Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall

A Scoping Review of Fall-Risk Screening Tools in the Emergency Department for Future Falls in Older Adults

BACKGROUND

Approximately one-third of adults over the age of 65 experience falls annually, with half resulting in injury. Peak bodies have recommended the use of fall-risk screening tools in the emergency department (ED) to identify patients requiring in-depth assessment and potential fall-prevention intervention. This study aimed to examine the scope of published studies on fall-risk screening tools used in the ED and evidence of associations between screening and future falls.

SUMMARY

PubMed, Embase and CINAHL were searched for peer-reviewed journal articles published since 2012 that examined one or more screening tools to identify patient-level fall risk. Eligible studies described fall-risk tools applied in the ED. Data extracted included sample information, variables measured, and statistical analysis. Sixteen studies published since 2012 were included after full-text review. Fourteen unique screening tools were found. Eight tools were fall-risk screening tools, one tool was a functional screening tool, one tool was a frailty-screening tool, two tools were rapid physical tests, one tool was a trauma triage tool, and one tool was a component of a health-related quality-of-life measure. Studies that evaluated prognostic performance (n = 11) generally reported sensitivity higher than specificity. Previous falls (n = 10) and high-risk medications (n = 6) were consistently associated with future falls. Augmentation with additional variables from the electronic medical record (EMR) improved screening tool prognostic performance in one study.

KEY MESSAGES

Current evidence on the association between the use of fall-risk screening tools in the ED for future falls consistently identifies previous falls and high-risk medications as associated with future falls. Comparison between tools is difficult due to different evaluation methods and different covariates measured. Augmentation of fall-risk screening using the EMR in the ED requires further investigation.

Risk factors for older people re-presenting to the emergency department with falls: A case-control analysis

OBJECTIVE

Falls are a leading cause for ED presentations among older adults. Existing secondary falls prevention interventions have not been shown to decrease fall-related ED re-presentation, indicating a need to better understand contributing factors. Our aim was to evaluate risk factors for fall re-presentations among the older patient population presenting to the ED.

METHODS

This is a single-centre case-control study. Cases were patients aged ≥65 years with two falls-related ED presentations within 6 months. Age- and sex-matched controls had a corresponding index, but no subsequent ED fall presentation. Data collected included falls risk factors and clinical features of the index presentation. Univariate and multivariate analyses were conducted to assess the relationship between potential exposures and fall re-presentation.

RESULTS

A total of 300 patients (mean age 83.8 years) were studied. On univariate analysis, factors significantly associated with ED fall re-presentation included increasing multimorbidity (P < 0.0001), increasing number of medications (P < 0.0001) and residing in residential aged care facility (RACF) (odds ratio [OR] 3.06, P < 0.001). No factors remained significant on multivariate analysis. Post-hoc analyses for the RACF subgroup showed that psychotropic medication use (OR 1.65, P = 0.04) and prior fall within 12 months (OR 2.68, P < 0.001) were significantly associated with re-presentation. Initial presentation with serious musculoskeletal injury was a significant protective factor (OR 0.21, P = 0.02).

CONCLUSION

The present study failed to identify factors independently associated with ED fall re-presentation, suggesting that the factors are complex and inter-related. Two high-risk populations were identified - those from RACF and those initially presenting with falls not resulting in serious injury.

A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program

BACKGROUND

As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program.

METHODS

To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions.

DISCUSSION

This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Comparing Sensitivity, Specificity, and Accuracy of Fall Risk Assessments in Community-Dwelling Older Adults

Purpose

The US Centers for Disease Control and Prevention (CDC) has implemented the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. This initiative provides an algorithm for fall risk screening. However, the algorithm has the potential to overcategorize individuals as high risk for falling upon initial screening, which may burden clinicians with the task of recategorizing individuals after follow-up testing. Therefore, this study aimed to compare the accuracy, sensitivity, and specificity of fall risk appraisal between the STEADI, Short Fall-Efficacy Scale International (FES-I), and portable balance system (BTrackS) assessments in community-dwelling older adults.

Patients and Methods

This cross-sectional analysis included 122 community-dwelling older adults, comprising 94 women and 28 men. Center-of-pressure postural sway was assessed using the BTrackS, fear of falling was assessed using the Short FES-I questionnaire, and all participants completed the STEADI checklist. Each assessment categorized participants as either high or low fall risk and fall risk appraisal was compared between groups using McNemar tests.

Results

The STEADI checklist (high risk: n = 62; low risk: n = 60) significantly differed in fall risk appraisal compared to the BTrackS (high risk: n = 44; low risk: n = 78; p = 0.014) and the Short FES-I (high risk: n = 42; low risk: n = 80; p = 0.002). Compared to the BTrackS, the STEADI checklist had a specificity of 62.8%, sensitivity of 70.5%, and accuracy of 65.6%. Compared to the Short FES-I, the STEADI checklist had a specificity of 67.5%, sensitivity of 81.0%, and accuracy of 72.1%.

Conclusion

The STEADI checklist appears to overcategorize individuals as high fall risk more frequently than direct assessments of postural sway and fear of falling. Further research is needed to examine potential improvements in accuracy when combining the STEADI checklist with direct assessments of postural sway and/or fear of falling.

Automating risk stratification for geriatric syndromes in the emergency department

BACKGROUND

Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients.

METHODS

We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery.

RESULTS

Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care.

CONCLUSIONS

Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.

[Prognosis in elderly patients with falls treated in emergency departments: The EDEN-3 study]

OBJECTIVE

To investigate whether falls in people ≥65 years old are a prognostic factor for adverse events compared to the rest of older patients who consult emergency departments, and identify factors related to a worse long-term evolution.

METHOD

EDEN cohort that included patients ≥65 years old. Those patients who consulted for fall and the rest were distinguished. Twelve variables were collected. For comparison: two groups matched by fall propensity score. We compared mortality at one year and combined adverse event post-discharge at one year. In patients with falls, variables independently related to evolution were identified.

RESULTS

Two thousand seven hundred and forty-five patients treated for falls and 22,920 for other reasons. Mortality at one year was 14.4% (9.5% vs. 15.0%, respectively, P<.001) and the combined post-discharge adverse event at one year was 60.6% (52.2% vs. 61.7%, respectively, P<.001). In 4748 patients matched by fall propensity score (2372 in each group), the inverse association between consultation for fall and mortality (HR: 0.705, 95% CI: 0.5880.846) and post-discharge combined adverse event (0.758, 0.701-0.820) remained significant. Factors associated with mortality in patients with falls were ≥80 years (2.097, 1.521-2.891) and comorbidity (2.393, 1.574-3.636) while being female was a protective factor (0.758, 0.584-0.985). Between the factors associated with post-discharge combined adverse hospitalization in the index event was a protective factor (0.804, 0.685-0.943).

CONCLUSIONS

Patients over 65 years of age treated in the emergency room for falls have a better prognosis. Hospitalization was a protective factor of combined postdischarge adverse event.

A short multi-factor screening tool to assess falls-risk in older people presenting to an Australian emergency department: A feasibility study

OBJECTIVE

The purpose of this study was to evaluate use of a short multi-factor falls-risk screening tool for older people within the emergency department, to enable rapid identification of falls-risk and triggers for multidisciplinary referral for further falls-specific assessment.

METHODS

Older people, aged ≥70 years, presenting to the emergency department with a fall-related injury or disease (n = 137) were recruited by a research nurse following randomisation. A short multi-factor screening tool was completed, comprised of 14 falls-risk-related assessment components.

RESULTS

Only one participant did not generate any referrals. Participants generated most referrals for medications (85.4%), social and housing (84.6%), vision (67.2%), podiatry (66.9%), or function and mobility (54.7%). Based on our results, the screening tool could be reduced to eleven components. The median time-to-screen was 11 min (IQR 9-15), with 736 triggers generated for referral and further assessment of falls-risk.

CONCLUSION

Falls are a major cause of ED presentation for older people. A short multi-factor screening tool with eleven components could be adapted to local familiar falls-risk tools and be completed in less than 10 min. Further research to trial the feasibility of completing ED referrals based on screening results is required to confirm the usefulness of such screening and referral within the ED.

Balance Differences between North and South American Older Adults: A Cross-Sectional, Age and Sex Matched Study

This study aimed to characterize the risk of falling in low-, moderate- and high-risk participants from two different geographical locations using a portable force-plate. A sample of 390 older adults from South and North America were matched for age, sex, height and weight. All participants performed a standardized balance assessment using a force plate. Participants were classified in low, moderate and high risk of falling. No differences were observed between South and North American men, nor comparing North American men and women. South American women showed the significantly shorter center of pressure path length compared to other groups. The majority of the sample was categorized as having low risk of falling (male: 65.69% and female: 61.87%), with no differences between men and women. Moreover, no differences were found between North vs. South Americans, nor between male and female groups compared separately. In conclusion, South American women had better balance compatible with the status of the 50–59 years’ normative age-range. The prevalence of low falls risk was~61–65%; the prevalence of moderate to high risk was~16–19%. The frequency of fall risk did not differ significantly between North and South Americans, nor between males and females.

Collaborative design and implementation of a clinical decision support system for automated fall-risk identification and referrals in emergency departments

Of the 3 million older adults seeking fall-related emergency care each year, nearly one-third visited the Emergency Department (ED) in the previous 6 months. ED providers have a great opportunity to refer patients for fall prevention services at these initial visits, but lack feasible tools for identifying those at highest-risk. Existing fall screening tools have been poorly adopted due to ED staff/provider burden and lack of workflow integration. To address this, we developed an automated clinical decision support (CDS) system for identifying and referring older adult ED patients at risk of future falls. We engaged an interdisciplinary design team (ED providers, health services researchers, information technology/predictive analytics professionals, and outpatient Falls Clinic staff) to collaboratively develop a system that successfully met user requirements and integrated seamlessly into existing ED workflows. Our rapid-cycle development and evaluation process employed a novel combination of human-centered design, implementation science, and patient experience strategies, facilitating simultaneous design of the CDS tool and intervention implementation strategies. This included defining system requirements, systematically identifying and resolving usability problems, assessing barriers and facilitators to implementation (e.g., data accessibility, lack of time, high patient volumes, appointment availability) from multiple vantage points, and refining protocols for communicating with referred patients at discharge. ED physician, nurse, and patient stakeholders were also engaged through online surveys and user testing. Successful CDS design and implementation required integration of multiple new technologies and processes into existing workflows, necessitating interdisciplinary collaboration from the onset. By using this iterative approach, we were able to design and implement an intervention meeting all project goals. Processes used in this Clinical-IT-Research partnership can be applied to other use cases involving automated risk-stratification, CDS development, and EHR-facilitated care coordination.

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement

BACKGROUND

Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci.

METHODS

GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference.

RESULTS

We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2).

CONCLUSION

Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Addressing Fall Risk From the Emergency Department: What Are We Missing?

The Research to Practice column focuses on improving the research critique skills of emergency nurses and advanced practice providers to assist with the translation of research into practice. In this issue, we discuss the findings of a secondary data analysis conducted by K. Davenport, M. Alazemi, J. Sri-On, and S. Liu (2020) that examined emergency department provider identification of modifiable risk factors when assessing older adults who present after a fall. The results found that providers frequently miss identifying and intervening in modifiable risk factors that contribute to adverse outcomes and readmissions following discharge. The results suggest future research needs and have implications for emergency nurse practitioner educational preparation.