More than 40 percent of people aged 65 years or older experience one or more falls each year, often resulting in injuries [1, 2]. Consequences of falls include a reduction in physical activity and functional decline which in turn can lead to a poorer quality of life and social isolation. All these factors increase the risk of dependency and institutionalisation [3–5].
Many older people do not seek medical attention after a fall  but a significant and increasing number require paramedic attendance as a consequence of a fall. In the period July 2008 – June 2009, the Ambulance Service of New South Wales (ASNSW), Australia attended to 42,331 fallers aged 65 years and older which constitutes approximately 5.1% of all emergency ambulance responses . This proportion is similar to the 7.5% reported in an urban Emergency Medical Service system in the USA . The demand for emergency services to assist older fallers is likely to increase with population ageing.
In most countries, the current practice for ambulance service paramedics is to convey older people who fall to the hospital Emergency Department (ED) unless the person refuses or declines transport. Fallers account for almost one fifth of ED presentations by older adults [1, 9] and in the absence of physical injury, abnormal physiological parameters or change in usual functional status, it could be argued that routine conveyance by ambulance to the ED is not the most effective or efficient use of resources. Furthermore, ED personnel face significant time constraints and therefore focus on addressing the immediate consequences of a fall which leaves little scope for considering a person’s risk of future falls and the provision of appropriate prevention strategies.
Currently the ASNSW has a 25% non-conveyance rate for older fallers which is similar to that reported by ambulance services in other countries [34% in the United Kingdom (UK) , 40% in the United States of America . A number of articles have described non-conveyance to be due to the treatment on scene being “sufficient” or the person requiring “lift assist only” [10–14]. What happens to these older fallers subsequent to the acute event is unclear, although a study from the UK highlighted substantial unplanned healthcare contact within two weeks, with 47% of these people calling the ambulance service again and 24% presenting to an Emergency Department . An independent clinical review of these cases demonstrated that paramedics were almost certainly making correct decisions about conveyance at the time of assessment, but functional declines as a result of the fall frequently occurred 1–2 days later . A recently completed study in New South Wales, Australia has also highlighted the high-risk nature of non-conveyed older fallers, demonstrating that within a 6 month follow-up period 58% of people fell again, 40% sustained a fall-related injury and 27% called an ambulance again due to a fall .
Rapid referral and timely access to alternate services to ED was identified as a gap in service provision in the UK based study and there is now evidence that an individualised multifactorial fall prevention program provided by community falls teams has significant benefits for non-conveyed older fallers . This approach to intervention is consistent with the UK clinical fall guidelines  and included strength and balance training, assessment and modification of home hazards and medication review. The intervention group experienced significantly fewer falls (incidence rate ratio 0.45, 95% confidence interval (CI) 0.35 to 0.58) and the time to first subsequent fall was also significantly longer (median difference 145 days, HR 0.32, 95% CI 0.23 to 0.44). Furthermore, the intervention group made significantly fewer emergency calls for ambulance services within the follow-up period, compared to the control group participants who received standard emergency care (IRR 0.60, 95% CI 0.40 to 0.92).
Older fallers who require ambulance care in NSW appear to be comparable to their counterparts in the UK regarding level of fall risk, so it is likely that non-conveyed older fallers living in NSW also have the potential to benefit from timely access to fall risk assessment and intervention. The aim of this randomised controlled trial is to evaluate the effect of a rapid, timely and tailored intervention in older people who are not conveyed to a hospital ED following a fall.
The impact of the project will be evaluated over 12 months using a) rate of falls and fall-related injury, b) use of Ambulance resources, c) use of ED and in-patient services, d) incremental costs (or cost savings) of implementing this targeted approach, e) impact on the health care system (i.e. post acute care services (PACS) or Home Medication Review (HMR) services, etc.), f) uptake and adherence to recommendations and g) the benefits beyond fall prevention i.e. improved level of function and better quality of life. Importantly, rather than setting up a new service, our intervention will involve expanding existing services where possible, such as PACS which are capable of rapid responses to the urgent needs of community dwelling older people [19, 20].