According to results from a prospective study published in the journal Annals of Internal Medicine, shared decision-making between paramedics and primary care physicians (PCPs) could reduce unnecessary transport to the emergency department (ED) for assisted living residents who fall.

The researchers 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. 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.

Eleven patients recommended for non-transport experienced a protocol-defined time-sensitive condition (a wound requiring repair, any fracture, and 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. Nearly two-thirds of transports 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. A unique setup in Wake County with Advanced Practice Paramedic program and the Doctors Making Housecalls group, perhaps limiting generalizability of 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.

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. 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.

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. ED visits are a major source of healthcare costs in the U.S., and the study developed 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. It is almost impossible for any intervention in medicine to have a zero rate of complications.