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Chary AN, Suh M, Ordoñez E, Cameron-Comasco L, Ahmad S, Zirulnik A, Hardi A, Landry A, Ramont V, Obi T, Weaver EH, Carpenter CR. A scoping review of geriatric emergency medicine research transparency in diversity, equity, and inclusion reporting. J Am Geriatr Soc 2024. [PMID: 38994587 DOI: 10.1111/jgs.19052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The intersection of ageism and racism is underexplored in geriatric emergency medicine (GEM) research. METHODS We performed a scoping review of research published between January 2016 and December 2021. We included original emergency department-based research focused on falls, delirium/dementia, medication safety, and elder abuse. We excluded manuscripts that did not include (1) original research data pertaining to the four core topics, (2) older adults, (3) subjects from the United States, and (4) for which full text publication could not be obtained. The primary objective was to qualitatively describe reporting about older adults' social identities in GEM research. Secondary objectives were to describe (1) the extent of inclusion of minoritized older adults in GEM research, (2) GEM research about health equity, and (3) feasible approaches to improve the status quo of GEM research reporting. RESULTS After duplicates were removed, 3277 citations remained and 883 full-text articles were reviewed, of which 222 met inclusion criteria. Four findings emerged. First, race and ethnicity reporting was inconsistent. Second, research rarely provided a rationale for an age threshold used to define geriatric patients. Third, GEM research more commonly reported sex than gender. Fourth, research commonly excluded older adults with cognitive impairment and speakers of non-English primary languages. CONCLUSION Meaningful assessment of GEM research inclusivity is limited by inconsistent reporting of sociodemographic characteristics, specifically race and ethnicity. Reporting of sociodemographic characteristics should be standardized across different study designs. Strategies are needed to include in GEM research older adults with cognitive impairment and non-English primary languages.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Michelle Suh
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, USA
| | - Edgardo Ordoñez
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lauren Cameron-Comasco
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oaks, Michigan, USA
| | - Surriya Ahmad
- Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Alexander Zirulnik
- Department of Emergency Medicine, Massachusetts General Brigham, Boston, Massachusetts, USA
| | - Angela Hardi
- Olin Medical Library, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alden Landry
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vivian Ramont
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Tracey Obi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Jiang LG, McGinnis C, Benton E, Nawa E, Stern M, Xi W, Sharma R, Daniels B. Using tele-paramedicine to conduct in-home fall risk reduction after emergency department discharge: Preliminary data. J Am Geriatr Soc 2024. [PMID: 38979847 DOI: 10.1111/jgs.19080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Older adults discharged from our emergency department (ED) do not receive comprehensive fall risk evaluations. We conducted a quality improvement project using an existing Community Tele-Paramedicine (CTP) program to perform in-home fall risk assessment and mitigation after ED discharge. METHODS High falls-risk patients, as defined by STEADI score >4, were referred for a CTP home visit by community paramedics supervised virtually by emergency physicians. Home hazards assessment, Timed Up and Go test (TUG), medication reconciliation, and psychosocial evaluation were used to develop fall risk mitigation plans. Outcomes assessed at 30 days post ED-discharge included: completed CTP visits, falls, ED revisits, hospital admissions, and referrals. RESULTS Between November 2022 and June 2023, 104 (65%) patients were discharged and referred to CTP. The mean age of enrolled patients was 80 years, 66% were female, 63% White, 79% on Medicare or Medicaid, most lived with a family member (50%) or alone (38%). Sixty-one (59%) patients received an initial CTP visit, 48 (79%) a follow-up visit, and 12 (11%) declined a visit. Abnormal TUG tests (74%), home hazards (67%), high-risk medications (36%), or need for outpatient follow-up (49%) or additional home services (41%) were frequently identified. At 30 days, only one of the CTP patients reported a fall, one patient had a fall-related ED visit, and one patient was admitted secondary to a fall. CONCLUSIONS A quality improvement initiative using CTP to perform fall risk reduction after ED discharge identified areas of risk mitigation in the home where most falls take place. Further controlled studies are needed to assess the impact of CTP on clinical outcomes important to patients and health systems.
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Affiliation(s)
- Lynn G Jiang
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Christina McGinnis
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Emily Benton
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Emilee Nawa
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Michael Stern
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Wenna Xi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Rahul Sharma
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Brock Daniels
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
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Jones AE, Kennedy M, Hayden EM, Ouchi K, N Shankar K, Chary A, Li A, Loughlin KM, White B, Franco-Garcia E, Dellheim V, Liu SW. A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program. Pilot Feasibility Stud 2024; 10:79. [PMID: 38762531 PMCID: PMC11102199 DOI: 10.1186/s40814-024-01502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 04/30/2024] [Indexed: 05/20/2024] Open
Abstract
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.
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Affiliation(s)
- Abigail E Jones
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, USA
| | - Kalpana N Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, USA
| | - Anita Chary
- Departments of Emergency Medicine and Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Angel Li
- Valley Health System, Las Vegas, NV, USA
| | | | - Benjamin White
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Esteban Franco-Garcia
- Department of Internal Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
| | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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White J, Maier AB, Iacobaccio L, Iseli R. Foot Problems in Older Adults Presenting to a Falls and Balance Clinic. Gerontology 2024; 70:732-740. [PMID: 38697042 DOI: 10.1159/000539160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/23/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Foot problems, including musculoskeletal problems, peripheral neuropathy, peripheral arterial disease and dermatologic pathology are common in older adults and are associated with an increased risk of falling. Multicomponent podiatry interventions have been shown to reduce the incidence of falls. This paper aimed to identify older adults requiring podiatry input in a Falls and Balance clinic; to describe the model of foot health care they receive; to explore cross-sectional associations between foot problems and function and ultimately demonstrate the role of podiatry input in the multidisciplinary management of falls risk. METHODS Cohort study of patients attending a Falls and Balance Clinic for Comprehensive Geriatric Assessment. Demographic information was collected and functional independence, mobility, foot problems, and footwear were assessed in the clinic. RESULTS One-hundred and two patients were included; median age 79.3 (73-84.3) years, 68.6% female, 93.1% residing independently, 62.7% used a gait aid. Podiatry referrals were made in 80.4% of cases, with muscle weakness being the most common problem identified (90.2%); 74.8% were found to be wearing inappropriate footwear. Most patients received footwear education and half were prescribed foot and ankle strengthening exercises. Hallux and lesser toe weakness were associated with lower Short Physical Performance Battery scores (p < 0.001). CONCLUSION The majority of older adults in the Falls and Balance Clinic required podiatry input, with foot weakness and inappropriate footwear being common reasons for referral. Those with weakness of the hallux and lesser toes had poorer balance and mobility, which is known to be associated with greater falls risk. This highlights the need for podiatry assessment and interventions as part of the multidisciplinary approach to the management of falls risk in older adults.
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Affiliation(s)
- Josephine White
- Department of Medicine, Dentistry and Health Science, University of Melbourne, Parkville, Victoria, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Centre for Healthy Longevity, National University Health System, Singapore, Singapore
| | - Laura Iacobaccio
- Department of Podiatry, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rebecca Iseli
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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Reider L, Falvey JR, Okoye SM, Wolff JL, Levy JF. Cost of U.S emergency department and inpatient visits for fall injuries in older adults. Injury 2024; 55:111199. [PMID: 38006782 DOI: 10.1016/j.injury.2023.111199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Falls are a leading cause of injury and hospital readmissions in older adults. Understanding the distribution of acute treatment costs across inpatient and emergency department settings is critical for informed investment and evaluation of fall prevention efforts. METHODS This study used the 2016-2018 National Inpatient Sample and National Emergency Department Sample. Annual treatment cost of fall injury among adults 65 years and older was estimated from charges, applying cost-to-charge and professional fee ratios. Weighted multivariable generalized linear models were used to separately estimate cost for inpatient and emergency department (ED) setting by injury type and individual demographic and health characteristics after adjusting for payer and hospital level characteristics. RESULTS Older adults incurred an estimated 922,428 inpatient and 2.3 million ED visits annually due to falls with combined annual costs of $19.8 billion. Over half of inpatient visits for fall injury were for fracture. Notably, 23% of inpatient visits were for fractures other than hip fracture and 14% of inpatient visits were for multiple fractures with costs totaling $3.4 billion and $2.5 billion, respectively. Annual ED costs were driven by superficial injury totaling $1.5 billion. Cost of ED visits were higher for adults 85 years and older (adjusted cost ratio (aCR): 1.11, 95% Confidence Interval (CI)I: 1.11-1.12) and those with dementia (aCR: 1.14, 95% CI: 1.13-1.15). Higher inpatient and ED visit cost was also associated with high-energy falls and discharge to post-acute care. CONCLUSION The study found that more than 3 million older adults in the United States seek hospital care for fall injuries annually, a major concern given increasing capacity strain on hospitals and EDs. The $20 billion in annual acute treatment costs attributed to fall injury indicate an urgent need to implement evidence-based fall prevention interventions and underscores the importance of newly launched ED-based fall prevention efforts and investments in geriatric emergency departments.
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Affiliation(s)
- Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States.
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, United States
| | - Safiyyah M Okoye
- Department of Graduate Nursing, Drexel University College of Nursing and Health Professions, United States; Department of Health Management and Policy, Drexel University Dornsife School of Public Health Philadelphia, PA, United States
| | - Jennifer L Wolff
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States
| | - Joseph F Levy
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States
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Schuster AK, Weisbach L, Kesselmeier M, Stumme C, Behringer W, Hartmann M, Farker K. [Tendency to fall and injuries related to the Covid-19 pandemic at a department of emergency medicine]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 182-183:26-31. [PMID: 37596161 DOI: 10.1016/j.zefq.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 05/11/2023] [Accepted: 05/20/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION This study investigates whether restrictions associated with the Covid-19 pandemic, in particular the temporary restrictions on social contacts in 2020, affected the number of inpatients admitted by the Department of Emergency Medicine of Jena University Hospital with a documented susceptibility to falls, injury or a susceptibility to falls resulting in at least one injury. METHODS Using the ICD-10-GM code for susceptibility to falls (R29.6) and the codes for injuries (S00 to T14) from medicare claims data, the incidence rates of inpatient admissions between the years 2019 and 2020 were compared. In addition to all inpatient admissions recorded by the Department of Emergency Medicine, the cases of inpatients aged 65 years or older were considered separately, as they have an increased risk of having a fall. RESULTS In 2020, the number of inpatient admissions in all age groups with one or more codes for injuries (S00 to T14) was significantly lower than in 2019 (2019: 19.2%, 2020: 17.3%, p<0.001). Regarding the codes for a documented susceptibility to falls (R29.6) or a documented susceptibility to falls (R29.6) with at least one injury (S00-T14), no differences were observed between the two years. In the group of inpatients 65 years or older, there were also no differences between 2019 and 2020 for any of the diagnoses considered. CONCLUSION In this monocentric study of Jena University Hospital, it could be demonstrated for the first time that the Covid-19 pandemic had little impact on the number of inpatients admitted to the Department of Emergency Medicine with a documented diagnosis of susceptibility to falls (R29.6) and of susceptibility to falls in combination with at least one documented injury (S00-T14). As observed in previous publications, the number of inpatient admissions with documented injury diagnoses (S00 to T14) decreased.
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Affiliation(s)
| | - Laura Weisbach
- Apotheke des Universitätsklinikums Jena, Jena, Deutschland
| | - Miriam Kesselmeier
- Institut für Medizinische Statistik, Informatik und Datenwissenschaften (IMSID), Universitätsklinikum Jena, Jena, Deutschland
| | - Christoph Stumme
- Medizincontrolling und MD-Management, Universitätsklinikum Jena, Jena, Deutschland
| | - Wilhelm Behringer
- Klinik für Notfallmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | | | - Katrin Farker
- Apotheke des Universitätsklinikums Jena, Jena, Deutschland.
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Sheikh S, Fernandez R, Smotherman C, Brailsford J, Langaee T, Velasquez E, Henson M, Munson T, Bertrand A, Hendry P, Anton S, Fillingim RB, Cavallari LH. A pilot study to identify pharmacogenomic and clinical risk factors associated with opioid related falls and adverse effects in older adults. Clin Transl Sci 2023; 16:2331-2344. [PMID: 37705211 PMCID: PMC10651658 DOI: 10.1111/cts.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/01/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023] Open
Abstract
Given the high prevalence of pain in older adults and current trends in opioid prescribing, inclusion of genetic information in risk prediction tools may improve opioid risk assessment. Our objectives were to (1) determine the feasibility of recruiting socioeconomically disadvantaged and racially diverse middle aged and older adult populations for a study seeking to identify risk factors for opioid-related falls and other serious adverse effects and (2) explore potential associations between the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (CIP-RIOSORD) risk class and other patient factors with falls and serious opioid adverse effects. This was an observational study of 44 participants discharged home from the emergency department with an opioid prescription for acute pain and followed for 30 days. We found pain interference may predict opioid-related falls or serious adverse effects within older, opioid-treated patients. If validated, pain interference may prove to be a beneficial marker for risk stratification of older adults initiated on opioids for acute pain.
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Affiliation(s)
- Sophia Sheikh
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Rosemarie Fernandez
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Carmen Smotherman
- Center for Data SolutionsUniversity of Florida, College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Jennifer Brailsford
- Center for Data SolutionsUniversity of Florida, College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFloridaUSA
| | - Esteban Velasquez
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Morgan Henson
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Taylor Munson
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Andrew Bertrand
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Phyllis Hendry
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Stephen Anton
- Department of Physiology and AgingUniversity of FloridaGainesvilleFloridaUSA
| | - Roger B. Fillingim
- Department of Community Dentistry and Behavioral ScienceUniversity of Florida College of DentistryGainesvilleFloridaUSA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFloridaUSA
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Fulbrook P, Miles SJ, McCann B, Steele M. A short multi-factor screening tool to assess falls-risk in older people presenting to an Australian emergency department: A feasibility study. Int Emerg Nurs 2023; 70:101335. [PMID: 37659216 DOI: 10.1016/j.ienj.2023.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/21/2023] [Accepted: 07/16/2023] [Indexed: 09/04/2023]
Abstract
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.
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Affiliation(s)
- Paul Fulbrook
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia; Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia.
| | - Sandra J Miles
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia; Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia.
| | - Bridie McCann
- Nursing and Midwifery Informatics, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Michael Steele
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia; School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia.
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The Predictive Validity and Clinical Application of Stopping Elderly Accidents, Deaths & Injuries (STEADI) for Fall Risk Screening. ADVANCES IN GERIATRIC MEDICINE AND RESEARCH 2022; 4:e220008. [PMID: 36315107 PMCID: PMC9615094 DOI: 10.20900/agmr20220008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fall prevention is critical for older adults. Stopping Elderly Accidents, Deaths, and Injuries (STEADI) is a fall prevention initiative, promoted by the Center for Disease Control (CDC). The purpose of this review aims to discuss the predictive validity, improve the predictive validity of STEADI, and apply STEADI in clinical settings.
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10
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Addressing Fall Risk From the Emergency Department: What Are We Missing? Adv Emerg Nurs J 2021; 43:2-9. [PMID: 33952869 DOI: 10.1097/tme.0000000000000337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Shankar KN, Lin F, Epino H, Temin E, Liu S. Emergency department falls: a longitudinal analysis of revisits and hospitalisations between patients who fall and patients who did not fall. BMJ Open 2020; 10:e041054. [PMID: 33303454 PMCID: PMC7733199 DOI: 10.1136/bmjopen-2020-041054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Older adult falls are a national issue comprising 3 million emergency department (ED) visits and significant mortality. We sought to understand whether ED revisits and hospitalisations for fallers differed from non-fall patients through a secondary analysis of a longitudinal, statewide cohort of patients. DESIGN We performed a secondary analysis using the non-public Patient Discharge Database and the ED data from the California Office of Statewide Health Planning and Development. This is a 5-year, longitudinal observational dataset, which was used to assess outcomes for fallers and non-fall patients, defined as anyone who did not carry a fall diagnosis during this time period. SETTING 2005-2010 non-public Patient Discharge Database and the ED Data from the state of California. PARTICIPANTS Older adults 65 years and older MAIN OUTCOME MEASURE: ED revisits and hospitalisations for fallers and non-fall patients. RESULTS Patients who came to the ED with an index visit of a fall were more likely to be discharged home after their fall (61.1% vs 45.0%, p<0.001). Fallers who were discharged or hospitalised after their index visit were more likely to come back to the ED for a fall related complaint compared with non-fallers (median time: 151 days vs 352 days, p<0.001 and hospitalised: 45 days vs 119 days, p<0.01) and fallers who were initially discharged also returned to the ED sooner for a non-fall related complaint (median time: 325 days vs 352 days, p<0.001). CONCLUSION Fall patients tend to be discharged home more often after their index visit, but returned to the ED sooner compared with their non-fall counterparts. Given a faller's rates of ED revisits and hospitalisations, EDs should consider a fall as a poor prognostic indicator for future healthcare utilisation.
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Affiliation(s)
- Kalpana N Shankar
- Department of Emergency Medicine, Boston University Medical Campus, Boston, Massachusetts, USA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Henry Epino
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth Temin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Davenport K, Alazemi M, Sri-On J, Liu S. Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall. Ann Emerg Med 2020; 76:730-738. [DOI: 10.1016/j.annemergmed.2020.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 04/22/2020] [Accepted: 06/09/2020] [Indexed: 01/25/2023]
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Samson M, Davenport K, Rizzo C, Liu SW. Stand Up and Fight Falls: Can a Video Intervention Help Reduce Falls in the Geriatric Population? Cureus 2020; 12:e11508. [PMID: 33354452 PMCID: PMC7744203 DOI: 10.7759/cureus.11508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Falls are a major source of morbidity and mortality in the geriatric population. However, efforts to reduce falls have had limited success. This study examines if a video intervention presented in the ED to patients who have fallen could improve fall education and reduce future falls. Methods: Patients 65 years and older who presented to a large academic ED for a fall between June and December 2017 were identified via triage note for an intercept study. Patients who did not speak English, who were cognitively impaired, or whose condition was too acute (determined by providing physician) were excluded. Sixty-two eligible and consenting patients were shown a six-minute video intervention with recommendations to prevent future falls. Primary objectives include (1) whether patients found the recommendations reasonable to implement and (2) rate of implementation. Secondary aims were (3) perceived health status between patients who followed the recommendations versus those who did not and (4) rates of recurrent falls and ED revisits between the two groups. Data were analyzed using the Newcombe-Wilson Score Method and Fisher's exact two-tailed t-tests. Results: Of 62 patients enrolled, 38 were retained at a six-month follow-up. Ninety-two percent of patients found the video intervention to be a reasonable education tool. At six months, 44.7% of patients implemented behavioral changes discussed in the video, and 21.1% had at least one new fall, with no significant difference between people who implemented video interventions and those who did not (23.5% and 19.0%, difference 0.045, 95% CI [-0.24 to 0.34], p=1.0). The rate of return to the ED at six months for all patients was 31.6%, with no significant difference between the two groups (23.5% versus 38.1%, difference 0.146, 95% CI [-0.18 to 0.43], p=0.49). Difference in the proportion of people feeling the same or better between the two groups was not significant at either the one-month (66.7% versus 75.0%, difference 0.083, 95% CI [-0.21 to 0.34], p=0.75) or six-month follow up (64.7% versus 47.6%, difference 0.171, 95% CI [-0.17 to 0.46], p=0.34). Conclusion: This study found that while most patients find behavioral interventions feasible and reasonable to implement, only half actually make changes to their lives to reduce the risk of falling. This suggests that identifying and limiting barriers to implementation should be a priority in future studies, along with exploring the relationship between interventions and health status, ED revisits, and recurrent falls.
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Affiliation(s)
- Margot Samson
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Kathleen Davenport
- Emergency Medicine, University of North Carolina Hospital, Chapel Hill, USA.,Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Caroline Rizzo
- Emergency Medicine, Massachussetts General Hospital, Boston, USA
| | - Shan W Liu
- Emergency Medicine, Massachusetts General Hospital, Boston, USA.,Emergency Medicine, Harvard Medical School, Boston, USA
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Newgard CD, Lin A, Caughey AB, Eckstrom E, Bulger EM, Staudenmayer K, Maughan B, Malveau S, Griffiths D, McConnell KJ. The Cost of a Fall Among Older Adults Requiring Emergency Services. J Am Geriatr Soc 2020; 69:389-398. [PMID: 33047305 DOI: 10.1111/jgs.16863] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures. DESIGN Retrospective cohort analysis. SETTING Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. PARTICIPANTS We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage. MEASUREMENTS The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates. RESULTS The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189). CONCLUSION Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.
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Affiliation(s)
- Craig D Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Oregon, Portland, USA
| | - Elizabeth Eckstrom
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Kristan Staudenmayer
- Department of Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Brandon Maughan
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Susan Malveau
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Denise Griffiths
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - K John McConnell
- Department of Emergency Medicine, Center for Health Systems Effectiveness, Oregon Health & Science University, Oregon, Portland, USA
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Fall prevention initiative: A fall screening and intervention pilot study on the ambulatory setting. J Trauma Acute Care Surg 2020; 88:101-105. [PMID: 31626026 DOI: 10.1097/ta.0000000000002514] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Falling is the most common cause of trauma in the geriatric population. To identify patients that were at-risk for falling, we implemented a provider-directed fall prevention screening initiative in the ambulatory setting of a large tertiary care referral center. We used three clinician-directed questions from the Stopping Elderly Accidents, Death and Injuries toolkit. Our goal was to intervene on patients who were screened as at-risk for falling by referring them to our physical therapy program and evaluating its effects to these patients. METHODS Patients 55 years or older who live in the community were screened from June 2017 to June 2018. Patients who answered yes to any of the three questions were identified as at-risk for falling, and referred to the Fall Prevention Initiative Physical Therapy Program (FPIPTP). The FPIPTP is a program that establishes a quantifiable fall risk using the Time Up and Go (TUG) test, which then initiates PT treatments, designed to prevent future falls by improving, gait, balance, and fitness. The Wilcoxon signed rank test was used to determine significance (p < 0.05). RESULTS We identified 112 patients with a median age of 76.5 years (IQR, 68-82 years) to be at-risk for falling. The initial median TUG score in this group of patients is 15.85 seconds (12-20.33 seconds), which is consistent with a high fall-risk (time >12 seconds). After completing the FPIPTP, the median TUG score significantly improved to 12 seconds (9-15 seconds, p < 0.0001). CONCLUSION We conclude that a provider can use the three specific questions from the Stopping Elderly Accidents, Death and Injuries toolkit to identify patients (≥55 years) that are at-risk for falling. Additionally, the FPIPTP is able to significantly improve the TUG score in this group. We will need to confirm this conclusion with a larger population study. LEVEL OF EVIDENCE Therapeutic, Level IV.
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O' Keeffe A, O' Grady S, Cronin F, Dolan C, O' Hea A, O' Shea KL, Naughton C. Evaluation of an emergency department falls pathway for older people: A patient chart review. Int Emerg Nurs 2020; 51:100869. [PMID: 32354620 DOI: 10.1016/j.ienj.2020.100869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
The number of older adults presenting to EDs following a fall continues to rise, yet falls management often ignores opportunities for secondary falls risk reduction. Advanced Nurse Practitioners (ANPs) in EDs have an important clinical leadership role in improving outcomes for this group of patients. AIM This study describes the development of an ANP led falls pathway in an ED to improve safe discharge. It evaluates compliance with the pathway and referrals to community falls prevention services. It also draws comparison with baseline practice as recorded in 2014. METHODS The Falls Pathway involves four steps: 1) screening at triage (3 questions), 2) risk stratification (low, medium, high), 3) risk assessment (lying and standing blood pressure (B/P), timed-up and go (TUG), 4-AT for delirium screening, polypharmacy), and 4) referral to community falls services. We undertook a 12-month chart review of all patients aged 65 years or older presenting following a fall to the ANP service in 2018. We compared data to a baseline audit in 2014; descriptive and Chi squared statistics were used to examine the data. RESULTS The 2018 audit involved 77 patients representing 27% of ANP caseload. A repeat fall occurred in 42% (32/77) of cases and 35% (22/77) reported a fear of falling. The Falls Pathway was initiated in nearly 80% (62/77) of patients and compliance with falls risk assessment ranged from 42% for lying and standing B/P to 75% for TUG. In 2014, a review of 59 patient charts showed 27% (16/59) experienced a repeat fall, but other risk factors such as fear of falling were not recorded. In 2018, the majority of patients (88%) discharged home were referred to community falls prevention services compared to 22% in 2014. CONCLUSION The Falls Pathway improved falls risk assessment in the ED, identified opportunities for risk reduction and optimised referral to community falls services. The pathway continues to be a valuable tool but requires resources for ongoing implementation among the wider ED team.
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Affiliation(s)
| | - Sile O' Grady
- Mercy University Hospital, Cork City, Co Cork, Ireland.
| | - Finola Cronin
- North Lee Community Health, Cork City, Co Cork, Ireland.
| | - Clodagh Dolan
- Mercy University Hospital, Cork City, Co Cork, Ireland.
| | - Ann O' Hea
- Mercy University Hospital, Cork City, Co Cork, Ireland.
| | - Katie Louise O' Shea
- School of Nursing and Midwifery, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, College Road, Cork T12 AK54, Ireland.
| | - Corina Naughton
- UCC School of Nursing and Midwifery, Professor in Clinical Nursing in Older Person HealthCare, School of Nursing and Midwifery, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, College Road, Cork T12 AK54, Ireland.
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Affiliation(s)
- J E Morley
- John E. Morley, MB,BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104,
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