Failure of falls risk screening tools to predict outcome: a prospective cohort study

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

BACKGROUND

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

SUMMARY

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

KEY MESSAGES

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

A physiotherapy-led review of guideline-based care for community-dwelling older people presenting to a metropolitan hospital with accidental falls

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.

Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients

OBJECTIVES

Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone.

DESIGN

Retrospective, combined analysis of 2 prospective cohorts.

SETTING AND PARTICIPANTS

Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department.

METHODS

We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models' clinical value (ie, net benefit) against that of falls history for different decision thresholds.

RESULTS

During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively.

CONCLUSIONS AND IMPLICATIONS

The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.

Older Adult Falls in Emergency Medicine, 2023 Update

Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.

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.