The results demonstrate that patients are highly amenable to the Transport Plus intervention and overwhelmingly found it helpful. EMTs found the intervention feasible to incorporate into their workflow. The preliminary data on return ED visits and readmission confirm that this is a high-risk population. It is a reasonable hypothesis that future studies involving more rigorous methods such as a randomized controlled trial may find a causal relationship between interventions associated with transport home and readmission reduction given the significant rates of deficiency correction in both the FSA and DCA. This hypothesis would be consistent with previous findings that discharge comprehension issues and post-discharge falls are highly prevalent, that both are linked to readmission, and that patients transported home by ambulance are known to be at high risk for readmission.[3, 4, 6]
Several challenges pertaining to the feasibility of the Transport PLUS intervention were identified and addressed during this pilot study. Training was initially in-person but the program experienced high EMS staff turnover rates, leading to a need for online training. Our experience was consistent with EMS literature which has found high EMT turnover to be a national phenomenon with one longitudinal study finding a mean annual turnover rate in EMS agencies of 10.7%. This problem remains unresolved and has been further exacerbated by the global pandemic. Therefore, any training program associated with ambulance personnel must prepare for frequent turnover and be able to provide rapid training to new EMS staff.
Resource-related challenges were also faced in delivering the program. Supervisors were responsible for maintaining fidelity of the program. These supervisors were a limited resource and could only periodically observe visits. It was also envisioned that EMS dispatch would be able to determine when a patient might be eligible and prioritize dispatch of a Transport PLUS capable unit. In practice, this was challenging to implement given the numerous other responsibilities that took precedence, such as call acuity, response time, and resource management. Lastly, the checklists were paper forms that needed to be carefully handled and delivered, a problem which was avoided in further study by digitization of the checklists.
Focus group results indicated concerns related to intrusive searches regarding high-reach items in cabinets, as well as concerns from EMTs over the additional minutes spent on the scene. The former was used to inform modifications to the intervention, such as replacing the request for cabinet search with a less obtrusive question asking patients to report if they had any high-reach items of need. EMS operational data was also reviewed to address time concerns and no notable disruptions to call response were observed due to the additional time spent at the patient’s home.
Our findings were limited by a lack of a comparison group. As the intervention was funded as a demonstration project, it was offered to all qualifying patients with trained providers capable of providing the intervention. Another limitation of the study is that it was limited to patients being discharged from a single urban hospital and the results may not be generalizable to other patient populations.
We can, however, compare Transport PLUS to similar EMS-based interventions in existing literature. Infinger et al. recently reported the development of a reliable survey of environmental risk factors for elderly patients in the prehospital setting. Their content validation procedure ultimately yielded a 9-item checklist with high demonstrated interrater reliability. Notable similarities to the list deployed here in the FSA include walkway trip hazards, rugs, clutter, and adequate lighting. Notable inclusions in their tool, which were absent in our intervention, are furniture, slippery floors, and stair condition. It may be worth adjusting the Transport PLUS checklist in future iterations to accommodate these important areas of concern.
Transport PLUS is yet another step in developing the emerging field of Community Paramedicine/Mobile Integrated Healthcare (CP/MIH,) which aims to reduce emergency utilization of EMS through early recognition and intervention. A randomized control trial conducted by Agarwal et al. deployed community paramedicine using validated tools and compared utilization between buildings that received the intervention, termed CP@clinic, and those receiving usual care. Their intervention resulted in a 19% reduction in relative EMS call volume. In yet another study, CP/MIH for a Medicare Advantage population was found to save 2.4 million and result in a 2.97 million (USD) return on investment, further highlighting reduced utilization. These findings add credence to the importance of prevention and education that can be uniquely and effectively administered by EMS providers. A randomized control trial is currently underway evaluating, as primary outcomes, falls occurring in the following three months and 3-day and 30-day readmission rates for the Transport PLUS intervention.