Contra Costa Emergency Medical Services EMS System Modernization Study conducted by Fitch and Associates EMCC Workshop Literature October, 2013 A compilation of evidence‐based and best practice literature on Emergency Medical Services ADESCRIPTIVE STUDY OF THE “LIFT-ASSIST”CALL David C. Cone, MD, John Ahern, Christopher H. Lee, MD, MS, Dorothy Baker, PhD, Terrence Murphy, PhD, Sandy Bogucki, MD, PhD ABSTRACT evaluation. Key words: emergency medical services; geri- atrics; accidental falls Introduction. Responses for “lift assists” (LAs) are common in many emergency medical services (EMS) systems, and PREHOSPITAL EMERGENCY CARE 2013;17:51–56 result when a person dials 9-1-1 because of an inability to get up, is subsequently determined to be uninjured, and NTRODUCTION is not transported for further medical attention. Although I LAs often involve recurrent calls and are generally not reim- When elderly or disabled persons fall or are unable bursable, little is known of their operational effects on EMS to move from an undesirable position to a preferred systems. We hypothesized that LAs present an opportunity one, they may call 9-1-1 for assistance. Often there is for earlier treatment of subtle-onset medical conditions and no perceived injury or illness, so these individuals do injury prevention interventions in a population at high risk not want medical treatment or transport to the hospi- for falls. Objectives. To quantify LA calls in one community, describe EMS returns to the same address within 30 days tal. They simply want responders to physically help following an index LA call, and characterize utilization of them back to a bed, chair, or wheelchair. These calls EMSbyLApatients.Methods. Data from the computer- are locally known as “lift assists.” aided dispatch (CAD) system of a suburban fire-based EMS It is likely that in some percentage of cases, a lift- system were retrospectively reviewed. All LAs from 2004 assist call represents a “sentinel event” or a marker to 2009 were identified using “exit codes” transmitted by of deterioration in function of the patient.1 This could paramedics after each call. The number and nature of return be due to an unapparent medical condition such as visits to the same address within 30 days were examined. a urinary tract infection or pneumonia, or could in- Results. From 2004 through 2009, there were 1,087 LA re- dicate a new stage of gradual decline in physical or sponses (4.8% of EMS incidents) to 535 different addresses. cognitive capacity related to chronic disease, such as Two-thirds of the LA calls (726; 66.8%) were to one-third of Alzheimer’s disease or osteoarthritis. It could also her- these addresses (174 addresses; 32.5%); 563 of the return calls to the same address occurred within 30 days after the index ald a loss of (or ongoing lack of) social support and For personal use only. LA. For 214 of these return visits, it was possible to com- assistance in activities of daily living. pare patient age and sex with those associated with the ini- Anecdotally, emergency medical services (EMS) tial LA, revealing that 85% of return visits were likely for the providers report frequently returning to the same same patients. Of these, 38.5% were for another LA/refusal address in the days, weeks, or even hours following of transport, 8.2% for falls and other injuries, and 47.3% an initial lift assist, either for another lift assist, or for for medical complaints. Hospital transport was required in a more serious problem such as a fall with injury, or 55.5% of these return visits. The EMS crews averaged 21.5 a medical emergency, often resulting in transport to minutes out of service per LA call. Conclusion. Lift-assist the emergency department (ED). In the case of older calls are associated with substantial subsequent utilization patients, there is considerable expense associated with of EMS, and should trigger fall prevention and other safety a trip to the ED because these patients receive a greater interventions. Based on our data, these calls may be early in- number of diagnostic tests, remain in the ED longer, dicators of medical problems that require more aggressive 2 Prehosp Emerg Care Downloaded from informahealthcare.com by Astellas Pharma US Inc on 09/05/13 have higher ED charges, and are more likely to be admitted to acute or intensive care units.3 Perhaps the lift-assist call can be used to trigger interventions to help prevent the “next call,” thereby improving Received January 10, 2012 from the Section of EMS, Department the quality of care and reducing the use of financial of Emergency Medicine (DCC, JA, CHL, SB) and the Section of Geriatrics, Department of Internal Medicine (TM, DB), Yale resources. Screening of elders has been advocated University School of Medicine, New Haven, Connecticut. Revision by national organizations as a key component of received May 29, 2012; accepted for publication June 14, 2012. high-quality geriatric emergency care;4 perhaps such The authors report no conflicts of interest. screening should begin in the field, at the patient’s Reprints are not available. home. Since at least one vehicle and crew must respond to Address correspondence to: David C. Cone, MD, Yale Univer- each lift-assist call in order to locate and assess the sity School of Medicine, Section of Emergency Medicine, 464 patient and resolve the problem, lift assists consume Congress Avenue, Suite 260, New Haven, CT 06519. e-mail: EMS resources. In some cases, multiple vehicles and [email protected] personnel must respond to these calls. Examples in- doi: 10.3109/10903127.2012.717168 clude bariatric patients who cannot be safely lifted by 51 52 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2013 VOLUME 17 / NUMBER 1 two providers, or patients behind locked doors requir- dence, and describe other characteristics of lift-assist ing forced entry. There is generally no way for EMS calls. agencies to recover the costs associated with lift-assist calls, since with few exceptions, EMS efforts are re- Study Protocol imbursed only when patients are transported to the hospital. The CAD system database was queried for the records While there are published studies of the EMS re- of all lift-assist calls (as identified by exit code) occur- sponse to falls,5,6 including analysis of patients who ring between 2004 and 2009, inclusive. These data were are not transported, no research describing lift-assist exported to the investigators in a single Excel spread- calls, the patients involved, or the workload for the sheet (Microsoft Inc., Redmond, WA). The system be- EMS system have been reported to date. We hypoth- gan using ePCRs in July 2007; no PCRs were avail- esized that lift assists present an opportunity for ear- able for the study period prior to July 2007. However, lier treatment of subtle-onset medical conditions and dispatchers sometimes enter free-text “CAD notes” injury prevention interventions in a population at high such as “80 y/o male unable to get off floor.” The risk for falls. As the first step of a multiphase project, combination of address, age, and sex can be consid- we conducted a descriptive study of lift-assist calls in ered identifying information; therefore, relevant data one EMS jurisdiction. Specific objectives were: 1) to privacy practices were followed for the entire study quantify the frequency and demographics of lift-assist period. calls in one suburban EMS system, 2) to describe EMS The spreadsheets were scanned manually and by Ex- returns to the same address within 30 days following cel utilities for data inconsistencies, such as calls with an index lift-assist call, and 3) to grossly estimate the the lift-assist exit code that also reported transport resources used by the EMS system by these lift-assist times and destination codes indicating that the patient responses. was taken by ambulance to a hospital, or calls with multiple exit codes. In each case found to have such METHODS internal conflicts, the ePCR was reviewed to determine Study Setting and Population whether the call was indeed a lift assist, in which case the data were included. If an ePCR was unavailable, The study was conducted in Branford, Connecticut, or unexplained inconsistencies persisted after review, a shoreline town with a population of approximately that call was excluded from the study. In addition, all 29,000 and an area of about 22 square miles (57 km2). incidents that occurred at addresses of public settings For personal use only. The town has a higher population of residents over the such as businesses or parks were excluded from the age of 65 years (19.9%) than either the rest of the state study. Thus, all lift-assist calls included in this study (14.2%) or the United States as a whole (13%).7 involved responses to private residences. The town has a fire department–based EMS system that provides both basic and advanced life support Data Analysis first response and transport, and responds to approx- imately 4,000 EMS calls and 1,600 fire calls per year. The lift-assist calls for each year and for the entire The public safety answering point, including EMS dis- study interval were recorded both as total numbers patch, is maintained by the town’s police department, and as proportions of all EMS calls. Poisson regressions using the Medical Priority Dispatch System (Salt Lake with robust estimation of standard errors were used City, UT). to assess for linear trends in call volume and lift-assist Prehosp Emerg Care Downloaded from informahealthcare.com by Astellas Pharma US Inc on 09/05/13 At the conclusion of each call, in addition to com- volume over time, and the Cochrane-Armitage trend pleting electronic patient care report (ePCR) documen- test was used to assess for trends in the proportion of tation, the EMS crew verbally transmits an “exit code” the department’s call volume that consisted of lift as- to the dispatcher by radio.