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Reducing Elderly Transports to the ED for Falls

January 25, 2018

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Paramedics responding to elderly patients who had fallen in an assisted living facility followed a protocol that included discussing the case with the patient’s primary care physician (PCP).  This drastically reduced the number actually getting transported to the ED by 63% and was safe.

Why does this matter?
Elderly patients who fall in a nursing home are often taken to the ED as a matter of protocol.  Very often, they are not injured or have minor injuries.  Transport to the ED is not only unsettling for the patient who has fallen but is very costly in terms of healthcare expenditures, time, and resource utilization.  Is there a way to reduce transports when elderly patients have fallen but have minimal injury?

“I’ve fallen, and I can get up!”
This was a prospective study of 22 care facilities for elderly patients, all with the same group of PCPs.  Paramedics triaged patients into one of three categories.  Tier 1 included obvious badness (unstable vitals, uncontrolled bleeding, etc), and residents were transported.  Tier 2 included falls with anticoagulant use, extremity needing a splint, borderline VS, baseline mental status precluding assessment, etc.  These were discussed with the PCP prior to transport.  Some were transported, but 70% remained at the assisted living facility.  Tier 3 had very minor contusions, skin tears, or no complaints.  These cases did not require PCP discussion and were not transported.  Almost 1000 participated, and there were 840 falls over the 43 month study period. The protocol recommended no transport for 553 of the falls.  Of these, 549/553 (99.3%) were triaged and treated appropriately with the protocol.  Patients who were not transported were seen by their PCP a median time of 10 hours after injury.  This protocol could reduce ED transports significantly.  The downside is expense and extra training for the paramedics.  However, Ali Raja with Journal Watch pointed out, “in a capitated risk model, saving an avoidable ED visit would more than justify the cost.”

Improving Decisions About Transport to the Emergency Department for Assisted Living Residents Who Fall. Ann Intern Med. 2017 Dec 12. doi: 10.7326/M17-0969. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.  

What are your thoughts?