Introduction: About 20% of the emergency 911 calls made by older adults are related to a fall. All those patients are subsequently transported to the ED in the province of Quebec. However, only one third of older adults following a fall attended by paramedics will have a time-sensitive condition and most patients will be discharged back to the community. Fall is a growing societal problem that needs innovative approach to improve care. Prehospital fall assessment protocols aiming to identify patients who would benefit from being referred to community services rather than being transported to an ED have been introduced around the world, but they are infrequently a standard of care in Canada.
Research question: Can a standardized prehospital fall assessment protocol for older adults safely identify patients with time-sensitive conditions and reduce the number of unnecessary transports to the ED?
Objectives: The main objective of this study is to evaluate the safety of a prehospital fall assessment protocol by determining its negative predictive value to identify patients with at least one time-sensitive condition following a ground or lower-level fall. Secondary objectives are: 1) to determine the potential reduction in the number of transports to the ED; 2) to evaluate the impact of this protocol on the time spent on the field and the availability of paramedics for other interventions; and 3) to evaluate the cost-effectiveness of this new care pathway.
Methods: This is a prospective cohort study. A standardized prehospital fall assessment protocol was pilot-tested at the CIUSSS de l’Estrie from October 2019 to January 2020. After refinement following the first 100 cases, the final fall assessment protocol will be implemented concomitantly at the CIUSSS de l’Estrie and the CIUSS de la Capitale-Nationale in March 2020. All hemodynamically stable older adults who have sustained a ground-level (or lower) fall and who do not require spinal immobilization will be included. Patients who are actively receiving palliative care will be excluded from the analysis. The trained paramedics will perform the on-site assessment. During this implementation phase, all patients will subsequently be transported to the ED. Relevant prehospital and inhospital data will be collected and analyzed.
Variables: The main outcome will be the presence or the absence of at least one time-sensitive condition. A predetermined consensus-based list of time-sensitive condition (either as the cause (eg. myocardial infarction, etc.) or the consequence (eg. traumatic intracranial hemorrhage, etc.)) of the fall was developed. The number of potentially avoidable transports will be considered as the number of patients correctly identified by the protocol as patients for which it would have been safe to do not transport to the ED.
Sample size: A sample size of 1516 patients will be required to assess the protocol’s safety with an expected negative predictive value of 96% (accepted width of 2%) to identify patients with time-sensitive conditions.
Impact: This study is expected to decrease the number of prehospital transports to ED for older adults who have fallen, the risk associated with unnecessary ED visit and the ED crowding. It will inform prehospital care across Canada.