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San Juan C, Appiah-Kubi L, Mitropoulos J, Thomson L, Demosthenous A, Kelly AM. Risk factors for older people re-presenting to the emergency department with falls: A case-control analysis. Emerg Med Australas 2024. [PMID: 39086015 DOI: 10.1111/1742-6723.14471] [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: 01/17/2024] [Revised: 06/22/2024] [Accepted: 07/07/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVE Falls are a leading cause for ED presentations among older adults. Existing secondary falls prevention interventions have not been shown to decrease fall-related ED re-presentation, indicating a need to better understand contributing factors. Our aim was to evaluate risk factors for fall re-presentations among the older patient population presenting to the ED. METHODS This is a single-centre case-control study. Cases were patients aged ≥65 years with two falls-related ED presentations within 6 months. Age- and sex-matched controls had a corresponding index, but no subsequent ED fall presentation. Data collected included falls risk factors and clinical features of the index presentation. Univariate and multivariate analyses were conducted to assess the relationship between potential exposures and fall re-presentation. RESULTS A total of 300 patients (mean age 83.8 years) were studied. On univariate analysis, factors significantly associated with ED fall re-presentation included increasing multimorbidity (P < 0.0001), increasing number of medications (P < 0.0001) and residing in residential aged care facility (RACF) (odds ratio [OR] 3.06, P < 0.001). No factors remained significant on multivariate analysis. Post-hoc analyses for the RACF subgroup showed that psychotropic medication use (OR 1.65, P = 0.04) and prior fall within 12 months (OR 2.68, P < 0.001) were significantly associated with re-presentation. Initial presentation with serious musculoskeletal injury was a significant protective factor (OR 0.21, P = 0.02). CONCLUSION The present study failed to identify factors independently associated with ED fall re-presentation, suggesting that the factors are complex and inter-related. Two high-risk populations were identified - those from RACF and those initially presenting with falls not resulting in serious injury.
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Affiliation(s)
- Charlene San Juan
- Department of Geriatric Medicine, Western Health, Melbourne, Victoria, Australia
| | - Linda Appiah-Kubi
- Department of Geriatric Medicine, Western Health, Melbourne, Victoria, Australia
| | - Joanna Mitropoulos
- Department of Geriatric Medicine, Western Health, Melbourne, Victoria, Australia
| | - Lorne Thomson
- Department of Emergency Medicine, Western Health, Melbourne, Victoria, Australia
| | | | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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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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Curiati PK, Arruda MDS, Carpenter CR, Morinaga CV, Melo HMA, Avelino-Silva TJ, Aliberti MR. Predicting posthospitalization falls in Brazilian older adults: External validation of the Carpenter instrument. Acad Emerg Med 2024; 31:688-695. [PMID: 38450932 DOI: 10.1111/acem.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVES This study sought to explore and externally validate the Carpenter instrument's efficacy in predicting postdischarge fall risk among older adults admitted to the emergency department (ED) for reasons other than falls or related injuries. METHODS A prospective cohort study was conducted on 779 patients aged ≥ 65 years from a tertiary hospital in São Paulo, Brazil, who were monitored for up to 6 months post-ED hospitalization. The Carpenter instrument, which evaluates the four risk factors nonhealing foot sores, self-reported depression, inability to self-clip toenails, and prior falls, was utilized to assess fall risk. Follow-up by telephone occurred at 30, 90, and 180 days to identify falls and mortality. Fine-Gray models estimated the predictive power of Carpenter instrument for future falls, considering death as a competing event and sociodemographic factors, frail status, and clinical measures as confounders. RESULTS Among 779 patients, 68 (9%) experienced a fall within 180 days post-ED admission, and 88 (11%) died. The majority were male (54%), with a mean age of 79 years. Upon utilizing the Carpenter score, those with a higher fall risk (≥2 points) displayed more comorbidities, greater frailty, and increased clinical severity at baseline. Regression analyses showed that every additional point on the Carpenter score increased the hazard of falls by 73%. Two primary contributors to its predictive potential were identified: a history of falls in the preceding year and an inability to self-clip toenails. However, the instrument's discriminative accuracy was suboptimal, with an area under the curve of 0.62. CONCLUSIONS While the Carpenter instrument associated with a higher 6-month postadmission fall risk among older adults post-ED visit, its accuracy for individual patient decision making was limited. Given the significant impact of falls on health outcomes and health care costs, refining risk assessment tools remains essential. Future research should focus on enhancing these assessments and devising targeted proactive strategies.
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Affiliation(s)
- Pedro K Curiati
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
- Geriatric Center for Advanced Medicine, Sírio-Libanês Hospital, São Paulo, Brazil
| | - Marcela Dos S Arruda
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
- Gerontology Post Graduate Program, Health Sciences Center, Pernambuco Federal University
| | | | - Christian V Morinaga
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
| | - Hugo M A Melo
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
- Gerontology Post Graduate Program, Health Sciences Center, Pernambuco Federal University
| | - Thiago J Avelino-Silva
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
- Geriatric Center for Advanced Medicine, Sírio-Libanês Hospital, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Marlon R Aliberti
- Geriatric Emergency Department Research Group (ProAGE), Sírio-Libanês Hospital, São Paulo, Brazil
- Geriatric Center for Advanced Medicine, Sírio-Libanês Hospital, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
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Llorens P, Guillén Bobe A, Gallardo Vizcaíno P, Ponte Márquez P, Llauger L, Cañete M, Ruescas E, Espinosa B. [Prognosis in elderly patients with falls treated in emergency departments: The EDEN-3 study]. J Healthc Qual Res 2024; 39:3-12. [PMID: 37914589 DOI: 10.1016/j.jhqr.2023.10.003] [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: 05/02/2023] [Revised: 07/09/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To investigate whether falls in people ≥65 years old are a prognostic factor for adverse events compared to the rest of older patients who consult emergency departments, and identify factors related to a worse long-term evolution. METHOD EDEN cohort that included patients ≥65 years old. Those patients who consulted for fall and the rest were distinguished. Twelve variables were collected. For comparison: two groups matched by fall propensity score. We compared mortality at one year and combined adverse event post-discharge at one year. In patients with falls, variables independently related to evolution were identified. RESULTS Two thousand seven hundred and forty-five patients treated for falls and 22,920 for other reasons. Mortality at one year was 14.4% (9.5% vs. 15.0%, respectively, P<.001) and the combined post-discharge adverse event at one year was 60.6% (52.2% vs. 61.7%, respectively, P<.001). In 4748 patients matched by fall propensity score (2372 in each group), the inverse association between consultation for fall and mortality (HR: 0.705, 95% CI: 0.5880.846) and post-discharge combined adverse event (0.758, 0.701-0.820) remained significant. Factors associated with mortality in patients with falls were ≥80 years (2.097, 1.521-2.891) and comorbidity (2.393, 1.574-3.636) while being female was a protective factor (0.758, 0.584-0.985). Between the factors associated with post-discharge combined adverse hospitalization in the index event was a protective factor (0.804, 0.685-0.943). CONCLUSIONS Patients over 65 years of age treated in the emergency room for falls have a better prognosis. Hospitalization was a protective factor of combined postdischarge adverse event.
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Affiliation(s)
- P Llorens
- Unidad de Estancia Corta y Hospitalización a Domicilio, Servicio de Urgencias, Hospital Doctor Balmis de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, España; En representación de la red SIESTA
| | - A Guillén Bobe
- Servicio de Urgencias, Hospital Miguel Servet, Zaragoza, España; En representación de la red SIESTA
| | - P Gallardo Vizcaíno
- Servicio de Urgencias, Hospital del Mar, Barcelona, España; En representación de la red SIESTA
| | - P Ponte Márquez
- Servicio de Urgencias, Hospital Santa Creu y Sant Pau, Barcelona, España; En representación de la red SIESTA
| | - Ll Llauger
- Servicio de Urgencias, Hospital Universitario de Vic, Vic, Barcelona, España; En representación de la red SIESTA
| | - M Cañete
- Servicio de Urgencias, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, España; En representación de la red SIESTA
| | - E Ruescas
- Servicio de Urgencias, Hospital Universitario Vinalopó, Elche, Alicante, España; En representación de la red SIESTA
| | - B Espinosa
- Unidad de Estancia Corta y Hospitalización a Domicilio, Servicio de Urgencias, Hospital Doctor Balmis de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, España; En representación de la red SIESTA.
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Using Healthcare Resources Wisely: A Predictive Support System Regarding the Severity of Patient Falls. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:3100618. [PMID: 35958052 PMCID: PMC9359836 DOI: 10.1155/2022/3100618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/18/2022]
Abstract
Background An injurious fall is one of the main indicators of care quality in healthcare facilities. Despite several fall screen tools being widely used to evaluate a patient's fall risk, they are frequently unable to reveal the severity level of patient falls. The purpose of this study is to build a practical system useful to predict the severity level of in-hospital falls. This practice is done in order to better allocate limited healthcare resources and to improve overall patient safety. Methods Four hundred and forty-six patients who experienced fall events at a large Taiwanese hospital were referenced. Eight predictors were used to ascertain the severity of patient falls solely based on the above study population. Multinomial logistic regression, Naïve Bayes, random forest, support vector machine, eXtreme gradient boosting, deep learning, and ensemble learning were adopted to establish predictive models. Accuracy, F1 score, precision, and recall were utilized to assess the models' performance. Results Compared to other learners, random forest exhibited satisfying predictive performance in terms of all metrics (accuracy: 0.844, F1 score: 0.850, precision: 0.839, and recall: 0.875 for the test dataset), and it was adopted as the base learner for a severity-level predictive system which is web-based. Furthermore, age, ability of independent activity, patient sources, use of assistive devices, and fall history within the past 12 months were deemed the top five important risk factors for evaluating fall severity. Conclusions The application of machine learning techniques for predicting the severity level of patient falls may result in some benefits to monitor fall severity and to better allocate limited healthcare resources.
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Tang S, Liu M, Yang T, Ye C, Gong Y, Yao L, Xu Y, Bai Y. Association between falls in elderly and the number of chronic diseases and health-related behaviors based on CHARLS 2018: health status as a mediating variable. BMC Geriatr 2022; 22:374. [PMID: 35484497 PMCID: PMC9047259 DOI: 10.1186/s12877-022-03055-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Falling is one of the main causes of death and morbidity in the elderly. This study aims to explore the association between elderly patients with chronic diseases and their health-related behaviors and falls in the elderly, and to provide clues for the prevention and intervention of injuries caused by falls in the elderly. METHODS Based on the basic demographic characteristics data, number of chronic diseases, health-related behaviors, and physical and mental health data of 5867 elderly people aged 60 and above in the 2018 CHARLS data, this paper used ordered logit regression to analyze the correlation between chronic diseases and their health-related behaviors and falls of Chinese elderly. On this basis, it also distinguishes whether there is care or not, explores whether the related factors of falls of elderly people will be different, and tests the intermediary effect of health status to further explore its mechanism. RESULTS The number of chronic diseases and health-related behaviors in the four dimensions of sleeptime, drinking, smoking, and activity are significantly correlated with falls in the elderly. Among them, health status plays a significant mediating role in the relationship of the number of chronic diseases and sleeptime and activity on the falls of the elderly. In addition, compared with the elderly without care, the risk of falls in the elderly in care is only related to the number of chronic diseases and sleeptime, while the elderly without care is related to the number of chronic diseases and multiple factors such as smoking, drinking and activity. CONCLUSION Falls are significantly associated with chronic disease and health-related behaviors, while risk or protective factors for falls vary according to whether older adults are cared for. Therefore, targeted interventions can be made for the factors that affect the fall of the elderly according to different situations.
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Affiliation(s)
- Shaoliang Tang
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China.
| | - Meixian Liu
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Tongling Yang
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Chaoyu Ye
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ying Gong
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ling Yao
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yun Xu
- School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yamei Bai
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
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