Date: Summer 2015
Guest Skeptic: Dr. Julie Gyi and Dr. Jordan Jeong. Emergency medicine residents at St. Joseph’s Regional Medical Center in Paterson, New Jersey.
Guest Host: Dr. Chris Carpenter @SAEMEBM. Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. C0-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules.
Case: An 80 year old female presents with left wrist pain following a fall. You diagnose and treat a Colles fracture with no other acute injuries, but at discharge her family wonders if she is at significant risk for further falls and, if so, how to prevent them?
Background: Falls don’t just happen in hospitals and nursing homes. About one in three older adults who live at home suffer a standing level fall every year.
That is over eight million non-fatal falls in the U.S. alone every year. Almost 800,000 fallers present to U.S. EDs annually. This has an estimated yearly cost of $68 billion.
Ground level falls are the number one cause of geriatric-trauma related mortality. The ACEP/SAEM/ENA/AGS Geriatric Emergency Department Guidelines make the following recommendations regarding falls prevention:
- “It is the policy of the Geriatric ED to initiate a comprehensive evaluation for geriatric patients presenting after a fall or for those who may be at high risk for a future fall. Patients will be evaluated for injuries, including those injuries that may be ‘occult’ in the geriatric population. Furthermore, patients will be evaluated for causes of and risk factors for falls. Patients will be assessed prior to disposition for safety with the goal to prevent further injury and falls.”
More information on geriatric falls can be found on SGEM#89 Preventing Falling to Pieces.
Clinical Question: Do older adults receive guideline-directed evaluation in the emergency department following a standing level fall?
Reference: Tirrell G et al. Evaluation of Older Adult Patients with Falls in the Emergency Department: Discordance with National Guidelines. Acad Emerg Med 2015
- Population: Geriatric adults presenting to one academic emergency department after a standing level fall.
- Intervention: Adherence to American Geriatric Society fall prevention guidelines and/or ACEP Geriatric Emergency Department Guidelines recommendations for fall assessment and management
- Comparison: No comparison group (observational study)
- Outcome: Proportion of cases in which history and physical exam incorporated elements of either the American Geriatric Society (AGS) or the American College of Emergency Physician (ACEP) Guideline recommendations for falls
Author’s Conclusions: “The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines.”
Quality Checklist for Observational Trials:
- Did the study address a clearly focused issue? Yes. Randomly selected subset of patients who presented to the ED for falls in 2012, identified via medical record review using ICD-9 codes for accidental fall, excluding patients transferred from another ED.
- Did the authors use an appropriate method to answer their question? No
- Was the cohort recruited in an acceptable way? Yes
- Was the exposure accurately measured to minimize bias? Unsure
- Was the outcome accurately measured to minimize bias? Unsure
- Have the authors identified all-important confounding factors? No
- Was the follow up of subjects complete enough? Unsure
- How precise are the results/is the estimate of risk? See results
- Do you believe the results? Yes
- Can the results be applied to the local population? Yes
- Do the results of this study fit with other available evidence? Yes
Key Results: Over 12 months, 981 patients met eligibility criteria, 450 were randomly selected via random number generator, and 350 were included in the analysis.
- Mean age 80 years
- 35% male
- 85% community-dwelling
- 93% white
- 91% English-speaking.
Adherence to AGS and GED Guidelines was greatest for documentation of fall cause (85%) and location (81%), whle evaluation of gait, balance, footwear, foot-health, vision, floor-time, and recent melena were documented in <5% of charts.
The kappa value for “signs of trauma” was 0.87 (95% CI 0.63-1.00) and 0.76 (95% CI 0.46-1.00) for ’cause of fall’.
- Kappa is one method to measure agreement beyond chance alone when evaluating an event or characteristic or finding that might be subject to interpretation (a subjective finding). Kappa values can range from -1 (perfect disagreement) to 0 (no agreement) to 1 (perfect agreement). Kappa values of 0.87 and 0.76 are excellent and very good.
The authors also reported that more than half of patients were discharged home. Older patients, those with higher co-morbid illness scores, and assisted living patients were more likely to receive more guideline-directed falls assessment.
SGEM Commentary: Older adults in one academic, urban, Level I trauma center ED do not receive AGS or ACEP/SAEM/ENA directed guideline care for older adult fall victims.
This was a retrospective study that adhered to some chart-review methods (Gilbert et al and Worster and Haines). They adhered to using structured abstraction form and assessing inter-abstractor reliability, but they did not elaborate on handling of missing data, training chart abstractors, or defining important variables.
The study is a descriptive study of documented adherence, not a prospective evaluation of first-hand adaptation and incorporation of guideline recommendations into bedside assessment and management.
Nonetheless, failure to document key aspects of older adult fall victims’ risk assessment, such as past-falls, likely represents an accurate portrayal of actual events in the busy emergency department.
Comment on author’s conclusion compared to SGEM Conclusion: Retrospective design limits ability to confidently conclude that guidelines are not used at the point-of-care. In addition, this research is a single hospital that is not representative of general, non-academic emergency departments and the patients (>90% white and English-speaking) are also not representative of many emergency departments.
Despite these limitations, this manuscript adds to an increasing body of evidence from multiple settings indicates that emergency department-based falls care is suboptimal and misses opportunities to prevent future falls.
Significant challenges for future emergency department-based falls investigators include (1) identifying accurate, reliable, and feasible fall-risk stratification instruments (Carpenter et al 2014); (2) assessing available and effective emergency department or post-emergency department interventions to prevent subsequent falls (Carpenter 2010); and (3) understanding the barriers and facilitators for widespread implementation of emergency department-based falls prevention interventions (Carpenter 2015). Future guidelines are more likely to be incorporated into practice if they are based on research in emergency department settings, use resources/personnel that are widely available, use dissemination and implementation science principles, do not impede patient care, and demonstrate significant ability to reduce falls and injurious falls.
SGEM Bottom Line: Older adults visiting emergency departments after an accidental fall do not receive guideline directed assessment, risk-stratification, or management in one large academic emergency department. The keys to better penetration of guidelines are multifold, including producing more evidence-based guidelines, using a targeted dissemination strategy and implementation science to reduce the knowledge-to-action delay from 17-years to something lesser, and providing opportunity for clinicians/policy-makers to adapt guideline recommendations for local settings, capacity, and need.
Case Resolution: After reviewing the previous SGEM podcast on assessing future fall risk, I inform the patient and her family that past falls predict future falls so she is at increased risk. However, since fear-of-falling is a severely limiting consequence of falls in older adults, you provide her with several fall prevention resources to review with her primary care physician at her follow-up appointment in 2-days.
- CDC Older Adults Falls
- NIH Falls and Older Adults
- Carpenter et al. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med 2014
Clinically Application: No current clinical applicability because there were no implementation solutions evaluated, but this research provides opportunity for clinicians and emergency department administrators to review the GED Guidelines and weigh the value of recommendations for their emergency department system.
What do I tell my patient? Falls sometimes represent a window of opportunity to prevent future fallls that can cause life-threatening injury in senior citizens. Multiple organizations like the American Geriatrics Society and the American College of Emergency Physicians have published guidelines about how to risk-stratify fall patients in emergency department settings, but many clinicians are unaware that these recommendations exist. Your physician may ask you some questions or watch you walk to help evaluate your risk of future falls.
Keener Question: Listen to the podcast for the keener question. Send your answer to TbeSGEM@gmail.com The first correct answer will receive a cool skeptical prize.