Journal Watch: Community-Level Fall Prevention

Reviewed This Month

Assessment of Fall-Related Emergency Medical Service Calls and Transports After a Community-Level Fall-Prevention Initiative

Authors: Quatman-Yates CC, Wisner D, Weade M, et al.    

Published in: Prehosp Emerg Care, 2021 May 27; 1–12. 

In this month’s column we review a quality improvement study that described the development, evolution, and outcomes for a community-level fall-prevention initiative that utilized community paramedics. 

As any field provider is likely aware, 9-1-1 calls for falls have been increasing, and while some are limited to lift assists, falls can be particularly harmful for older adults. Even when care is limited to a lift assist, that EMS resource may be diverted from a higher-acuity patient. Evidence has suggested fall-related EMS calls present opportunities for prevention efforts.  

The Community-Centered Fall Intervention Team (Community-FIT) described in this study employed structured plans/protocols for care (clinical pathways) and a learning health system that used “scientific evidence, informatics, and patient-clinician partnerships to support continuous and rapid improvement in the effectiveness and efficiency of care.” The authors hypothesized that “by systematically facilitating fall prevention directly in the homes of vulnerable individuals, implementation of Community-FIT would result in sustained decreases in [the] incidence of falls requiring EMS involvement and the proportion of EMS fall-related calls resulting in transport to a hospital in the target community.” 

The initiative took place from 2016–2019 and had the goal of reducing the number of fall-related 9-1-1 calls as well as fall-related transports per month by at least 20% by 2019. The target community was a Midwestern suburban city served by fire-based EMS. There were two stations in the community, staffed by approximately 50 firefighter/paramedics. About 17% of the community was 65 or older. 

The EPIS framework was used to design and evaluate Community-FIT. EPIS has four phases: exploration, preparation, implementation, and sustainment. The exploration phase was a 12-month period (Sept. 2016–Aug. 2017) that did not include active community paramedics. Two staff firefighter/paramedics began community paramedic training during this phase. Their training focused on learning new skills for engaging with vulnerable community members and how to connect them to local resources. This phase was also used to establish baseline data for comparison following the implementation of Community-FIT. 

During the preparation phase (Sept. 2017–May 2018), community paramedics began engaging in general health promotion and fall-prevention activities such as home checks and care coordination assistance for frequent EMS utilizers. During this phase community paramedics also began engaging with academic partners and other groups on establishment of the Community-FIT collaborative, which was a “formal learning collaborative open to individuals from a variety of disciplines and organizations interested in working together and learning from each other to radically reduce the burden of falls in their communities.” 

The implementation phase (June 2018–Sept. 2018) was a short period where community paramedics and their academic partners developed and refined the clinical pathway and learning health system to systematically identify, intervene with, and monitor individuals at high risk for falls. Additional community paramedics were also trained. 

During the sustainment phase (Sept. 2018–Aug. 2019), community paramedics began receiving referrals from providers on the scenes of 9-1-1 calls. These referrals identified generally frail or vulnerable patients who could benefit from follow-up screening and potentially interventions. The community paramedic team also began sharing data with city and EMS agency leaders during this phase. 

Results

For the pre/post analysis, data from the exploratory phase was compared to data from the sustainment phase. The analysis evaluated relative risk reduction, a population-adjusted comparison in EMS lift assists, fall calls, and fall-related transports. The authors defined fall-related calls as the sum of lift assists where no additional care was needed and fall calls where the patient was potentially injured. 

There were 892 fall-related calls during the study period, representing 8.7% of the total 9-1-1 calls in this community. After the exploration phase, the community paramedic team completed 25 new visits in 2017. In 2018 there were 42 new visits and 194 follow-up visits. In 2019 there were 109 new visits and 398 follow-up visits. 

When directly comparing the exploration phase to the sustainment phase, the percentage of fall-related calls to total EMS calls decreased from 10.8% to 8.5%. There was a statistically significant reduction from 135 during the exploration phase to 46 in the sustainment phase in calls where the patient experienced a fall. This coincided with a relative risk reduction of 0.66 (95% CI, 0.53–0.76) and a population-adjusted reduction of 66.4% from baseline. Fall-related calls resulting in transport also decreased, from 96 during the exploration phase to 36 during the sustainment phase. When compared to baseline this represented a relative risk reduction of 0.49 (95% CI, 0.27–0.64) and a population-adjusted reduction of 63.8% in the number of fall-related calls resulting in transport. 

Interestingly, there was a minimal reduction in lift assist calls, with 213 in the exploration phase and 208 in the sustainment period. The authors note this finding may be due to lift assists largely representing first-time callers who could not yet have benefited from the community paramedic program efforts, but that such calls may be an early indicator of decline and represent an opportunity for Community-FIT to prevent future injury and EMS use. 

This was an interesting study that described a successful community paramedic fall-reduction program. There was a lot of collaboration, evaluation, reevaluation, and modifications that took place during this quality improvement study, far too much to fully describe here. However, this is a wonderful example of how involving EMS, academics, and other decision-makers in a collaborative initiative can lead to real improvements in injury prevention.  

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and serves on the board of advisors of the Prehospital Care Research Forum at UCLA.