G. Cabanas, J.B. Myers.
Final approval of the article: J.G. Williams, M.W. Bachman, M.D. Lyons, B.B. Currie, L.H. Brown, A.W. Jones, J.G. Cabanas, A.K. Kronhaus, J.B. Myers.
Provision of study materials or patients: A.K. Kronhaus.
Statistical expertise: L.H. Brown.
Administrative, technical, or logistic support: J.G. Williams, M.W. Bachman, M.D. Lyons, B.B. Currie.
Collection and assembly of data: J.G. Williams, M.W. Bachman, M.D. Lyons, B.B. Currie, A.W. Jones, J.B. Myers.
Residents of assisted living facilities who fall may not be seriously ill or injured, but policies often require immediate transport to an emergency department regardless of the patient's condition.
To determine whether unnecessary transport can be avoided.
Prospective cohort study.
One large county with a single system of emergency medical services.
Convenience sample of residents in 22 assisted living facilities served by 1 group of primary care physicians.
Paramedics providing emergency medical services followed a protocol that included consulting with a physician by telephone.
The number of transports after a fall and the number of time-sensitive conditions in nontransported patients.
Of the 1473 eligible residents, 953 consented to participate in the study (mean age, 86 years; 76% female) and 359 had 840 falls in 43 months. The protocol recommended nontransport after 553 falls. Eleven of these patients had a time-sensitive condition. At least 7 of them received appropriate care: 4 requested and received transport despite the protocol recommendation, and 3 had minor injuries that were successfully managed on site. Three additional patients had fractures that were diagnosed by outpatient radiography. The final patient developed vomiting and diarrhea, started palliative care, and died 60 hours after the fall. At least 549 of the 553 patients (99.3% [95% CI, 98.2% to 99.8%]) with a protocol recommendation for nontransport received appropriate care.
The resources required for this program will preclude use in some locations.
Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall.
Williams JG, Bachman MW, Lyons MD, et al. Improving Decisions About Transport to the Emergency Department for Assisted Living Residents Who Fall. Ann Intern Med. 2018;168:179–186. [Epub ahead of print 12 December 2017]. doi: https://doi.org/10.7326/M17-0969
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Published: Ann Intern Med. 2018;168(3):179-186.
Published at www.annals.org on 12 December 2017
Education and Training, Emergency Medicine, Geriatric Medicine, High Value Care.
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