Support and Assessment for Fall Emergency Referrals (SAFER) 2: a cluster randomised trial and systematic review of clinical effectiveness and cost-effectiveness of new protocols for emergency ambulance paramedics to assess older people following a fall with referral to community-based care when appropriate

Abstract

Background: Emergency calls are frequently made to ambulance services for older people who have fallen, but ambulance crews often leave patients at the scene without any ongoing care. We evaluated a new clinical protocol which allowed paramedics to assess older people who had fallen and, if appropriate, refer them to community-based falls services.\ud Objectives: To compare outcomes, processes and costs of care between intervention and control groups; and to understand factors which facilitate or hinder use.\ud Design: Cluster randomised controlled trial.\ud Participants: Participating paramedics at three ambulance services in England and Wales were based at stations randomised to intervention or control arms. Participants were aged 65 years and over, attended by a study paramedic for a fall-related emergency service call, and resident in the trial catchment areas.\ud Interventions: Intervention paramedics received a clinical protocol with referral pathway, training and support to change practice. Control paramedics continued practice as normal.\ud Outcomes: The primary outcome comprised subsequent emergency health-care contacts (emergency admissions, emergency department attendances, emergency service calls) or death at 1 month and 6 months. Secondary outcomes included pathway of care, ambulance service operational indicators, self-reported outcomes and costs of care. Those assessing outcomes remained blinded to group allocation.\ud Results: Across sites, 3073 eligible patients attended by 105 paramedics from 14 ambulance stations were randomly allocated to the intervention group, and 2841 eligible patients attended by 110 paramedics from 11 stations were randomly allocated to the control group. After excluding dissenting and unmatched patients, 2391 intervention group patients and 2264 control group patients were included in primary outcome analyses. We did not find an effect on our overall primary outcome at 1 month or 6 months. However, further emergency service calls were reduced at both 1 month and 6 months; a smaller proportion of patients had made further emergency service calls at 1 month (18.5% vs. 21.8%) and the rate per patient-day at risk at 6 months was lower in the intervention group (0.013 vs. 0.017). Rate of conveyance to emergency department at index incident was similar between groups. Eight per cent of trial eligible patients in the intervention arm were referred to falls services by attending paramedics, compared with 1% in the control arm. The proportion of patients left at scene without further care was lower in the intervention group than in the control group (22.6% vs. 30.3%). We found no differences in duration of episode of care or job cycle. No adverse events were reported. Mean cost of the intervention was £17.30 per patient. There were no significant differences in mean resource utilisation, utilities at 1 month or 6 months or quality-adjusted life-years. In total, 58 patients, 25 paramedics and 31 stakeholders participated in focus groups or interviews. Patients were very satisfied ...

A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?

“…In 2014 Snooks et al reported no differences in the total cost of subsequent healthcare utilisation (MD £247; 95% CI −£247 to £741) among diverted and standard care patients 13. In a follow-up study in 2017, Snooks et al reported similar total costs of healthcare resource use at 1 month (adjusted mean change  £190.24; 95% CI −£13.83 to £394.31) or 6 months (adjusted mean change £24.20; 95% CI −£468.01 to £516.40) between elderly patients diverted to a fall service compared with patients transported to the ED 12. Dixon et al reported a decreased cost associated with reduced ED attendance (MD −£32; 95% CI −£38 to –£26) among diverted patients; however, no significant differences were found with regard to the total costs associated with same day or subsequent healthcare utilisation (MD −£140; 95% CI −£694 to £415), which included same-day and subsequent ED presentations and inpatient costs 14.…”

Paramedics’ perceptions of the care they provide to people who self-harm: A qualitative study using evolved grounded theory methodology

“…Heightened factors were those which might be found in relation to a range of presentations but were likely to be particularly prevalent and/or challenging in relation to SH. The struggles reported by paramedics with accessing appropriate care pathways (including care from GPs and Crisis Teams) which might provide a safe and effective alternative to conveyance to hospital, can also be found in relation to other patient presentations, such as falls [ 45 ] and severe hypoglycaemia [ 46 ].…”

Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study

“…Around 10 days later, we followed normal research consent processes when patients were visited by a research nurse who discussed the study and provided written materials. Research ethics committees consider that this approach is less stressful and gives more time for potential participants to consider taking part in research 54–56. Gaining consent from patients to participate in prehospital research must recognise the cognitive effect of emergency care 57.…”