Improving Decisions About Transport to the Emergency Department for Assisted Living Residents Who Fall.

Background: Residents of assisted living facilities who fall may not be seriously ill or injured, but policies often require immediate transport to an emergency department regardless of the patient's condition. Objective: To determine whether unnecessary transport can be avoided. Design: Prospective cohort study. Setting: One large county with a single system of emergency medical services. Participants: Convenience sample of residents in 22 assisted living facilities served by 1 group of primary care physicians. Intervention: Paramedics providing emergency medical services followed a protocol that included consulting with a physician by telephone. Measurements: The number of transports after a fall and the number of time-sensitive conditions in nontransported patients. Results: Of the 1473 eligible residents, 953 consented to participate in the study (mean age, 86 years; 76% female) and 359 had 840 falls in 43 months. The protocol recommended nontransport after 553 falls. Eleven of these patients had a time-sensitive condition. At least 7 of them received appropriate care: 4 requested and received transport despite the protocol recommendation, and 3 had minor injuries that were successfully managed on site. Three additional patients had fractures that were diagnosed by outpatient radiography. The final patient developed vomiting and diarrhea, started palliative care, and died 60 hours after the fall. At least 549 of the 553 patients (99.3% [95% CI, 98.2% to 99.8%]) with a protocol recommendation for nontransport received appropriate care. Limitation: The resources required for this program will preclude use in some locations. Conclusion: Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall. Primary Funding Source: None.

Prevalence and Medication Management of Dementia by a Medical Practice Providing Onsite Care in Assisted Living.

BACKGROUND/OBJECTIVES: Assisted living (AL) is an important provider of long-term residential care to people with dementia, but little research has used clinician's records-arguably the most reliable and valid source of medically related information. This article uses clinician records to examine the prevalence of dementia, treatment with dementia-specific medications and antipsychotic medications, and how prescribing varies by assisted living residence (ALR) and resident characteristics. DESIGN: Analysis of medical records from a long-term care medical practice. SETTING: Ninety ALRs that had onsite care provided to some or all of their residents by one group practice that specializes in home-based primary care. PARTICIPANTS: Records for 3175 AL residents. MEASUREMENTS: Thirty-six variables related to the ALR, resident demographics, and medical conditions and pharmaceutical treatment. RESULTS: Seventy-six percent of patients had a documented diagnosis of dementia, 41% who were treated with a medication for dementia other than an antipsychotic, and 37% who received an antipsychotic. Dementia medications were more likely to be prescribed to patients with dementia living in ALRs that had a memory care unit, and also to patients who were not Medicaid beneficiaries. Antipsychotic prescribing was similarly more common for residents with dementia living in ALRs that had memory care units. CONCLUSION: The 76% prevalence rate of dementia in ALRs larger than 25 beds may be a more accurate reflection of the prevalence of dementia reported elsewhere, because it is based on diagnoses documented by patients' primary care clinicians. The reporting of treatment rates for dementia medications and antipsychotics, and how they vary in relation to ALR and resident characteristics, is meant to generate discussion about "best practices" and standards of care in the medication management of dementia and its behavioral comorbidities-topics that have received scant attention to date other than widespread attention to the need to reduce antipsychotic prescribing.

Retrospective Validation of a Protocol to Limit Unnecessary Transport of Assisted-living Residents Who Fall.

Abstract Objective. Emergency medical services (EMS) often transports patients who suffer simple falls in assisted-living facilities (ALFs). An EMS "falls protocol" could avoid unnecessary transport for many of these patients, while ensuring that patients with time-sensitive conditions are transported. Our objective was to retrospectively validate an EMS protocol to assist decision making regarding the transport of ALF patients with simple falls. Methods. We conducted a retrospective cohort study of patients transported to the emergency department from July 2010 to June 2011 for a chief complaint of "fall" within a subset of ALFs served by a specific primary care group in our urban EMS system (population 900,000). The primary outcome, "time-sensitive intervention" (TSI), was met by patients who had wound repair or fracture, admission to the ICU, OR, or cardiac cath lab, death during hospitalization, or readmission within 48 hours. EMS and primary care physicians developed an EMS protocol, a priori and by consensus, to require transport for patients needing TSI. The protocol utilizes screening criteria, including history and exam findings, to recommend transport versus nontransport with close primary care follow-up. The EMS protocol was retrospectively applied to determine which patients required transport. Protocol performance was estimated using sensitivity, specificity, and negative predictive value (NPV). Results. Of 653 patients transported across 30 facilities, 644 had sufficient data. Of these, 197 (31%) met the primary outcome. Most patients who required TSI had fracture (73) or wound repair (92). The EMS protocol identified 190 patients requiring TSI, for a sensitivity of 96% (95% CI: 93-98%), specificity of 54% (95% CI: 50-59%), and NPV of 97% (95% CI: 94-99%). Of 7 patients with false negatives, 3 were readmitted (and redischarged) after another fall, 3 sustained hip fractures that were surgically repaired, and 1 had a lumbar compression fracture and was discharged. Conclusions. In this cohort, two-thirds of patients with falls in ALFs did not require TSI. An EMS protocol may have sufficient sensitivity to safely allow for nontransport of these patients with falls in ALFs. Prospective validation of the protocol is necessary to test this hypothesis.