Effect of a practice guideline for emergency department care of falls in elder patients on subsequent falls and hospitalizations for injuries

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.

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation.

The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty.

Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis

OBJECTIVE

To assess the effects of fall prevention services initiated in the emergency department (ED) to support patients after discharge.

METHODS

A systematic review and meta-analysis were conducted. Analysis of pooled data used random-effects modelling with results presented as a risk ratio (RR).

RESULTS

Eleven studies were identified (n = 4,018). The proportion of older adults who fell did not differ between the intervention and control groups (RR 0.93; 95% CI, 0.82-1.06, I² 68%, P = 0.28). There was a significant (P = 0.01) reduction in the monthly rate of falling (RR 0.69; 95% CI, 0.52-0.91, I² 93%), fall-related injuries (RR 0.72; 95% CI, 0.59-0.88, I² 0%, P = 0.001), and hospital admissions (RR 0.76; 95% CI, 0.64-0.90, I² 0%, P = 0.002).

CONCLUSIONS

ED fall prevention services did not significantly reduce the proportion of older adults who had future falls. However, multifactorial intervention significantly reduced fall-related injuries and hospital admissions with low heterogeneity.

Randomized Controlled Trial of Screening, Risk Modification, and Physical Therapy to Prevent Falls Among the Elderly Recently Discharged From the Emergency Department to the Community: The Steps to Avoid Falls in the Elderly Study

OBJECTIVE

To evaluate the effectiveness of a multifactorial, tailored program of physical therapy to reduce the occurrence of falls among a heterogeneous group of high-risk elderly Singaporeans recently discharged from the emergency department (ED).

DESIGN

Randomized controlled trial.

SETTING

Communities.

PARTICIPANTS

Adults (N=354) aged ≥65 years who were seen in the ED for a fall or fall-related injuries and discharged home.

INTERVENTIONS

The intervention primarily consisted of a tailored program of physical therapy focused on progressive training in strength, balance, and gait for a period of 3 months. Participants in the intervention group also received screening and follow-up for vision, polypharmacy, and environmental hazards. Participants in the control group received usual care prescribed by a physician and educational materials on falls prevention.

MAIN OUTCOME MEASURES

The primary outcome measure was experiencing at least 1 fall during the 9-month study period (a 3-mo active intervention phase and a 6-mo maintenance phase). Secondary outcome measures were the occurrence of at least 1 injurious fall during the study period and a change in the Short Physical Performance Battery (SPPB) score. Participants were assessed both after 3 and 9 months.

RESULTS

During the 9-month study period, 37.8% of the control group and 30.5% of the intervention group fell at least once, which was not statistically significantly different (odds ratio [OR]=.72; 95% confidence interval [CI], .46-1.12; P=.146). The intervention group had statistically significantly fewer individuals with injurious falls (OR=.56; 95% CI, .32-.98; P=.041) and less deterioration in physical performance, reflected by a mean difference of 0.6 in SPPB scores (P=.029). Multivariate analyses indicated a strong interaction effect between the intervention and the presence of 2 or more major comorbidities; after accounting for this effect, the intervention program reduced the number of people experiencing at least 1 fall (OR=.34; 95% CI, .17-.67; P=.002).

CONCLUSIONS

We observed that in this heterogeneous population, the proportion of participants experiencing at least 1 fall during the study period was not statistically significantly lower in the intervention group compared with the control group. Secondary analyses strongly suggest that individuals with 2 or more major comorbidities do not benefit from a tailored physical therapy program; however, individuals with less comorbidity may substantially benefit.

Evaluation of older adult patients with falls in the emergency department: discordance with national guidelines

OBJECTIVES

The objective was to examine whether the emergency department (ED) evaluation of older adult fallers is concordant with the Geriatric Emergency Department Guidelines.

METHODS

This study was a chart review of randomly selected older adult ED fall patients from one urban academic teaching hospital. Patients 65 years and older who had ED fall visits in 2012 and who had primary care physicians within our hospital network during the past 3 years were included. Transferred patients were excluded. The data collection instrument was adapted from ED fall evaluation recommendations.

RESULTS

There were 350 patients in this study. The mean (±SD) patient age was 80.1 (±8.8) years, 124 (35%) were male, 327 (93%) were white, and 298 (85%) were community dwelling. The range with which history and physical examination findings were concordant with fall guidelines was 1% to 85%. Cause and location of fall were the two most frequently reported history items (85 and 81%, respectively), while asking about baseline vision was only reported 1% of the time. Evaluating for sensory deficits and muscle strength were the two most frequently reported physical examinations (63 and 48%, respectively), while balance was evaluated with the lowest frequency (1%). Patients who received more guideline-recommended evaluations were older with more comorbid conditions and were transferred to an observation unit or admitted to the hospital more frequently. Overall, more than half of these elderly patients (56%) were discharged from the ED to their place of preadmission residence.

CONCLUSIONS

The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines.

Predicting geriatric falls following an episode of emergency department care: a systematic review

BACKGROUND

Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored.

OBJECTIVES

This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity.

METHODS

A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED.

RESULTS

A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%.

CONCLUSIONS

This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.

Analyzing the problem of falls among older people

Falls are a serious problem facing the elderly. The prevention of falls that contribute to disability, mainly in elderly people, is an important issue. Ensuring the greatest possible functionality for elderly people is an important element in the prevention of disability. This paper analyzes the importance of falls, risk factors for falls, and interventions to prevent falls. Recent publications as well as research regarding the prevention and rehabilitation for falls are reviewed.

Implementing the evidence for preventing falls among community-dwelling older people: a systematic review

PROBLEM AND OBJECTIVE

The translation of the evidence-base for preventing falls among community-dwelling older people into practice has been limited. This study systematically reviewed and synthesised the effectiveness of methods to implement falls prevention programmes with this population.

METHODS

Articles published between 1980 and May 2010 that evaluated the effects of an implementation strategy. No design restrictions were imposed. A narrative synthesis was undertaken.

RESULTS

15 studies were identified. Interventions that involved the active training of healthcare professionals improved implementation. The evidence around changing the way people who fall are managed within primary care practices, and, layperson, peer or community delivered models was mixed.

IMPACT ON INDUSTRY

Translating the evidence-base into practice involves changing the attitudes and behaviours of older people, healthcare professionals and organisations. However, there is a need for further evaluation on how this can be best achieved.

Emergency orthogeriatrics: concepts and therapeutic alternatives

Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery.

Short-term functional decline and service use in older emergency department patients with blunt injuries

BACKGROUND

Injuries are a common reason for emergency department (ED) visits by older patients. Although injuries in older patients can be serious, 75% of these patients are discharged home after their ED visit. These patients may be at risk for short-term functional decline related to their injuries or treatment.

OBJECTIVES

The objectives were to determine the incidence of functional decline in older ED patients with blunt injuries not requiring hospital admission for treatment, to describe their care needs, and to determine the predictors of short-term functional decline in these patients.

METHODS

This institutional review board-approved, prospective, longitudinal study was conducted in two community teaching hospital EDs with a combined census of 97,000 adult visits. Eligible patients were > or = 65 years old, with blunt injuries <48 hours old, who could answer questions or had a proxy. We excluded those too ill to participate; skilled nursing home patients; those admitted for surgery, major trauma, or acute medical conditions; patients with poor baseline function; and previously enrolled patients. Interviewers collected baseline data and the used the Older Americans Resources and Services (OARS) questionnaire to assess function and service use. Potential predictors of functional decline were derived from prior studies of functional decline after an ED visit and clinical experience. Follow-up occurred at 1 and 4 weeks, when the OARS questions were repeated. A three-point drop in activities of the daily living (ADL) score defined functional decline. Data are presented as means and proportions with 95% confidence intervals (CIs). Logistic regression was used to model potential predictors with functional decline at 1 week as the dependent variable.

RESULTS

A total of 1,186 patients were evaluated for eligibility, 814 were excluded, 129 refused, and 13 were missed, leaving 230 enrolled patients. The mean (+/-SD) age was 77 (+/-7.5) years, and 70% were female. In the first week, 92 of 230 patients (40%, 95% CI = 34% to 47%) had functional decline, 114 of 230 (49%, 95% CI = 43% to 56%) had new services initiated, and 76 of 230 had an unscheduled medical contact (33%, 95% CI = 27% to 39%). At 4 weeks, 77 of 219 had functional decline (35%, 95% CI = 29% to 42%), 141 of 219 had new services (65%, 95% CI = 58% to 71%), and 123 of 219 had an unscheduled medical contact (56%, 95% CI = 49% to 63%), including 15% with a repeated ED visit and 11% with a hospital admission. Family members provided the majority of new services at both time periods. Significant predictors of functional decline at 1 week were female sex (odds ratio [OR] = 2.2, 95% CI = 1.1 to 4.5), instrumental ADL dependence (IADL; OR = 2.5, 95% CI = 1.3 to 4.8), upper extremity fracture or dislocation (OR = 5.5, 95% CI = 2.5 to 11.8), lower extremity fracture or dislocation (OR = 4.6, 95% CI = 1.4 to 15.4), trunk injury (OR = 2.4, 95% CI = 1.1 to 5.3), and head injury (OR = 0.48, 95% CI = 0.23 to 1.0).

CONCLUSIONS

Older patients have a significant risk of short-term functional decline and other adverse outcomes after ED visits for injuries not requiring hospitalization for treatment. The most significant predictors of functional decline are upper and lower extremity fractures.

Comparison of balance assessment modalities in emergency department elders: a pilot cross-sectional observational study

Background

More than one-third of US adults 65 and over fall every year. These falls may cause serious injury including substantial long-term morbidity (due declines in activities of daily living) and death. The emergency department (ED) visit represents an opportunity for identifying high risk elders and potentially instituting falls-related interventions. The unique characteristic of the ED environment and patient population necessitate that risk-assessment modalities be validated in this specific setting. In order to better identify elders at risk of falls, we examined the relationship between patient-provided history of falling and two testing modalities (a balance plate system and the timed up-and-go [TUG] test) in elder emergency department (ED) patients.

Methods

We conducted a cross-sectional observational study of patients ≥ 60 years old being discharged from the ED. Patient history of falls in the past week, month, 6 months, and year was obtained. Balance plate center of pressure excursion (COP) measurements and TUG testing times were recorded. COP was recorded under four conditions: normal stability eyes open (NSEO) and closed (NSEC), and perturbed stability eyes open and closed. Correlation between TUG and COP scores was measured. Univariate logistic regression was used to identify the relationship between patient-provided falls history and the two testing modalities. Proportions, likelihood ratios, and receiver-operating-characteristic (ROC) curves for prediction of previous falls were reported.

Results

Fifty-three subjects were enrolled, 11% had fallen in the previous week and 42% in the previous year. There was no correlation between TUG and any balance plate measurements. In logistic regression, neither testing modality was associated with prior history of falls (p > 0.05 for all time periods). Balance plate NSEO and NSEC testing cutoffs could be identified which were 83% sensitive and had a negative likelihood ratio (LR-) of 0.3 for falls in the past week. TUG testing was not useful for falls in the past week, but performed best for more distant falls in the past month, 6 months, or year. TUG cutoffs with sensitivity over 80% and LR(-) of 0.17-0.32 could be identified for these time periods.

Conclusion

Over 40% of community-dwelling elder ED patients report a fall within the past year. Balance plate and TUG testing were feasibly conducted in an ED setting. There is no relationship between scores on balance plate and TUG testing in these patients. In regression analysis, neither modality was significantly associated with patient provided history of falls. These modalities should not be adopted for screening purposes in elders in the ED setting without validation in future studies or as part of multi-factorial risk assessment.

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients?

BACKGROUND

Fall-related morbidity is a serious public health issue in older adults referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas the specific assessment of functional consequences and opportunities for prevention remain scarce. The aim of this study was to determine the factors influencing 6-month independence.

METHODS

We used a prospective observational study at the ED of a tertiary teaching hospital over a 6-month period. Uni- and multivariate assessments of factors related to loss of independence were examined.

RESULTS

A total of 367 patients survived to 6 months, mean age was 86 years, and 79% were women. The population was initially healthy and independent. Because this independence reassured the medical staff, more than 42% percent were directly discharged home without any improvement of home facilities; only 63% had recovered their independence at the end of the follow-up. There were 111 patients were hospitalized for 30 days or more. Older patients, initial Katz score, and absence of immediate trauma consequences were associated with an increased risk for loss of independence.

CONCLUSIONS

Because prevention is an emerging role of ED, a multidisciplinary team should evaluate fallers and propose medical and environmental changes as required for those discharged after their ED visit.

Identification of fall risk factors in older adult emergency department patients

OBJECTIVES

Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6-month fall risk in community-dwelling older adults discharged from the emergency department (ED).

METHODS

This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non-ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6-month fall incidence.

RESULTS

A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow-up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow-up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6-month follow-up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one's own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self-reported depression (HR = 1.72, 95% CI = 0.83 to 3.55).

CONCLUSIONS

Falls, recurrent falls, and injurious falls in community-dwelling elder ED patients being evaluated for non-fall-related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self-reported depression, not clipping one's own toenails, and previous falls are all associated with falls after ED discharge.

Management of fall-related injuries in the elderly: a retrospective chart review of patients presenting to the emergency department of a community-based teaching hospital

PURPOSE

To identify current practice for elderly individuals who have sustained a fall-related injury and subsequently presented to the emergency department (ED) of a community-based hospital in Toronto, Ontario.

METHODS

A retrospective longitudinal chart review was conducted for 300 persons, 65 years of age and older, who presented to the ED of a community-based teaching hospital with a fall from June 2004 through May 2005. Data were collected using a tool created by the investigators (based on information gathered through a literature review) to capture information related to risk factors for falling.

RESULTS

Our study sample was demographically similar to elderly individuals in other fall-related studies. Most patients discharged directly from the ED did not receive multidisciplinary care. In the ED, all patients saw a nurse or physician, while only 1.3% (n = 4) saw a physical therapist, 3.0% (n = 9) saw an occupational therapist, and 5.3% (n = 16) saw a social worker. At discharge, 62% (n = 152) had no documented referral for follow-up care. Abilities related to falls in elderly individuals were not consistently assessed in the ED. Frequency of assessment for these abilities was as follows: (1) gait, 10.2%; (2) balance, 4.1%; (3) lower-extremity range of motion, 4.9%; (4) lower-extremity strength, 2.0%; (5) cognition, 26.1%; (6) vision, 2.0%; (7) ability to perform activities of daily living, 7.3%. In the 6 months following the index fall, 8.3% of patients returned to the ED of the same hospital because of a subsequent fall.

CONCLUSIONS

In the ED, fall-related risk factors were not consistently assessed or documented, and few patients received multidisciplinary management. Since elderly individuals who fall commonly present to the ED, the implementation of evidence-based strategies aimed at preventing repeat falls should be considered.

Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention

Little is known about the characteristics of elderly persons who present to an ED after a fall or about the nature of the care received for the fall itself. We identified elders presenting to a large urban United States ED after a fall, determined risk factors that may have contributed to the fall, and assessed the extent to which falls were addressed in the ED setting. One hundred seventeen fallers were identified. Nearly half were aged 80 years or older. After age, polypharmacy was the most common fall risk factor, followed by more than 1 contributing medical condition and cognitive impairment. Fall risk factors differed significantly for older compared with younger subgroups. More than half (57%) who had fallen were admitted. Of the remainder who fell and were discharged, more than half were scheduled for follow-up of their fall-related injury only, with no follow-up scheduled to address prevention of future falls. In summary, elders who present to an ED after having fallen have a variety of risk factors for falls that can be addressed to reduce their risk of future falls and injury; however, many may not receive such follow-up care. There must be increased awareness among ED providers of the need for a medical evaluation of a fall. Randomized trials evaluating the effect of a focused fall risk factor assessment after presentation to the ED may be warranted.

An Emergency Medical Services Program to Promote the Health of Older Adults

OBJECTIVES

To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs.

DESIGN

A cluster sample design evaluation of an intervention conducted by EMS in one of two communities.

SETTING

Two rural communities in upstate New York.

PARTICIPANTS

Two hundred fifty-eight intervention-group and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005.

INTERVENTION

EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients' physicians were notified of screening results to provide interventions. Control group patients were provided usual care.

MEASUREMENTS

Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs.

RESULTS

Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found.

CONCLUSION

EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients' needs.

Trends in Geriatric Emergency Medicine

To better understand future emergency department use, it is valuable to analyze the current emergency department use rates of the geriatric population. This article reviews emergency department use by demographics, causes of death, principal reason for emergency department visits, number of emergency department visits per person per year, prescription drugs used, and recent trends in emergency department visits.

Preventive care in the emergency department: should emergency departments institute a falls prevention program for elder patients? A systematic review

OBJECTIVE

To perform a systematic review of the emergency medicine literature to assess the appropriateness of an intervention to identify, counsel, and refer emergency department (ED) patients >64 years old who are at high risk for falls.

METHODS

The systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. A reference librarian did two PubMed searches using the following: ED visits, patients >64 years old, falls, high risk, and effectiveness of intervention. Emergency Medical Abstracts, Science Citation Index, and the Cochrane Collaboration database were searched. Two team members reviewed the abstracts and selected pertinent articles. References were screened for additional pertinent articles.

RESULTS

Twenty-six articles were reviewed. None were ED-based primary or secondary falls prevention in older patients. One randomized controlled trial of an intervention to decrease subsequent falls in elder community-dwelling patients who presented with a fall showed a structured interdisciplinary approach significantly reducing the number of falls. Two ED-based studies showed it was possible to identify ED patients at risk for falls.

CONCLUSIONS

Based on one randomized controlled trial demonstrating a significant reduction in the risk of further falls, the burden of suffering caused by falls, and other studies demonstrating the value of interventions to reduce the risk of falling, the authors recommend that EDs conduct research to evaluate the effectiveness of clinical interventions to identify, counsel, and refer ED patients >64 years old who are at high risk for an unintentional fall.