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

Ann Intern Med. 2018 Feb 6;168(3):179-186. doi: 10.7326/M17-0969. Epub 2017 Dec 12.


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.

MeSH terms

  • Accidental Falls*
  • Aged, 80 and over
  • Assisted Living Facilities*
  • Decision Making*
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Male
  • North Carolina
  • Prospective Studies
  • Quality Improvement*
  • Transportation of Patients / standards*
  • Unnecessary Procedures