Older Adult Falls Seen by Emergency Medical Service Providers: A Prevention Opportunity

Identifying opportunities for community EMS fall prevention

BACKGROUND

Falls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions.

MATERIALS AND METHODS

We linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall.

RESULTS

Of 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p < 0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p < 0.001; 10% vs. 6% enrolled in Medicaid, p < 0.001) compared to those without a prior EMS encounter.

CONCLUSIONS

A significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.

"Mind the gap": An exploratory qualitative study of paramedics' experiences attending older adults who fall in Western Australia

PURPOSE

To explore paramedics' experiences and perspectives about attending and managing older adults who had fallen.

PROCEDURES

This qualitative, exploratory study used a purposive sample of paramedics in Western Australia. Participants had at least one year of clinical experience. Semi-structured interviews were undertaken. Data were analysed via an inductive thematic approach.

FINDINGS

Fourteen paramedics were interviewed (Median age: 38 years, n = 5 females). The main theme identified that experiences were positive when attending patients with high-acuity medical problems or injuries following falls because binary decision-making (transport vs non-transport) was appropriate. Themes highlighted that decision-making for low-acuity falls attendances was a complex balance between 1) patient context, 2) risk management, 3) paramedic reactions, and 4) the lack of alternate referral pathways available. Experiences could be stressful and frustrating when attending falls call-outs for older adults with no injuries or medical problems. Participants concurred that when transport to hospital was not required there were no available, alternative pathways to refer onwards for appropriate health or social care.

CONCLUSION

Attending low-acuity call-outs for falls was often frustrating and required complex decision-making, with gaps in services identified. Further exploration of alternative referral pathways for health care for pre-hospital management of adults who fall is required.

Community emergency medical services approaches to fall prevention: a systematic review

BACKGROUND

Falls are a leading cause of morbidity and mortality among older adults in the USA. Current approaches to fall prevention often rely on referral by primary care providers or enrolment during inpatient admissions. Community emergency medical services (CEMS) present a unique opportunity to rapidly identify older adults at risk for falls and provide fall prevention interventions in the home. In this systematic review, we seek to assess the efficacy and qualitative factors determining success of these programs.

METHODS

Studies reporting the outcomes of fall prevention interventions delivered by EMS were identified by searching the electronic databases PubMed, Embase, Web of Science Core Collection, CINAHL and the Cochrane Central Register of Controlled Trials through 11 July 2023.

RESULTS

35 studies including randomised and non-randomised experimental trials, systematic reviews and qualitative research primarily from Western Europe, the USA, Australia and Canada were included in our analysis. Current fall prevention efforts focus heavily on postfall referral of at-risk community members. CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes.

CONCLUSIONS

CEMS programmes provide an opportunity for direct, proactive fall prevention on the individual level. Addressing barriers to implementation in the context of current emergency medical systems in the USA is the next step toward widespread implementation of these novel fall prevention interventions.

Exploring the Effectiveness of Emergency Medical Services Becoming Active in Fall Prevention: A Literature Review

Falls, particularly among the elderly, are a prevalent and growing healthcare issue in the United States. Individuals who experience falls face heightened morbidity and mortality risks, along with substantial expenses associated with managing any resulting injuries. First responders frequently respond to 911 calls related to falls, with a significant portion of these cases not resulting in hospital or healthcare facility transfers. As such, many fall victims receive treatment without any preventive measures being implemented. The purpose of this review is to explore the current studies that examine whether Emergency Medical Service personnel can effectively act in fall prevention. While earlier studies present conflicting findings, recent research indicates the potential for preventive strategies that go beyond mere referrals.

An Emergency Medical Technician Administered Falls-Assessment Protocol to Safely Identify Elderly Adults with Non-Urgent Conditions that may Avoid Transport to Emergency Department

Background

Approximately two-thirds of patients transported to emergency departments (ED) for a fall are discharged from the ED without urgent treatment. This pilot study tests the feasibility of implementing a pre-hospital falls-assessment protocol performed by emergency medical technicians (EMTs) to determine whether a patient who fell needs an ED assessment or could be referred safely to a community resource.

Methods

The protocol was administered by trained EMTs to adults aged ≥ 65 after a fall between October 2019 and March 2020 in Sherbrooke (QC). All patients were transported to ED regardless of protocol outcome (transport recommended/not recommended). The objective was to assess if EMTs could complete the protocol and make the appropriate decision concerning the transport to ED. Secondary objectives aimed to assess the accuracy in identifying patients who do not require transport, and to measure the impact on avoidable ambulance transports.

Results

A total of 125 EMTs interventions were carried out: 17 patients were in the transport not recommended group, representing 14% of transport to hospital for falls-related EMTs calls that could be possibly avoided. Of these, 110 were transported to ED. Mean duration of on-site EMTs interventions was of 31 minutes. Forty-seven patients were admitted, mostly for infections and fractures, including four in the transport not recommended group.

Conclusions

This study showed that EMTs can administer a falls-assessment protocol aimed at identifying patients that need an ED evaluation. Results permitted to amend the protocol before the second phase of the project evaluating the safety of the protocol.

Timing of emergency medical services activations for falls

Objective

Falls are a major challenge to public health, particularly among older adults. Understanding factors that influence fall risk is pivotal in the prevention of falls and fall-related injuries. This study evaluated the timing of emergency medical service (EMS) activations for falls and transport patterns for adults age ≥65.

Methods

A patient care report system at a single fire-based emergency medical service agency in a suburban, Midwest city was retrospectively reviewed. Type of call (lift assist/fall), time of injury (time, day, and month), and demographics (sex, age) were collected for residents age ≥65 who activated 9-1-1 for a lift assist or fall.

Results

1169 calls met inclusion criteria. Mornings and afternoons were the time of day associated with falls (33 % and 36 % of EMS activations, respectively, vs. 21 % and 10 % for evenings and nights, respectively; p = 0.002) while day of the week and month were not associated with falls or lift assists. More males requested lift assists than females (256 vs. 238) and more females called for falls than males (408 vs. 267; p < 0.001). Falls were more likely to be associated with transport to the hospital than lift assists (78% vs. 7 %). Female sex was associated with increased risk for transport to the hospital (60 % of females vs. 40 % of males; p < 0.001).

Conclusions

Mornings and afternoons were associated with increased risk for falls and sex (female) with increased risk for transport to the hospital.

Emergency Medical Service Attendances for Adults with Repeat Falls in Western Australia: A State-Wide Retrospective Cohort Study

OBJECTIVES

The risk of falls increases with age and often requires an emergency medical service (EMS) response. We compared the characteristics of patients attended by EMS in response to repeat falls within 30 days and 12 months of their first EMS-attended fall; and explored the number of days between the index fall and the subsequent fall(s).

METHODS

This retrospective cohort study included all adults (> =18 years of age) who experienced their first EMS-attended fall between 1 January 2016 and 31 December 2020, followed up until 31 December 2021. Patients who experienced > =1 subsequent fall, following their first recorded fall, were defined as experiencing repeat falls. Multivariable logistic regression was used to identify the factors associated with repeat falls; and Kaplan-Meier analysis was used to estimate the time (in days) between consecutive EMS-attended falls.

RESULTS

A total of 128,588 EMS-attended fall-related incidents occurred involving 77,087 individual patients. Most patients, 54,554 (71%) were attended only once for a fall-related incident (30,280 females; median age 73 years, inter-quartile range (IQR): 55-84). A total of 22,533 (29%) patients experienced repeat EMS-attended falls (13,248 females; median age 83 years, IQR: 74-89, at first call). These 22,533 patients accounted for 58% (74,034 attendances) of all EMS-attendances to fall-related incidents. Time between EMS-attended falls decreased significantly the more falls a patient sustained. Among the 22,533 patients who experienced repeat falls, 13,363 (59%) of repeat falls occurred within 12 months: 3,103 (14%) of patients sustained their second fall within 30 days of their index fall, and 10,260 (46%) between 31 days to 12 months. Patients who were transported to the hospital, via any urgency, at their first EMS-attended fall, had a reduced odds of sustaining a second EMS-attended fall within both 30 days and 31 days to 12 months, compared to non-transported patients.

CONCLUSION

Nearly 30% of all patients attended by EMS for a fall, sustained repeat falls, which collectively accounted for nearly 60% of all EMS-attendances to fall-related incidents. Further exploration of the role EMS clinicians play in identifying and referring patients who sustain repeat falls into alternative pathways is needed.

Integrating Fall Prevention Strategies into EMS Services to Reduce Falls and Associated Healthcare Costs for Older Adults

Purpose

The purpose of this study is to detail the implementation of fall prevention initiatives through emergency medical services (EMS) and associated outcomes.

Methods

Paramedics with MedStar Mobile Healthcare utilized the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention model to screen and direct intervention through 9-1-1 emergency response, High Utilization Group (HUG), and 30-day Hospital Readmission Avoidance (HRA) programs. Outcomes from 9-1-1 calls measured the number of older adults screened for falls and identified risk factors. The HUG and HRA programs measured change in quality of life with EuroQol-5D, referral service utilization, falls, emergent healthcare utilization, and hospital readmission data. Analysis included costs associated with reduced healthcare usage.

Results

Emergency paramedics provided fall risk screening for 50.5% (n=45,090) of adults aged 65 and older and 59.3% were at risk of falls, with 48.1% taking medications known to increase the risk of falls. Services provided through the HUG and HRA programs, along with additional needed referral services, resulted in a 37.2% reduction in fall-related 9-1-1 calls and a 29.5% increase in overall health status related to quality of life. Analysis of the HUG program revealed potential savings of over $1 million with a per-patient enrolled savings of $19,053. The HRA program demonstrated a 16.4% hospital readmission rate, in comparison to a regional average of 30.2%, and a cost-savings of $4.95 million or $15,618 per enrolled patient.

Conclusion

Implementation of the STEADI model into EMS services provides an effective and cost-saving model for addressing fall prevention for older adults, provides meaningful and impactful improvement for older adults, and could serve as a model for other EMS programs.

Epidemiology of ambulance-attended adults who fell in Western Australia 2015 - 2021: An increasing incidence in an ageing population

BACKGROUND

Emergency Medical Services (EMS) are attending an increasing number of adults who fall. This study aimed to describe the incidence, patient characteristics, treatments and disposition of ambulance attended patients who fell in Western Australia (WA).

METHODS

An ordinal logistic regression (using STATA) was conducted in this retrospective cohort study, analysing predictors of lower compared to higher transport urgency levels. Participants were adults ( ≥ 18 years) who fell and required ambulance attendance in WA between 1st January 2015 - 31st December 2021.

RESULTS

A total of 188,720 patients (female = 107,811, 57 %) were attended by ambulances after falls, (median age = 80 years [IQR 67-87]). The age-standardized incidence rate of ambulance attended falls increased from 115 cases/100,000 person-years to 161 cases/100,000 person-years between 2015 and 2021. A total of 89,140 (47 %) patients had an injury recorded by paramedics, most often lacerations or suspected fractures. The electronic patient care record showed, 50,044 (26.5 %) patients received medication and 30,954 (16.4 %) patients received other intervention, e.g., ECG. A total of 148,050 (78 %) patients were transported to hospital with the following urgency levels: 2,371 (2 %) via urgency one; 27,882 (19 %) via urgency two, 93,447 (63 %) via urgency three and 22,584 (15 %) via urgency four and five ( < 1 % unknown urgency). Positive predictors of lower level transport urgency to hospital included being female and older than 65 years of age.

CONCLUSION

Older, female patients had higher odds of being transported via a lower urgency, with 50 % of this cohort transported via urgency three. While 19 % of patients were attended via a Priority one, only 1 % were transported to hospital via urgency one. The incidence rate of falls requiring ambulance attendance has increased over time, increasing the demand placed on EMS annually.

Down with falls! Paramedicine scope regarding falls amongst older adults in rural and remote communities: A scoping review

INTRODUCTION

Australian rural and remote areas are faced with the double burden of an ageing population paired with inequitable access to health resources due to the paradigm of major city centred health care. This complicates fall management within this space. Paramedics are a registered health profession, which provides mobile, equitable health care. However, this resource is not being effectively utilised in rural and remote areas where primary care access barriers may cause patient needs to go unmet.

OBJECTIVE

To describe the existing literature and describe the international scope of current paramedicine practice in the out-of-hospital management of falls amongst older adults in rural and remote settings.

DESIGN

Joanna Briggs Institute scoping review methodology was employed. CINAHL (EBSCO), MEDLINE (Ovid), EMBASE (Ovid), SCOPUS (Elsevier), Google Scholar and These Global were searched and Australian, New Zealand and the UK ambulance service guidelines were sought.

FINDINGS

Two records met inclusion criteria. Currently, rural and remote paramedic fall management involves preventative health promotion through patient education, population-based screening and referrals.

DISCUSSION

The use of paramedics to screen at-risk populations and refer is vital, as many rural adults had screened positive to fall risks and other unmet needs. There is poor recollection of physically printed education material and low acceptance of further in-home assessments following paramedic departure.

CONCLUSION

This scoping review has highlighted a significant knowledge gap on this topic. Further research is needed to effectively utilise paramedicine within areas where access to primary care is not possible to achieve downstream, risk reducing care in the home.

[Pre-emptive emergency service-Preventive missions and promotion of health literacy at the intersections with emergency medical services]

In the Emergency Medical Service Acts of the Federal States, the statements in these Acts have so far essentially been limited to the implementation of measures to maintain the health of emergency patients and to transport them to a suitable hospital. Preventive fire protection, on the other hand, is regulated in the Fire Brigade Acts or by statutory ordinances. Increasing numbers of emergency service missions and a lack of facilities for alternative care justify the need for a preventive emergency service. This includes all measures that take place before an event occurs in order to prevent emergencies from occurring. As a result, the risk of an emergency event leading to the emergency call 112 should be reduced or delayed. The preventive rescue service should also help to improve the outcome of medical care for patients. Furthermore, it should be made possible to provide those seeking help with a suitable form of care at an early stage.

The prehospital management of ambulance-attended adults who fell: A scoping review

BACKGROUND

The ageing population is requiring more ambulance attendances for falls. This scoping review aimed to map and synthesise the evidence for the prehospital management of Emergency Medical Services (EMS) attended adult patients who fall.

METHODS

The Joanna Briggs Institute methods for scoping reviews were used. Six databases were searched (Medline, Scopus, CINAHL, Cochrane, EMBASE, ProQuest), 1st August 2021. Included sources reported: ambulance attended (context), adults who fell (population), injuries, interventions or disposition data (concept). Data were narratively synthesised.

RESULTS

One-hundred and fifteen research sources met the inclusion criteria. Detailed information describing prehospital delivered EMS interventions, transport decisions and alternative care pathways was limited. Overall, adults< 65 years were less likely than older adults to be attended repeatedly and/or not transported. Being male, falling from height and sustaining severe injuries were associated with transport to major trauma centres. Older females, falling from standing/low height with minor injuries were less likely to be transported to major trauma centres.

CONCLUSION

The relationship between patient characteristics, falls and resulting injuries were well described in the literature. Other evidence about EMS management in prehospital settings was limited. Further research regarding prehospital interventions, transport decisions and alternative care pathways in the prehospital setting is recommended.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Predictors of Non-Transport for Older Adult EMS Patients Encountered for Falls

BACKGROUND

Emergency medical services (EMS) encounters for falls among older adults have been linked to poor outcomes when the patient is not transported by EMS to a hospital. However, little is known regarding characteristics of this patient population. Our primary objective was to describe characteristics associated with non-transport among older adult EMS patients encountered for falls.

METHODS

We performed a national retrospective cross-sectional study of 9-1-1 patient contacts from the 2019 ESO Data Collaborative. We included patients who had 9-1-1 encounters for ground-level falls and were aged 60 years or older. Patients residing in congregate living facilities, interfacility transports, cardiac arrests, and suspected drowning patients were excluded. Potential predictors of non-transport included patient demographics, initial vital signs, who requested 9-1-1 service, incident location, alcohol/substance use, and urbanicity. We used multivariable logistic regression to determine associations between non-transport and potential predictors.

RESULTS

We identified 195,204 EMS encounters for older adults who fell in 2019, including 27,563 (14.1%) non-transports. Most patients were female (62.4%), non-Hispanic White (85.4%), and fell at a home or residence (80.4%). Greater odds of non-transport were identified among males (OR 1.37, 95% CI 1.32-1.42) and Hispanic/Latino patients (OR 1.24, 95% CI 1.14-1.35). Older age was associated with greater odds of non-transport compared to patients aged 60-69 years (70-79 [OR 1.42, 95% CI 1.35-1.49], 80-89 [OR 1.51, 95% CI 1.42-1.59], ≥90 [OR 1.45, 95% CI 1.35-1.55]). Patients residing in Census tracts with larger percentages of the population living in poverty had lower odds of non-transport compared to those in areas with ≤5% in poverty (6-15% poverty [OR 0.82, 95% CI 0.78-0.84), 15-25% poverty [OR 0.78, 95% CI 0.73-0.82], and >25% poverty [OR 0.78, 95% CI 0.72-0.84]).

CONCLUSION

Males, older age groups, and Hispanic/Latino patients had higher odds of non-transport among this population of community-dwelling adults age 60 or greater. These findings may inform development of future targeted falls-related mobile integrated health or community paramedic services and referrals to community intervention programs. Future work is needed to understand underlying patient and clinician perspectives driving non-transport decisions among these patients to better equip EMS clinicians with tools and information on tailored risk/benefit discussions.

Trends in fall-related encounters and predictors of non-transport at a US Emergency Medical Services Agency

Non-transport to a hospital after emergency medical services (EMS) encounters for falls is common. However, incident factors associated with non-transport have not been well studied, especially beyond older adults. The objectives of this study are to (1) describe trends in fall-related EMS utilisation among adult patients from 2010 to 2018; (2) describe incident characteristics by age; and (3) identify incident factors associated with non-transport following a fall. This retrospective observational study includes prehospital clinical records data on falls from a large ambulance service in Minnesota, USA. Multivariable logistic regression was used to assess the independent association between non-transport and the following factors: sex, age, race, previous fall-related EMS encounter, incident location and primary impression. Of 62,835 fall-related encounters studied, 14.7% (9,245) did not result in transport by EMS. Fall calls were less common among younger people and the location and medical conditions primarily treated by an EMS provider during a 9-1-1 call differed greatly from those occurring among patients 65 and older. Factors most strongly associated with an increased risk of non-transport in the multivariable model were a primary impression of 'No apparent illness/injury' (OR = 34.5, 95% CI = 30.7-38.7), falling in a public location (OR = 2.09, CI = 1.96-2.22) and having had a fall-related EMS encounter during the prior year (OR = 1.15, CI = 1.1-1.2). Falls that occur in public locations, in patients with a previous fall, or result in no clinical detection of apparent illness or injury have a significantly increased odds of non-transport. Non-transport fall incidents in the United States require significant agency resources. Knowledge about the incident factors associated with non-transport calls is informative for development of alternative models for prehospital care delivery and initiatives to better serve patients.

Impact of a personalised care plan for the elderly calling emergency medical services after a fall at home: The RISING-DOM multi-centre randomised controlled trial protocol

BACKGROUND

A growing number of emergency calls are made each year for elderly people who fall. Many of them are not taken to hospital or are rapidly discharged from the Emergency Department (ED). Evidence shows that, with no further support, this vulnerable population is particularly at risk of injuries, dependency and death. This study aims to determine the effectiveness of a comprehensive geriatric assessment and a tailored intervention in the elderly calling on an Emergency Medical Service (EMS) for a fall at home, but not conveyed to the ED or rapidly discharged from it (less than 24 h from hospitalisation), to the time to institutionalisation or death.

METHODS

Rising-Dom is a two-arm randomised (ratio 1:1), interventional, multi-centre and open study. Community-dwelling elderly people (≥ 70 years) who call an EMS for a fall at home are recruited. The intervention group receives home visits by a nurse with a comprehensive fall risk assessment and a personalised intervention care plan with a planned follow-up (six nurse home visits and five nurse phone calls). Subjects enrolled in the usual care-control group continue to receive their routine care for the prevention or treatment of diseases. Primary (time to institutionalisation or death) and secondary (unscheduled hospitalisations, additional EMS calls relating to falls, functional decline and quality of life) outcome data will be collected for both groups through five phone calls made by Clinical Research Associates (CRA) blind to the participants' group during the follow-up period (24-months). Twelve hospital centres in the South-West of France are participating in the study as study sites. The inclusion period started in October 2019 and will end in March 2022. By the end of this period, 1,190 subjects are expected to be enrolled.

DISCUSSION

Studies on elderly home falls have rarely concerned people who were not taken to hospital. The Rising-Dom intervention scheme should enhance understanding of features related to this vulnerable population and investigate the impact of a nurse care at home on delaying death and institutionalisation.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT04132544. Registration date: 18/10/2019.

SPONSOR

University Hospital, Toulouse. https://www.clinicaltrials.gov/ct2/show/NCT04132544?term=rising-dom&draw=2&rank=1.

[Assessment in the home of the elderly following a first fall with Samu intervention]

The Rising-Dom study is a project to evaluate the impact of home intervention by an experienced geriatric nurse on mortality and institutionalization of older people who fall. It is a multicentre randomised interventional study. The two-year follow-up will compare the evolution of two groups: intervention (assessment by the nurse and proposal of a care plan) vs. usual care (simple information on ageing well and on the prevention of falls at home). First feedback from the field.

The Role of the US Trauma Centers in Older Adult Fall Prevention: A National Survey

INTRODUCTION

Approximately 27.5% of adults 65 and older fall each year, over 3 million are treated in an emergency department, and 32 000 die. The American College of Surgeons and its Committee on Trauma (ACSCOT) have urged trauma centers (TCs) to screen for fall risk, but information on the role of TC in this opportunity for prevention is largely unknown.

METHODS

A 29-item survey was developed by an ACSCOT Injury Prevention and Control Committee, Older Adult Falls workgroup, and emailed to 1000 trauma directors of the National Trauma Data Bank using Qualtrics. US TCs were surveyed regarding fall prevention, screening, intervention, and hospital discharge practices. Data collected and analyzed included respondent's role, location, population density, state designation or American College of Surgeons (ACS) level, if teaching facility, and patient population.

RESULTS

Of the 266 (27%) respondents, 71% of TCs include fall prevention as part of their mission, but only 16% of TCs use fall risk screening tools. There was no significant difference between geographic location or ACS level. The number of prevention resources (F = 31.58, P < .0001) followed by the presence of a formal screening tool (F = 21.47, P < .0001) best predicted the presence of a fall prevention program.

CONCLUSION

Older adult falls remain a major injury risk and injury prevention opportunity. The majority of TCs surveyed include prevention of older adult falls as part of their mission, but few incorporate the components of a fall prevention program. Development of best practices and requiring TCs to screen and offer interventions may prevent falls.

Evaluation of ambulance calls for patients over 65 years of age in İzmir, Turkey: a two- year retrospective analysis

Background/aim

Analysis of interventions for special patient groups is important for the planning of health services, especially emergency medical services. In this study, we aimed to evaluate emergency medical service (EMS) interventions for the elderly and determine the decisive factors affecting transfer to the hospital of EMS team over 2 years (2017 and 2018) in İzmir.

Materials and methods

Records of 112 emergency calls that were made between 2017 and 2018 followed up with interventions for patients aged 65 years and older were obtained from the 112 system. The reasons for the calls, outcomes, possible diagnoses of the patients, differences in time intervals and seasons, characteristics of the patients transferred to the hospital, and factors affecting the need for transfer to the hospital were investigated.

Results

A total of 176,104 elderly patients with a mean age of 78.02 ± 8.0 years required ambulance services, and out of them, 66% were transferred to the hospital. Transfer to the hospital was significantly associated with the event location, sex, time interval, international classification of diseases (ICD) codes, and physical examination findings.

Conclusion

Ambulance interventions are more frequently required in urban areas than in the countryside, and calls are mostly made during daytime hours and during winter months. The decision to transfer a patient to the hospital is based on the patient’s respiratory status, skin examination, state of consciousness, pulse, systolic blood pressure, call time, and the preliminary diagnosis of the crew.

The Dilemma of Falls in Older Persons: Never Forget to Investigate the Syncope

Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person.

The impact of health-related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care, Right Place, Right Time Project

OBJECTIVE

To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months.

DATA SOURCES/STUDY SETTING

Intervention sites included seven Boston-area buildings, with five buildings at comparable settings acting as controls. Data derive from building-level ambulance data from emergency responders; building-level Medicare claims data on emergency department utilization; and individual-level baseline assessment data from participants in the intervention (n = 353) and control (n = 208) sites.

STUDY DESIGN

We used a pre/postdifference in difference quasi-experimental design applying several analytic methods. The preintervention period was January 2016-March 2017, while the intervention period was July 2017-December 2018.

DATA COLLECTION/EXTRACTION METHODS

Emergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool.

PRINCIPAL FINDINGS

The study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings.

CONCLUSIONS

Health-related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.

Holistic Management of Older Patients With Hip Fractures

As the silver tsunami hits the world, older patients with hip fractures are expected to increase to 6.3 million by the year 2050, of which the majority will occur in Asia. The estimated global cost of hip fractures in the year 2050 is estimated to reach U.S. $130 billion. Hence, in addition to implementation of prevention strategies, it is important to develop an optimal model of care for older patients with hip fracture to minimize the huge medical and socioeconomic burden, especially in rapidly aging nations. This review summarizes the complications of hip fractures, importance of comprehensive geriatric assessment, and multidisciplinary rehabilitation, as well as predictors of rehabilitation outcome in older patients with hip fracture.

Development of a Content Valid and Reliable Prehospital Environmental Falls Risk Assessment Tool for Older Adults

Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing tools to assess environmental risk factors developed for consumers or home health providers, assessment of environmental falls risk by emergency medical services (EMS) providers represents a novel approach to primary and secondary prevention. The purpose of this study was to evaluate a content valid and reliable assessment of environmental fall risk to be performed in the prehospital setting. Methods: This was a mixed methods study, conducted from August, 2015 to September, 2017 in Mecklenburg County, NC, utilizing qualitative methodology to develop content valid items for an environmental falls risk assessment and quantitative methodology to assess those items for interrater reliability. Content validity was assessed using 2 expert panels. Expert Panel One was tasked with assessing validity of a construct to indicate an increased risk of an in-home fall for elderly individuals and expert Panel Two was responsible for assessing the likelihood of an EMS professional to identify a construct during their course of patient care. To assess reliability of the identified content valid items, 5 paramedics were recruited for interrater reliability (IRR) testing of the validated falls risk assessment tool. Each paramedic and their partner received education on documentation and deployment of the tool. Crews independently documented presence or absence of each item with pair agreement assessed using Cohen's kappa (κ). Results: A total of 87 items were identified for assessment through review of validated scales and relevant literature, with the content validation process reducing to 9 the number of items tested in the field for reliability. A total of 57 paired assessments were completed and included in analysis. One item returned almost perfect agreement (κ = 0.87), 5 items returned moderate agreement (κ = 0.41-0.54), with the remaining 3 items illustrating fair agreement (κ = 0.33-0.39). Conclusion: We developed a construct valid and reliable assessment of environmental falls risk to be performed in the prehospital setting. Further trials should be conducted using this tool to determine appropriate cut scores and deployment in the prehospital setting to help with primary and secondary fall prevention.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures.

RECENT FINDINGS

Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Fall-related emergency department visits and hospitalizations among community-dwelling older adults: examination of health problems and injury characteristics

BACKGROUND

Fall injuries and related healthcare use among older adults are increasing in the United States. This study examined chronic illnesses, sensory and memory problems, and injury characteristics that were associated with ED visits and hospitalizations among older adults who received medical attention for fall injuries within a 91-day reference period.

METHODS

Data were from the publicly available 2013-2017 US National Health Interview Survey files (unweighted N = 1840 respondents aged > 60 years with fall injuries). We first described socioeconomic, health/mental health, healthcare utilization, and injury characteristics among three groups: those who neither visited an ED nor were hospitalized for their fall injury, those who visited an ED only, and those who were hospitalized. Then, using multinomial logistic regression analysis, we examined associations of healthcare utilization (ED visit only and hospitalization vs. no ED visit/hospitalization) with chronic illnesses, other health problems, and injury characteristics, controlling for socioeconomic factors.

RESULTS

Of older adults who received medical attention for fall injuries, a little more than one-third had an ED visit only and a little less than a fifth had an overnight hospital stay. Multivariable analysis showed that lung disease and memory problems were associated with higher risk of ED visit only; hip and head injuries, facial injuries, and broken bones/fractures (from any type of injury) were more likely to result in hospitalization than other injuries. Fall injuries sustained inside the home, falls from loss of balance/dizziness, and living alone were also more likely to result in hospitalization.

CONCLUSIONS

These healthcare utilization findings indicate the significant toll that fall injuries exact on older adults and healthcare systems. Fall prevention should target risk factors that are specific to serious injuries requiring costly care. Strategies for implementing scalable, adaptable, and measurable fall prevention models by primary care and emergency medical service providers and ED staff are needed.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Background

Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.

Methods

Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.

Results

Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.

Conclusions

The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

Ten years of EMS Fall Calls in a Community: An Opportunity for Injury Prevention Strategies

Objective:

To determine whether fall calls, lift assists, and need for transport to the hospital over the past 10 years in one emergency medical services (EMS) system have altered coincident with demographic changes and to estimate health-care cost for lift assists.

Methods:

We conducted a retrospective chart review of EMS fall-related care. The HealthEMS database for a suburban community surveyed was queried from March 1, 2007, to March 1, 2017. Fall-related calls in patients 60 years or older were identified and determined to be either lift assists (calls that do not result in transport) or fall calls that resulted in transport to the hospital.

Results:

Of the 38 237 EMS care responses in patients 60 years or older, 11.5% were related to falls. Fall calls increased by 268% over the past 10 years (P = .0006), yet the number of transports to the hospital significantly decreased over time (P = .02). Lift assists increased significantly (P = .0003), nearly doubling over the decade. At the same time, fall calls that did not result in transport to the hospital cost the community an estimated US$1.5 million over a 10-year period.

Discussion:

There has been a dramatic shift in fall-related calls to EMS in older individuals with more frequent calls for lesser acuity needs. Utilization of EMS for lift assists has substantial financial consequences and diverts care from calls that need immediate triage and transport to care.

Conclusion:

Future work to reduce the frequency and increase the impact of EMS lift assists could have a significant cost benefit and provide opportunity for enrollment in appropriate community services and fall prevention programs.

Elder Abuse Identification in the Prehospital Setting: An Examination of State Emergency Medical Services Protocols

OBJECTIVES

To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting.

DESIGN

Cross-sectional analysis.

SETTING

Statewide EMS protocols in the United States.

PARTICIPANTS

Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website.

MEASUREMENTS

Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison.

RESULTS

Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse.

CONCLUSION

Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database

STUDY OBJECTIVE

The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region.

METHODS

Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport.

RESULTS

During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14).

CONCLUSION

More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Programs and Place: Risk and Asset Mapping for Fall Prevention

Identifying ways to measure access, availability, and utilization of health-care services, relative to at-risk areas or populations, is critical in providing practical and actionable information to key stakeholders. This study identified the prevalence and geospatial distribution of fall-related emergency medical services (EMS) calls in relation to the delivery of an evidence-based fall prevention program in Tarrant County, Texas over a 3-year time period. It aims to educate public health professionals and EMS first respondents about the application of geographic information system programs to identify risk-related “hot spots,” service gaps, and community assets to reduce falls among older adults. On average, 96.09 (±108.65) calls were received per ZIP Code (ranging from 0 calls to 386 calls). On average, EMS calls per ZIP Code increased from 30.80 (±34.70) calls in 2009 to 33.75 (±39.58) calls in 2011, which indicate a modest annual call increase over the 3-year study period. The percent of ZIP Codes offering A Matter of Balance/Volunteer Lay Leader Model (AMOB/VLL) workshops increased from 27.3% in 2009 to 34.5% in 2011. On average, AMOB/VLL workshops were offered in ZIP Codes with more fall-related EMS calls over the 3-year study period. Findings suggest that the study community was providing evidence-based fall prevention programming (AMOB/VLL workshops) in higher-risk areas. Opportunities for strategic service expansion were revealed through the identification of fall-related hot spots and asset mapping.

Coordinating Care for Falls via Emergency Responders: A Feasibility Study of a Brief At-Scene Intervention

Falls account for a substantial portion of 9-1-1 calls, but few studies have examined the potential for an emergency medical system role in fall prevention. We tested the feasibility and effectiveness of an emergency medical technician (EMT)-delivered, at-scene intervention to link elders calling 9-1-1 for a fall with a multifactorial fall prevention program in their community. The intervention was conducted in a single fire department in King County, Washington and consisted of a brief public health message about the preventability of falls and written fall prevention program information left at scene. Data sources included 9-1-1 reports, telephone interviews with intervention department fallers and sociodemographically comparable fallers from three other fire departments in the same county, and in-person discussions with intervention department EMTs. Interviews elicited faller recall and perceptions of the intervention, EMT perceptions of intervention feasibility, and resultant referrals. Sixteen percent of all 9-1-1 calls during the intervention period were for falls. The intervention was delivered to 49% of fallers, the majority of whom (75%) were left at scene. Their mean age (N = 92) was 80 ± 8 years; 78% were women, 39% had annual incomes under $20K, and 34% lived alone. Thirty-five percent reported that an EMT had discussed falls and fall prevention (vs. 8% of comparison group, P < 0.01); 84% reported that the information was useful. Six percent reported having made an appointment with a fall prevention program (vs. 3% of comparison group). EMTs reported that the intervention was worthwhile and did not add substantially to their workload. A brief, at-scene intervention is feasible and acceptable to fallers and EMTs. Although it activates only a small percent to seek out fall prevention programs, the public health impact of this low-cost strategy may be substantial.