26 Mar The Lift Assist Phenomena: An Innovative Solution
In Canada, it is estimated that the proportion of older adults aged 65 years and over will increase from 15.3% in 2013 to approximately 22.9% in 2030. With an increasing number of older adults, the pressure on the health care system will increase consequently placing added demand on paramedic services — especially through the growing number of non-emergent calls.
Forty percent of seniors are expected to fall at least once annually, and 21% of fallers attended to by paramedics visit the emergency room within two weeks of their fall. The risk of falls presents a serious cause of complications, mortality, and strain on the healthcare system. In Middlesex-London, falls are the second highest source of 9-1-1 repeat callers. However, some of these falls result in a growing non-emergent call type referred to as a “Lift Assist.”
A Lift Assist is defined as an event when a patient calls paramedic services and requests assistance to get up or mobilize, where the patient receives no treatment on scene, and refuses transport to the emergency department for further medical attention. Data has revealed that these are not uncommon calls, often involve recurrent callers and are not reimbursable. Thus, there is a significant amount of paramedic resources directed toward these patients.
International literature on the subject of Lift Assist calls and their effect on paramedic services is abundant. Cone and colleagues found that Lift Assists are becoming a burden on paramedic services within the United States. In Australia, Mikolaizak and colleagues determined that non-transportation rates are increasing in frequency. However, Lift Assists are under-recognized in North America and little research has gone into solving the problem. Coincidentally, some paramedic services within Ontario are experiencing a dramatic increase in this phenomena.
There are many factors that may contribute to an increased number of Lift Assist calls amongst older adults, such as falls, chronic diseases, and medication use. Falls can be classified as either mechanical, due to extrinsic factors (e.g. tripping over a rug), or non-mechanical, due to intrinsic factors (e.g. syncope or hypotension). The individual’s health status is of concern regarding risk of falling, as an increasing number of older adults suffer from chronic diseases and multi-morbidity. Chronic diseases are frequently managed by numerous medications, and thus the fall may be a result of side effects or interactions between medications. In addition to falls, there are other circumstances in which an individual might require a Lift Assist, such as when transferring from one location or position to another (e.g., wheelchair to bed), or after a slide (e.g., off the bed or chair).
Falls resulting in Lift Assists are not always a benign occurrence; they can be indicative of frailty and health decline in older adults. Without proper assessment there is significant health risk for these patients. However, current paramedic practices do not determine the underlying causes of falls and result in less vigilant documentation of vital signs. A study conducted by Leggatt et al., (2013) found that 21% of Lift Assist patients in London presented to the emergency department in the 14 days subsequent to the fall with a 1.1% mortality rate. Properly attending to Lift Assists is crucial for early detection of underlying health concerns and taking proactive measures to preserve a patient’s health.
Over the past two years, Western University collaborated with the Middlesex-London Paramedic Service’s (MLPS) Community Paramedicine (CP) program to study the impact of Lift Assists in the London community and propose a novel solution.
In 2017, MLPS responded to 1,871 Lift Assist calls — a notable increase from 2016 (1,767) and 2015 (1,612). These calls averaged 48 minutes from “Call Received” to “Depart Scene” time which accounted for over 62 days’ worth of paramedic services use, and operational cost of approximately $300,000. More interesting, the majority of the Lift Assist calls were generated by only 279 patients.
By 2030, MLPS has projected that the service will respond to an anticipated 4,000 Lift Assists, accounting for approximately 124 days’ worth of paramedic service use based on the population growth and percentage increase in additional Lift Assists from the last three years’ worth of data.
One component of the analysis was interviewing Lift Assist patients regarding their personal experiences. A common theme that emerged was feelings of guilt for calling 9-1-1 after a fall, but having no-one else to call. Currently the only service available to older adults who require a Lift Assist in Middlesex-London is to call 9-1-1 and wait for paramedic services. During the course of this research, the team also encountered an interesting policy effect worth noting: the implementation of “no lift policies” or “safe handling techniques” within community support organizations. These organizations include long term care facilities, retirement homes and home care services. No lift policies are intended to ensure staff safety by limiting patient lifting in work environments. Community support organizations often possess the appropriate resources to conduct safe lifts, yet as a result of no lift policies, paramedics are being called to patients receiving homecare or within long term care facilities, which is an undesirable use of paramedic resources.
Middlesex-London Paramedic Service continues to see an increase in call volume, a rise from 74,224 in 2013 to 86,091 in 2017. The majority of MLPS calls (65%) are dispatched as emergency calls (highest priority); Lift Assist calls are typically dispatched as lower priority calls and are therefore superseded by any emergency call. Unfortunately, this means that patients requiring a Lift Assist may wait upwards of one hour in some cases for paramedic assistance. As the number of calls continues to increase, so does the risk of adverse health outcomes linked to significant wait times for Lift Assist callers. Additionally, outcomes in Lift Assists may be further unintentionally negatively impacted by the newly proposed Ambulance Act amendments. In the newly proposed dispatch system, Lift Assists will remain classified as non-emergent calls, resulting in extended wait times, potentially spanning several hours.
In an effort to better address this phenomena, the research team proposed an innovative solution to position an existing Community Paramedicine program, Community Paramedicine Remote Patient Monitoring (CPRPM), to also support Lift Assists. CPRPM is an Ontario-wide initiative. Through partnership with Future Health Services and Canada Health Infoway, community paramedics are promoting longevity in the home for patients with chronic illness, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM). Patients with these chronic conditions are high users of the healthcare system and require long-term attention and care, which is not traditionally offered. The CPRPM is an innovative program that addresses this opportunity to improve care. It is designed to improve quality of life for patients with chronic illnesses by providing the monitoring of biometric data, access to community paramedic expertise, self-management education, and coordinated care among healthcare providers. The program delivers a higher quality of coordinated care to keep patients out of the hospital and healthier for longer.
The CPRPM program has shown great success during its first year of demonstration resulting in a significant reduction in unnecessary 9-1-1 calls, and non-essential emergency department presentations. Additionally, the vast majority of enrolled patients reported improved quality of life, self-management, and gained a greater understanding on their chronic condition. These statistics demonstrate that self-management education has enabled targeted patients to take control of their illness and reduced reliance on front-line paramedic services.
Similar to patients with chronic conditions, vulnerable patients such as those requiring a Lift Assist may also benefit from enhanced patient assessments and improved integration among other health care providers as supplied by the current CPRPM program. Specially trained paramedics can offer early recognition of health decline and provide proactive interventions to address developing health complications.
By expanding the existing CPRPM program to capture a broader population of vulnerable patients, CPRPM offers an innovative solution to help provide quality care. In the case of Lift Assist, patient advocacy and integrated communication through Circle of Care will be especially beneficial. In current practice, Lift Assists go unreported to other healthcare professions such that no one is aware that they are even occurring. By using this model not only will patient’s that require Lift Assists be recognized, but they will also be served by specially trained paramedics who understand the complexity of Lift Assists and have the qualified skillset to identify underlying reasons for falls.
By adapting paramedic response to Lift Assists through expansion of the existing CPRPM program, MLPS aims to directly improve patient care through personalized interactions and continued monitoring for this population. Patients will be advocated for within the health care system to enhance integration and collaboration promoting early recognition of developing health-related complications, provide comprehensive assessments and interventions to proactively address underlying issues to reduce future occurrences, resulting in reallocation of frontline paramedic resources and reduce health care spending.