Between 2004 and 2009, researchers in Yale’s Department of Emergency Medicine, Section of EMS, described the “lift assist” call and outlined some of the demographics of the population involved. Lift assists are services provided by EMTs and paramedics when an individual calls 9-1-1 because of inability to get up, usually after a fall. If the patient declines transport to a hospital, and both responders and patient agree that there is no evidence of acute injury or illness, then the patient is lifted into bed or chair by the crew, which then returns to service.
Over that study period, it was found that roughly 5% of local EMS calls were for lift assists, and both their incidence and their proportion of total run volume were increasing. More concerning was that over half of all lift assist incidents would be followed by another EMS call for service within the ensuing 30 days. Of those repeat calls, 55% required transport, mostly for illness or for another fall, now with injury. Nearly 40% of the repeat calls were for additional lift assists, and 15% had multiple lift assists within that 30-day follow up period.
In order to improve the health and safety of this obviously vulnerable patient population while reducing the burden of the lift assist call volume, and with state funding through the Connecticut Falls Prevention Collaborative, the Branford Fire Department and the New Haven Sponsor Hospital Program instituted the following interventions in 2010: at the time of the initial lift assist, the paramedics performed a more thorough evaluation of the patients than had been customary on these calls. This was to identify occult illness or other medical condition that might be disabling the patient compared with his or her baseline functional status. The medics’ evaluation included checking orthostatic blood pressures, doing a quick mental status assessment, obtaining the patient’s list of medications and recording the name of the patient’s primary medical care provider (PCP). If abnormalities or changes were found on assessment of the patient requesting the lift assist, the medics prevailed on the patients (and families) to permit transport for further evaluation in the emergency department. If the medic agreed that the lift assist and non-transport were appropriate, then the list of medications and the name of the PCP were submitted to the medical director, along with the patient care report (PCR).
In the medical director’s office, the medications were reviewed by a pharmacist familiar with the medications and combinations that increase the risk of elderly falls. The medical director notified the participating visiting nurse association (that had a separate grant for falls prevention) so that they could contact the patient and offer a free homecare evaluation if the patient agreed. Finally, the medical director contacted the patients’ PCP’s to let them know that the patients were falling at home, were sufficiently disabled to require a fire department response to pick them up, and of any medication list concerns identified by the pharmacist.
After this protocol had been in place for 8 months, the previously reported lift assist parameters were reviewed and compared with the data from the prior 6 years. It was found that both the number of lift assist calls and the proportion of the EMS run volume attributable to lift assists had decreased by 45% and 47% respectively. Furthermore, the number of initial lift assists that had a repeat call within 30 days was decreased by 38%, and the percentage of lift assist calls for patients with a previous lift assist call was decreased by 30%.
Largely due to the positive patient outcomes associated with these simple interventions, Yale EMS received a CMS Healthcare Innovations Award to determine whether their findings could be replicated over the wider region, and whether we could demonstrate substantial healthcare cost savings for this population which is comprised almost entirely of Medicare and Medicare/Medicaid beneficiaries. The title of the proposal (and program) is based on the paramedic on the 9-1-1 lift assist call not only assessing the individual for occult illness as before, but then referring the individual into the program for the fully funded VNA visit and funded transportation by taxi or paratransit to a near-future appointment that is made to ensure a visit with the PCP.