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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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van den Broek S, Westert GP, Hesselink G, Schoon Y. Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review. BMJ Open 2023; 13:e066030. [PMID: 36918249 PMCID: PMC10016244 DOI: 10.1136/bmjopen-2022-066030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVE Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults. DESIGN Systematic review. MEASUREMENTS We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest. RESULTS From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low. CONCLUSIONS Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes. PROSPERO REGISTRATION NUMBER CRD42021237345.
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Affiliation(s)
| | - Gert P Westert
- IQ Healtcare, Radboudumc, Nijmegen, Gelderland, Netherlands
| | - Gijs Hesselink
- Intensive Care Department, Radboudumc, Nijmegen, Gelderland, Netherlands
| | - Yvonne Schoon
- Geriatrics Department, Radboudumc, Nijmegen, Gelderland, Netherlands
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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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Development and delivery of an allied health team intervention for older adults in the emergency department: A process evaluation. PLoS One 2022; 17:e0269117. [PMID: 35617330 PMCID: PMC9135235 DOI: 10.1371/journal.pone.0269117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background There is encouraging evidence that interdisciplinary teams of Health and Social Care Professionals (HSCPs) can enhance patient care in the Emergency Department (ED), especially for older adults with complex needs. However, no formal process evaluations of implementations of ED-based HSCP interventions are available. The study aimed to evaluate the development and delivery of a HSCP team intervention for older adults in the ED of a large Irish teaching hospital. Methods Using the Medical Research Council (MRC) Framework for process evaluations, we investigated implementation and delivery, mechanisms of impact, and contextual influences on implementation by analysing the HSCP team’s activity notes and participant recruitment logs, and by carrying out six interviews and four focus groups with 26 participants (HSCP team members, ED doctors and nurses, hospital staff). Qualitative insights were analysed thematically. Results The implementation process had three phases (pre-implementation, piloting, and delivery), with the first two described as pivotal to optimise care procedures and build positive stakeholders’ involvement. The team’s motivation and proactive communication were key to promote acceptability and integration in the ED (Theme 1); also, their specialised skills and interdisciplinary approach enhanced patient and staff’s ED experience (Theme 2). The investment and collaboration of multiple stakeholders were described as essential contextual enablers of implementation (Theme 4). Delivering the intervention within a randomised controlled trial fostered credibility but caused frustration among patients and staff (Theme 3). Discussion This process evaluation is the first to provide in-depth and practical insights on the complexities of developing and delivering an ED-based HSCP team intervention for older adults. Our findings highlight the importance of establishing a team of HSCPs with a strong interdisciplinary ethos to ensure buy-in and integration in the ED processes. Also, actively involving relevant stakeholders is key to facilitate implementation. Trial registration ClinicalTrials.gov, NCT03739515; registered on 12th November 2018.
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Harper KJ, Arendts G, Barton AD, Celenza A. Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis. Australas J Ageing 2021; 40:116-128. [PMID: 33605050 DOI: 10.1111/ajag.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Kristie J Harper
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Glenn Arendts
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Annette D Barton
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Arendts G, Leyte N, Dumas S, Ahamed S, Khokulan V, Wahbi O, Lomman A, Hughes D, Clayden V, Mandal B. Efficiency gains from a standardised approach to older people presenting to the emergency department after a fall. AUST HEALTH REV 2020; 44:576-581. [PMID: 32600521 DOI: 10.1071/ah19187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/27/2019] [Indexed: 11/23/2022]
Abstract
Objective Falls are a major cause of hospital-related costs in people aged ≥65 years. Despite this, falls are often seen as trivial and given low priority in an emergency department (ED), especially in the absence of overt major injury. ED systems that care for falls patients are often inefficient. The aims of this study were to: (1) design and implement a standardised and systematic approach to patients presenting to an ED after a fall; and (2) achieve hospital efficiency gains, such as reduced hospital length of stay, through implementation of this approach. Methods A prospective study was conducted with pre- and postintervention measurement of outcomes. The key features of the intervention were direct admission to an ED short stay unit, standardised assessment of cognition, medications, mobility and discharge risk, and access in the ED to a geriatric consultation service for complex patients. Results In the 12 months of the intervention, 1435 male and female patients aged ≥65 years were enrolled in the study. At the end of 12 months, these patients had significantly higher ED discharge (66% vs 46%; P<0.001) and, if admitted, shorter median hospital stays (6 vs 2 days; P<0.001) compared with the baseline pre-intervention phase. Analysis 1 year later revealed that these outcomes were sustained or further improved. Conclusion A systematic approach to falls in older patients attending the ED is feasible and beneficial. Decreased hospital stay and improved rates of effective discharge from ED back to the community are achievable and sustainable. What is known about the topic? Falls are common, serious and costly. Not identifying and managing falls risk factors is a common feature of ED practice. As a result, admission rates to hospital for patients who fall are high. What does this paper add? In this large study we have shown that a systematic approach to falls assessment is feasible, sustainable and results in higher discharge rates from the ED. What are the implications for practitioners? EDs are the gateway to a hospital bed. It is possible to redesign ED flow and bring front-loaded multidisciplinary geriatric care into an ED short stay environment, to the benefit of patients and health systems.
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Affiliation(s)
- Glenn Arendts
- Emergency Medicine, University of Western Australia, Level 2R Block, QEII Medical Centre, Nedlands, WA 6009, Australia; and Department of Emergency Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ; ; and Corresponding author.
| | - Naomi Leyte
- Department of Emergency Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Sandra Dumas
- Department of Emergency Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Shabana Ahamed
- Department of Geriatric Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Vethanjaly Khokulan
- Department of Geriatric Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Ouday Wahbi
- Department of Emergency Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Andrea Lomman
- Department of Health, Western Australia. Level 1, B Block, 189 Royal Street, East Perth, WA 6004, Australia.
| | - David Hughes
- Department of Geriatric Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Vanessa Clayden
- Department of Emergency Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
| | - Bhaskar Mandal
- Department of Geriatric Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia. ; ; ;
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Abstract
PURPOSE OF REVIEW The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures. RECENT FINDINGS Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.
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Affiliation(s)
- S French
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - S Choden
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA.
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
- Rheumatology Section, Medical Service, San Francisco VA Hospital, San Francisco, CA, USA.
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Cassarino M, Robinson K, O'Shaughnessy Í, Smalle E, White S, Devlin C, Quinn R, Trépel D, Boland F, Ward ME, McNamara R, O'Connor M, McCarthy G, Ryan D, Galvin R. A randomised controlled trial exploring the impact of a dedicated health and social care professionals team in the emergency department on the quality, safety, clinical and cost-effectiveness of care for older adults: a study protocol. Trials 2019; 20:591. [PMID: 31615573 PMCID: PMC6792257 DOI: 10.1186/s13063-019-3697-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/03/2019] [Indexed: 12/03/2022] Open
Abstract
Background Older people are frequent emergency department (ED) users who present with complex issues that are linked to poorer health outcomes following the index visit, often have increased ED length of stay, and tend to have raised healthcare costs. Encouraging evidence suggests that ED teams involving health and social care professionals (HSCPs) can contribute to enhanced patient flow and an improved patient experience by improving care decision-making and thus promoting timely and effective care. However, the evidence supporting the impact of HSCP teams assessing and intervening with older adults in the ED is limited and identifies important methodological limitations, highlighting the need for more robust and comprehensive investigations of this model of care. This study aims to evaluate the impact of a dedicated ED-based HSCP team on the quality, safety, and clinical- and cost-effectiveness of care of older adults when compared with usual care. Methods The study is a single-site randomised controlled trial whereby patients aged ≥65 years who present to the ED of a large Irish hospital will be randomised to the experimental group (ED-based HSCP assessment and intervention) or the control group (usual ED care). The recruitment target is 320 participants. The HSCP team will provide a comprehensive functional assessment as well as interventions to promote a safe discharge for the patient. The primary outcome is ED length of stay (from arrival to discharge). Secondary outcomes include: rates of hospital admissions from the ED, ED re-visits, unplanned hospital admissions and healthcare utilisation at 30 days, and 4 and 6 months of follow-up; patient functional status and quality of life (at baseline and follow-up); patient satisfaction; cost-effectiveness in terms of costs associated with ED-based HSCP compared with usual care; and perceptions on implementation by ED staff members. Discussion This is the first randomised controlled trial testing the impact of HSCPs working in teams in the ED on the quality, safety, and clinical- and cost-effectiveness of care for older patients. The findings of this study will provide important information on the effectiveness of this model of care for future implementation. Trial registration ClinicalTrials.gov, NCT03739515. Registered on 12 November 2018.
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Affiliation(s)
- Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Centre, University of Limerick, Limerick, Ireland.
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Centre, University of Limerick, Limerick, Ireland
| | - Íde O'Shaughnessy
- Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Eimear Smalle
- Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Stephen White
- Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Collette Devlin
- Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Rosie Quinn
- Emergency Department, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Dominic Trépel
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie E Ward
- School of Psychology, Trinity College, The University of Dublin, Dublin, Ireland
| | - Rosa McNamara
- Emergency Department, St. Vincent University Hospital, Dublin, Ireland
| | - Margaret O'Connor
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Gerard McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Damien Ryan
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Centre, University of Limerick, Limerick, Ireland
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Mascarenhas M, Hill KD, Barker A, Burton E. Validity of the Falls Risk for Older People in the Community (FROP-Com) tool to predict falls and fall injuries for older people presenting to the emergency department after falling. Eur J Ageing 2019; 16:377-386. [PMID: 31543730 DOI: 10.1007/s10433-018-0496-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The aims of this study were to (1) externally validate the accuracy of the Falls Risk for Older People in the Community (FROP-Com) falls risk assessment tool in predicting falls and (2) undertake initial validation of the accuracy of the FROP-Com to predict injurious falls (requiring medical attention) in people aged ≥ 60 years presenting to emergency departments (EDs) after falling. Two hundred and thirteen participants (mean age = 72.4 years; 59.2% women) were recruited (control group of a randomised controlled trial). A FROP-Com assessment was completed at a home visit within 2 weeks of ED discharge. Data on falls and injurious falls requiring medical attention were collected via monthly falls calendars for the next 12 months. Predictive accuracy was evaluated using sensitivity and specificity of a high-risk FROP-Com classification (score ≥ 19) in predicting a fall and injurious falls requiring medical attention. Fifty per cent of participants fell, with 60.4% of falls requiring medical attention. Thirty-two per cent were classified as high, 49% as moderate and 19% low falls risk. Low sensitivity was achieved for the FROP-Com high-risk classification for predicting falls (43.4%) and injurious falls (34.4%), although specificity was high (79.4% and 78.6%, respectively). Despite the FROP-Com's low predictive accuracy, the high fall rate and high falls risk of the sample suggest that older people who fall, present to ED and are discharged home are at high risk of future falls. In high-falls-risk populations such as in this study, the FROP-Com is not a valid tool for classifying risk of falls or injurious falls. Its potential value may instead be in identifying risk factors for falling to direct tailoring of falls prevention interventions to reduce future falls.
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Affiliation(s)
- Marlon Mascarenhas
- 1School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA 6485 Australia
| | - Keith D Hill
- 1School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA 6485 Australia
| | - Anna Barker
- 2Department of Epidemiology and Preventative Medicine, The Alfred Centre, Monash University, Melbourne, VIC 3004 Australia
| | - Elissa Burton
- 1School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA 6485 Australia
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Cassarino M, Robinson K, Quinn R, Naddy B, O’Regan A, Ryan D, Boland F, Ward ME, McNamara R, O’Connor M, McCarthy G, Galvin R. Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review. PLoS One 2019; 14:e0220709. [PMID: 31365575 PMCID: PMC6668840 DOI: 10.1371/journal.pone.0220709] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
Background Dedicated Health and Social Care Professional (HSCP) teams have been proposed for emergency departments (EDs) in an effort to improve patient and process outcomes. This systematic review synthesises the totality of evidence relating to the impact of early assessment and intervention by HSCP teams on quality, safety and effectiveness of care in the ED. Methods A systematic literature search was conducted in April 2019 to identify experimental studies examining the effectiveness of ED-based HSCP teams providing services to adults aged ≥ 18 years old and including two or more of the following disciplines: occupational therapist, physiotherapist, medical social worker, clinical pharmacist, or speech and language therapist. Data extraction and quality appraisal of each study were conducted independently by two reviewers. Results Six studies were included in the review (n = 273,886), all describing interdisciplinary Care Coordination Teams (CCTs) caring for adults aged ≥ 65 years old. CCT care was associated with on average 2% reduced rates of hospital admissions (three studies), improved referrals to community services for falls (one study), increased satisfaction (two studies) with the safety of discharge (patients and staff), and with the distribution of workload (staff), improved health-related quality of care (one study). No statistically significant differences between intervention and control groups emerged in terms of rates of ED re-visits, ranging between 0.2% and 3% (two studies); hospital length of stay (one hour difference noted in one study) or mortality rates (0.5% difference in one study). Increased rates of unplanned hospitalisations following the intervention (13.9% difference) were reported in one study. The methodological quality of the studies was mixed. Discussion We found limited and heterogeneous evidence on the impact of HSCP teams in the ED, suggesting a reduction in hospital admissions as well as improved patient and staff satisfaction. More robust investigations including cost-effectiveness evaluations are needed.
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Affiliation(s)
- Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Cluster, University of Limerick, Limerick, Ireland
- * E-mail:
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Cluster, University of Limerick, Limerick, Ireland
| | - Rosie Quinn
- Emergency Department, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Breda Naddy
- Clinical Strategy and Programmes Division, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew O’Regan
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Damien Ryan
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie E. Ward
- School of Psychology, Trinity College, the University of Dublin, Dublin, Ireland
| | - Rosa McNamara
- Emergency Department, St. Vincent’s University Hospital, Dublin, Ireland
| | - Margaret O’Connor
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Gerard McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, Ageing Research Cluster, University of Limerick, Limerick, Ireland
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Barker A, Cameron P, Flicker L, Arendts G, Brand C, Etherton-Beer C, Forbes A, Haines T, Hill AM, Hunter P, Lowthian J, Nyman SR, Redfern J, Smit DV, Waldron N, Boyle E, MacDonald E, Ayton D, Morello R, Hill K. Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial. PLoS Med 2019; 16:e1002807. [PMID: 31125354 PMCID: PMC6534288 DOI: 10.1371/journal.pmed.1002807] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Falls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program-RESPOND-had an effect on falls and fall injuries in older people presenting to the ED after a fall. METHODS AND FINDINGS Community-dwelling people aged 60-90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis-217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43-0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51-1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15-0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts (n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events. CONCLUSIONS In this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).
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Affiliation(s)
- Anna Barker
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Leon Flicker
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Glenn Arendts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Caroline Brand
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Melbourne EpiCentre, University of Melbourne, Melbourne, Victoria, Australia
- Melbourne EpiCentre, Melbourne Health, Melbourne, Victoria, Australia
| | - Christopher Etherton-Beer
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
- Allied Health Research Unit, Monash Health, Melbourne, Victoria, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | | | - Judy Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| | - Samuel R. Nyman
- Department of Psychology and Ageing & Dementia Research Centre, Faculty of Science and Technology, Bournemouth University, Poole, United Kingdom
| | - Julie Redfern
- Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
| | | | - Nicholas Waldron
- Health Networks Branch, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia
| | - Eileen Boyle
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Ellen MacDonald
- Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- * E-mail:
| | - Renata Morello
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Keith Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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12
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Nagaraj G, Hullick C, Arendts G, Burkett E, Hill KD, Carpenter CR. Avoiding anchoring bias by moving beyond 'mechanical falls' in geriatric emergency medicine. Emerg Med Australas 2018; 30:843-850. [PMID: 30091183 DOI: 10.1111/1742-6723.13129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Guruprasad Nagaraj
- Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.,Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Ellen Burkett
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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McEwan H, Baker R, Armstrong N, Banerjee J. A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department. Int J Emerg Med 2018; 11:33. [PMID: 30022394 PMCID: PMC6051952 DOI: 10.1186/s12245-018-0192-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 06/25/2018] [Indexed: 11/25/2022] Open
Abstract
Background The National Institute for Health and Care Excellence (NICE) 2004 Falls guideline was developed to improve the assessment and management of falls and prevention of future falls. However, adherence to the guideline can be poor. As emergency departments (EDs) are usually consulted by older adults (aged 65 and over) who experience a fall, they provide a setting in which assessments can be conducted or referrals made to more appropriate settings. The objective of this study was to investigate how falls are managed in EDs, reasons why guideline recommendations are not always followed, and what happens instead. Methods The study involved two EDs. We undertook 27 episodes of observation of healthcare professional interactions with patients aged 65 or over presenting with a fall, supported by review of the clinical records of these interactions, and subsequently, 30 interviews with healthcare professionals. The qualitative analysis used the framework approach. Results Various barriers and enablers (i.e. determinants of practice) influenced adherence at both EDs, including the following: support from senior staff; education; cross-boundary care; definition of falls; communication; organisational factors; and staffing. Conclusions A variety of factors influence adherence to the Falls guideline within an ED, and it may be difficult to address all of them simultaneously. Simple interventions such as education and pro-formas are unlikely to have substantial effects alone. However, taking advantage of the influence of senior staff on juniors could enhance adherence. In addition, collaborative care with other NHS services offers a potential approach for emergency practitioners to play a part in managing and preventing falls.
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Affiliation(s)
- Helen McEwan
- Department of Psychology, Faculty of Business, Law and Social Sciences, Birmingham City University, C303 Curzon Building, 4 Cardigan Street, Birmingham, B4 7BD, England.
| | - Richard Baker
- Department of Health Sciences, Centre for Medicine, University of Leicester, Leicester, England
| | - Natalie Armstrong
- Department of Health Sciences, Centre for Medicine, University of Leicester, Leicester, England
| | - Jay Banerjee
- Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, England
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Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06160] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BackgroundEmergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.ObjectivesTo systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.Main outcome measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.ResultsOf the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.LimitationsThis review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.Study registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Telephone Care Management of Fall Risk:: A Feasibility Study. Am J Prev Med 2017; 52:S290-S294. [PMID: 28215383 DOI: 10.1016/j.amepre.2016.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/29/2016] [Accepted: 08/11/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Care management has been found to be more effective than usual care for some chronic conditions, but few studies have tested care management for prevention of elder falls. This study aimed to assess the feasibility and preliminary efficacy of telephone care management of older adults presenting for medical attention due to a fall. METHODS The setting was an independent practice association in western Washington serving 1,300 Medicare Advantage-insured patients. Patients aged ≥65 years treated for a fall in an emergency department or their primary care provider's office were contacted via telephone by a care manager within 48 hours of their fall-related visit and invited to participate in a telephone-administered interview to identify modifiable fall risk factors and receive recommendations and follow-up to address identified risk factors. Data from care manager records, patient medical records, and healthcare claims for the first 6 months (November 2009-April 2010) of program implementation were analyzed in 2011. The feasibility of screening and management of fall risk factors over the telephone and the effect on medically attended falls were assessed. RESULTS Twenty-two patients eligible for fall care management were reached and administered the protocol. Administration took 15-20 minutes and integrated easily with the care manager's other responsibilities. Follow-through on recommendations varied, from 45% for those for whom exercise participation was recommended to 100% for other recommendations. No medically attended falls occurred over 6 months of follow-up. CONCLUSIONS Telephone care management of fall risk appears feasible and may reduce falls requiring medical attention.
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Ambrose AF, Cruz L, Paul G. Falls and Fractures: A systematic approach to screening and prevention. Maturitas 2015; 82:85-93. [PMID: 26255681 DOI: 10.1016/j.maturitas.2015.06.035] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 06/23/2015] [Indexed: 01/22/2023]
Abstract
Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated 30-40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries, fear of falling, loss of independence and death in a third of those patients. Falls account for 87 % of all fractures in the elderly. These fractures are almost always due to low impact injuries in osteoporotic bones. Several organizations have recommended screening older patients to identify those with a high risk of falling and, or fractures. The present review provides a brief summary and update of the relevant literature, summarizing screening tools and interventions to prevent falls and fractures. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Recommendations for the clinician to screen and prevent falls in older patients are also summarized.
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Affiliation(s)
- Anne Felicia Ambrose
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, United States.
| | - Lisanne Cruz
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, United States
| | - Geet Paul
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, United States
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17
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Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery 2015; 157:752-63. [DOI: 10.1016/j.surg.2014.10.017] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/22/2014] [Accepted: 10/31/2014] [Indexed: 10/23/2022]
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18
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May L, Gudger G, Armstrong P, Brooks G, Hinds P, Bhat R, Moran GJ, Schwartz L, Cosgrove SE, Klein EY, Rothman RE, Rand C. Multisite exploration of clinical decision making for antibiotic use by emergency medicine providers using quantitative and qualitative methods. Infect Control Hosp Epidemiol 2014; 35:1114-25. [PMID: 25111919 DOI: 10.1086/677637] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers. METHODS We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews. RESULTS Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics. CONCLUSIONS Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, George Washington University, Washington, DC
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19
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Russell M, Hill K, Day L, Oosterhuis T, Blackberry I, Dharmage SC. Predictors of long-term function in older community-dwelling people who have presented to an emergency department after a fall: a cohort study. Australas J Ageing 2014; 34:47-52. [PMID: 24382293 DOI: 10.1111/ajag.12126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To identify factors predictive of function 12 months after a fall and emergency department (ED) presentation. METHODS This was a prospective cohort study with 608 older people who had a fall. After presentation and discharge from the ED, a baseline assessment was initially undertaken and then repeated after 12 months. The Human Activity Profile Adjusted Activity Score (HAP-AAS) at the 12-month follow-up assessment was the functional outcome measure. RESULTS Over the follow-up period, 37.3% (95% CI 33.4, 41.2) of participants declined in their HAP-AAS score. Increased age, pre-index fall functional impairment, poorer mobility/balance, and sustaining falls and severe injuries over the 12-month follow-up period were some of the factors predictive of a lower HAP-AAS score. CONCLUSION This study highlights the importance of preventing falls in the 12 months after discharge from an ED. Some of the factors identified as being predictive of lower function are the same as those previously found to be predictive of falls.
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Affiliation(s)
- Melissa Russell
- Department of Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; National Ageing Research Institute, Parkville, Victoria, Australia
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20
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Flicker L. Advances in research, education and practice in geriatric medicine, 1982-2012. Australas J Ageing 2013; 32 Suppl 2:35-9. [PMID: 24164983 DOI: 10.1111/ajag.12074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Leon Flicker
- Western Australian Centre for Health and Ageing; Centre for Medical Research; Western Australian Institute for Medical Research; Perth West Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth West Australia Australia
- Department of Geriatric Medicine; Royal Perth Hospital; Perth West Australia Australia
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Mikolaizak AS, Simpson PM, Tiedemann A, Lord SR, Close JCT. Systematic review of non-transportation rates and outcomes for older people who have fallen after ambulance service call-out. Australas J Ageing 2013; 32:147-57. [PMID: 24028454 DOI: 10.1111/ajag.12023] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To review the evidence regarding non-transported older people who have fallen in relation to non-transportation rates, outcomes and impact of alternate care pathways. METHOD Electronic databases and reference lists of included studies (up to December 2011) were systematically searched. Studies were eligible if they included data on non-transportation rates, information on outcomes or alternate care pathways for older people who have fallen. RESULTS Twelve studies were included. Non-transportation rates following a fall ranged from 11% to 56%. Up to 49% of non-transported people who have fallen had unplanned health-care contact within 28 days of the initial incident. Attendance by specially trained paramedics and individualised multifactorial interventions significantly reduced adverse events including subsequent falls, emergency ambulance calls, emergency department attendance and hospital admission. CONCLUSION Limited but promising evidence shows that appropriate interventions can improve health outcomes of non-transported older people who have fallen. Further studies are needed to explore alternate care pathways and promote more efficient use of health services.
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Affiliation(s)
- A Stefanie Mikolaizak
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia
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Tiedemann A, Mikolaizak AS, Sherrington C, Segin K, Lord SR, Close JC. Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls. Aust N Z J Public Health 2013; 37:179-85. [DOI: 10.1111/1753-6405.12037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ryan D, Liu B, Awad M, Wong K. Improving older patients’ experience in the emergency room: the senior-friendly emergency room. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.78] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Frail seniors present a unique and growing challenge to emergency healthcare providers because of the complexity of their health conditions, the atypical nature of their presentations, the lack of frailty-focused knowledge and ageism. As a result, elderly patients are more likely to experience adverse events and negative health outcomes than younger people. Fortunately, research in this area has grown dramatically over the last few decades bringing opportunities to improve the elderly patient’s experience in the emergency room. In the present article we use a framework for building more senior-friendly hospitals to review these developments in five key domains – processes of care, the emotional and behavioral environment, ethics in care and research, the physical environment, and organizational support.
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Affiliation(s)
| | - Barbara Liu
- Regional Geriatric Program of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Marlene Awad
- Regional Geriatric Program of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Ken Wong
- Regional Geriatric Program of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
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Naughton C, McGrath E, Drennan J, Johnson F, Lyons I, Treacy P, Fealy G, Butler M. The profile and follow-up of patients who attend the Emergency Department following a fall. Int Emerg Nurs 2011; 20:243-50. [PMID: 23084513 DOI: 10.1016/j.ienj.2011.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 07/13/2011] [Accepted: 07/17/2011] [Indexed: 10/17/2022]
Abstract
UNLABELLED Falls in the older population are associated with increased morbidity and mortality especially in the absence of risk reduction measures. The study aims were to compare the characteristics of older people who present to the Emergency Department (ED) following a fall with the general older ED population and examine referral patterns following ED discharge. Face-to-face interviews were carried out with 306 people aged 65 years or older. Data was collected on demographic, socio-economic, health and social support factors. Descriptive and inferential statistics (Pearson chi-square test or independent t-test) were used to compare the falls and non-falls group. Falls occurred in 17% (53/306) of the study population and 43% sustained an injury requiring medical intervention. Patients in the falls group were significantly more likely to be female (68%), older (79 years (SD 6.6)) and living alone (59%). The physical and mental health profile of the falls and non-falls group was similar with 30-40% of people in both groups experiencing moderate to severe physical health impairment. A third of the falls group was discharged from the ED without evidence of referrals. CONCLUSION The older population that present to the ED following a fall requires comprehensive risk factor assessment especially physical function and referrals that include falls prevention. Implications for staff: ED staff need to examine current practice within their ED in relation to falls assessment, management and referral pathways.
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Affiliation(s)
- Corina Naughton
- UCD School of Nursing, Midwifery and Health Systems, UCD Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland.
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