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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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Jackson LE, Skains RM, Mudano A, Techarukpong N, Booth JS, Saag KG, Fraenkel L, Danila MI. An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture. JBMR Plus 2024; 8:ziae038. [PMID: 38681999 PMCID: PMC11055962 DOI: 10.1093/jbmrpl/ziae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/18/2023] [Accepted: 01/12/2024] [Indexed: 05/01/2024] Open
Abstract
Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the Emergency Department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in 2 tertiary-care EDs and triggered by the term "fall" in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2,608 EMR alerts among 2,509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.
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Affiliation(s)
- Lesley E Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Rachel M Skains
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Norma Techarukpong
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - James S Booth
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Liana Fraenkel
- Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, CT 06510, United States
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
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Barton L, Nelson M, Scholes C, Strudwick K. A physiotherapy-led review of guideline-based care for community-dwelling older people presenting to a metropolitan hospital with accidental falls. Australas J Ageing 2024; 43:43-51. [PMID: 37861178 DOI: 10.1111/ajag.13247] [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: 03/20/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE(S) Several guidelines exist to inform best-practice management of community-dwelling fallers. This study aimed to outline a pragmatic approach to developing an audit tool for guideline-based care of falls and provide an overview of current practice. METHODS An audit tool to determine compliance with guideline-based care was developed with an allied health and physiotherapy focus, utilising the Australian Commission on Safety and Quality in Health-Care Guidelines for Preventing Falls and Harm from Falls in Older People (2009) and Queensland State Government 'Stay on your Feet' guidelines. A retrospective audit of medical records was completed in July 2020 of community-dwelling people aged 65 years and over with a fall-related emergency department (ED) presentation in a medium-sized metropolitan hospital in Australia. Data were compared between patients admitted to hospital and those discharged home from the ED. RESULTS Ninety-three patients were included: 68 were discharged home from ED and 25 were admitted to hospital. There was a significant difference in receiving an allied health review (p < .001) between admitted patients (96%) and those who discharged home from ED (68%). The Clinical Frailty Scale was only completed for 23% of patients. Physiotherapy quality-of-care (n = 46 patients) was variable, with poor completion of physical outcome measures (7%) and fall education (4%). However, assessment of mobility was routinely completed (94%), and most patients were referred to an appropriate community service (66%). CONCLUSIONS Adherence to guideline-based care of community-dwelling fallers is inconsistent. Improvements are required in the consistency of risk stratification, comprehensive physical assessment and patient education.
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Affiliation(s)
- Loren Barton
- Physiotherapy Department, QEII Jubilee Hospital, Metro South Health, Brisbane, Queensland, Australia
| | - Mark Nelson
- Physiotherapy Department, QEII Jubilee Hospital, Metro South Health, Brisbane, Queensland, Australia
- RECOVER Injury Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | | | - Kirsten Strudwick
- Physiotherapy Department, QEII Jubilee Hospital, Metro South Health, Brisbane, Queensland, Australia
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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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Zou M, Lu R, Jiang Y, Liu P, Tian B, Liang Y, Wang X, Jiang L. Association between toileting and falls in older adults admitted to the emergency department and hospitalised: a cross-sectional study. BMJ Open 2023; 13:e065544. [PMID: 37263694 DOI: 10.1136/bmjopen-2022-065544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES This study aimed to explore the potential risk factors associated with toileting-related falls in community-dwelling older adults who presented to the emergency department and were subsequently hospitalised. DESIGN This was a cross-sectional study. SETTING AND PARTICIPANTS This study was conducted in two teaching hospitals in Shanghai, China between October 2019 and December 2021 among community-dwelling adults aged ≥60 years. METHODS In-person interviews, physical assessment and medical record review were performed to collect data on the characteristics and risk factors of falls. Associations of toileting-related falls with demographic characteristics and geriatric syndromes were examined using logistic regression models. MAIN OUTCOME MEASURES Potential risk factors for toileting-related falls. RESULTS This study included 419 older patients with a mean age of 73.8±9.7 years. Among 60 (14.3%) patients with toileting-related falls (mean age: 78.8±9.2 years), 63.3% of toileting-related falls, mainly occurred between 00:00 and 05:59 hours, compared with 17.3% of non-toileting-related falls, which primarily occurred during the daytime. The rate of recurrent falls (35%) was significantly higher in the toileting-related falls group than in the non-toileting-related falls group (21.2%) (p=0.02). Logistic regression showed that visual impairment (OR 2.7, 95% CI 1.1 to 7.1), cognitive impairment (OR 3.3, 95% CI 1.3 to 8.4), gait instability (OR 3.1, 95% CI 1.1 to 8.8) and urinary incontinence (OR 3.4, 95% CI 1.2 to 9.9) were strongly associated with toileting-related falls. Twenty-three (38.3%) patients in the toileting-related falls group had moderate and severe injuries, compared with 71.7% in the non-toileting-related falls group (p<0.05). CONCLUSIONS This study revealed that patients who reported toileting-related falls were more likely to have cognitive impairment, urinary incontinence, gait instability, visual impairment than patients who fell during other activities. Social and healthcare professionals should prioritise the management of toileting activities in older patients and provide targeted interventions to those in the high-risk group.
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Affiliation(s)
- Min Zou
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Lu
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijun Jiang
- Department of Pharmaceutics, Shanghai Pharmaceutical School, Shanghai, China
| | - Ping Liu
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bingjie Tian
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuqi Liang
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - XiaoLing Wang
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Liping Jiang
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Williamson M, Barton A, Edwards D, Morrisby C, Jacques A, Harper KJ. Improving care for older patients visiting emergency departments. Are they receiving falls prevention guideline care? Australas Emerg Care 2023; 26:84-89. [PMID: 35995675 DOI: 10.1016/j.auec.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The primary objective was to examine whether the Emergency Department (ED) treatment of older adults who fall in Australia is concordant with falls prevention and management clinical guideline care recommendations. METHODS A retrospective medical records audit was completed for patients 65years and older, who attended the ED with a fall and were discharged home. An audit tool was developed from local, national, and international falls clinical guidelines. RESULTS One thousand and twenty-seven patients presented following a fall throughout 2020. One hundred and seven patient medical records were audited. Assessment of cognition (94%), medication review (76%) and use of a falls risk screen (76%) were commonly completed. Under half of the patients had a documented gait evaluation (40%) and review of vision (18%). Concordance with guideline care was more likely for older patients (p = 0.042), with higher levels of comorbidity (p = 0.013), who required care assistance (p = 0.008) and received treatment from a multidisciplinary team (p < 0.001) in an observation ward (p < 0.001). CONCLUSIONS Older patients with increased comorbidities and higher care needs had more falls guideline care recommendations documented. This was likely to occur when patients were moved to the observation ward where more comprehensive care by a multidisciplinary team could occur.
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Affiliation(s)
- Melinda Williamson
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia.
| | - Annette Barton
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia
| | - Deborah Edwards
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia
| | | | - Angela Jacques
- Institute for Health Research, The University of Notre Dame Australia, Australia
| | - Kristie J Harper
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia; Curtin University, School of Allied Health, Australia
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DeWalt NC, Stahorsky KA, Sturges S, Bena JF, Morrison SL, Drobnich Sulak L, Szczepinski L, Albert NM. Simulation Versus Written Fall Prevention Education in Older Hospitalized Adults: A Randomized Controlled Study. Clin Nurs Res 2023; 32:278-287. [PMID: 35291853 DOI: 10.1177/10547738221082192] [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] [Indexed: 02/01/2023]
Abstract
Using a randomized controlled, non-blinded, two-group design, differences in fall risk assessment, post-discharge sustainable fall risk changes, fall events and re-hospitalization were examined in 77 older adults who received a simulation (n = 36) or written (n = 41) education intervention. Between-group differences and changes in pre- versus post-fall risk assessment scores were examined using Pearson's chi-square, Wilcoxon rank sum or Fisher's exact tests (categorical variables) and two-sample t-tests (continuous variables). There were no statistically significant differences between groups in demographic characteristics. Patients who received simulation education had higher fall risk post-assessment scores than the written education group, p = .022. Change in fall risk assessment scores (post-vs.-pre; 95% confidence intervals) were higher in the simulation group compared to the written education group, 1.43 (0.37, 2.50), p = .009. At each post-discharge assessment, fall events were numerically fewer but not significantly different among simulation and education group participants. There were no statistically significant between-group differences in re-hospitalization.
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Affiliation(s)
- Nancy C DeWalt
- Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
| | | | - Susan Sturges
- Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
| | - James F Bena
- Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
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Seo Y, Kim K, Kim JS. Trends of Nursing Research on Accidental Falls: A Topic Modeling Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3963. [PMID: 33918730 PMCID: PMC8068873 DOI: 10.3390/ijerph18083963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022]
Abstract
This descriptive study analyzed 1849 international and 212 Korean studies to explore the main topics of nursing research on accidental falls. We extracted only nouns from each abstract, and four topics were identified through topic modeling, which were divided into aspects of fall prevention and its consequences. "Fall prevention program and scale" is popular among studies on the validity of fall risk assessment tools and the development of exercise and education programs. "Nursing strategy for fall prevention" is common in studies on nurse education programs and practice guidelines to improve the quality of patient safety care. "Hospitalization by fall injury" is used in studies about delayed discharge, increased costs, and deaths of subjects with fall risk factors hospitalized at medical institutions due to fall-related injuries. "Long-term care facility falls" is popular in studies about interventions to prevent fall injuries that occur in conjunction with dementia in long-term care facilities. It is necessary to establish a system and policy for fall prevention in Korean medical institutions. This study confirms the trends in domestic and international fall-related research, suggesting the need for studies to address insufficient fall-related policies and systems and translational research to be applied in clinical trials.
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Affiliation(s)
| | | | - Ji-Su Kim
- Department of Nursing, Chung-Ang University, 84 Heukseok-Ro Dongjak-Gu, Seoul 06974, Korea; (Y.S.); (K.K.)
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