ORIGINAL CONTRIBUTION
Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines Gregory Tirrell, MS, Jiraporn Sri-on, MD, Lewis A. Lipsitz, MD, Carlos A. Camargo, Jr., MD, DrPH, Christopher Kabrhel, MD, MPH, and Shan W. Liu, MD, SD
Abstract Objectives: The objective was to examine whether the emergency department (ED) evaluation of older adult fallers is concordant with the Geriatric Emergency Department Guidelines. Methods: This study was a chart review of randomly selected older adult ED fall patients from one urban academic teaching hospital. Patients 65 years and older who had ED fall visits in 2012 and who had primary care physicians within our hospital network during the past 3 years were included. Transferred patients were excluded. The data collection instrument was adapted from ED fall evaluation recommendations. Results: There were 350 patients in this study. The mean (SD) patient age was 80.1 (8.8) years, 124 (35%) were male, 327 (93%) were white, and 298 (85%) were community dwelling. The range with which history and physical examination findings were concordant with fall guidelines was 1% to 85%. Cause and location of fall were the two most frequently reported history items (85 and 81%, respectively), while asking about baseline vision was only reported 1% of the time. Evaluating for sensory deficits and muscle strength were the two most frequently reported physical examinations (63 and 48%, respectively), while balance was evaluated with the lowest frequency (1%). Patients who received more guidelinerecommended evaluations were older with more comorbid conditions and were transferred to an observation unit or admitted to the hospital more frequently. Overall, more than half of these elderly patients (56%) were discharged from the ED to their place of preadmission residence. Conclusions: The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines. ACADEMIC EMERGENCY MEDICINE 2015;22:461–467 © 2015 by the Society for Academic Emergency Medicine
M
ore than 30% of adults aged 65 years and older in the United States fall annually.1 In 2005, there were an estimated 20,000 fatal falls and 7.9 million nonfatal falls in the United States, costing approximately $5.7 billion and $68.4 billion, respectively.2 Falls represent the most common reason for unintentional injury-related emergency department (ED) visits for all ages,3 producing 749,000 visits by older adults to the ED in 2009–2010.4 Adults aged 65 years and older
represent a growing portion of ED patients, and treating them requires more ED resources and incurs greater cost than caring for younger patients.5,6 Considering that the older adult population is estimated to double in the next 25 years,7 the appropriate ED evaluation of older adults who have fallen will become increasingly important to reduce morbidity and mortality among this population. There is a robust literature on the evaluation of older adult patients to prevent future falls.8–14 However, there
From the Department of Emergency Medicine (GT, JS, CAC, CK, SWL), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine (JS), Vajira Hospital, Navamindhadhiraj University, Bangkok, Thailand; the Division of Gerontology, Beth Israel Deaconess Medical Center (LL), Boston, MA; the Institute for Aging Research at Hebrew SeniorLife, Harvard Medical School (LL), Boston, MA; and the Department of Epidemiology (CAC), Harvard School of Public Health, Boston, MA. Received August 19, 2014; revisions received October 24 and November 7, 2014; accepted November 8, 2014. Funded by the Hartford Foundation’s Center of Excellence. The authors have no potential conflicts to disclose. Supervising Editor: Manish N. Shah, MD, MPH. Address for correspondence and reprints: Gregory Tirrell, MS; e-mail: [email protected]. A related article appears on page 478.
© 2015 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12634
ISSN 1069-6563 PII ISSN 1069-6563583
461 461
462
have been few studies regarding the evaluation of older adults who have fallen and present to the ED.15,16 Various fall guidelines exist, such as those published by the American Geriatrics Society (AGS) in 2001;8,10,15 however, there is a lack of widely accepted and implemented guidelines for the ED evaluation of older adult fallers.17,18 A previous study15 suggested a guideline for the evaluation and treatment of older adult fallers in the ED, but found no reduction in subsequent falls.19 Another study examined fall risk factors assessed in the ED, but did not specifically evaluate the rate of adherence to the guideline they used.16 The American College of Emergency Physicians, AGS, Emergency Nurses Association, and Society for Academic Emergency Medicine recently (2013) published a comprehensive guideline for the care of geriatric patients in the ED based on topics including staffing, necessary equipment in a geriatric ED, and standard procedures for the treatment of geriatric patients, among others.18 It is not known how well the current evaluation of older adult fallers in the ED is concordant with AGS and Geriatric Emergency Department Guidelines (GEDG) recommendations. In this study, we examined the extent to which the ED evaluation of older adult fallers is concordant with AGS and GEDG guidelines.8,18 METHODS Study Design This was a retrospective study in which we collected data through chart review of older adult patients who presented to an urban, Level I trauma center teaching hospital ED that averages 100,000 annual ED visits. The hospital’s institutional review board approved this study. Study Setting and Population We included all patients aged 65 and older who presented to the ED for falls between January 1, 2012, and December 31, 2012. This time period was chosen to exclude any seasonal bias in demographics of older adult fall patients or causes of falls. It was also the most recent complete calendar year at the time of data collection. We compiled a list of each patient aged 65 and older who presented to our ED, who had an admitting International Classification of Diseases, revision 9 (ICD9) “E” code of an accidental fall (E880–E886 and E888) and had been seen by a primary care physician affiliated with this hospital in the past 3 years (to improve the likelihood that we would be able to collect follow-up data after the patient’s discharge from the ED, as well as to improve the validity of patient comorbidities). We excluded patients who were transferred to our ED from other hospitals because these patients are more likely to have missing data and a higher likelihood of not following up within our network. We listed patients by ED visit dates and then selected patients based on a random-number generator. Study Protocol Our instrument was adapted from the recommendations of the AGS and the British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older
Tirrell et al. • EVALUATION OF OLDER ADULT ED PATIENTS
Persons, 2010,8 and the GEDG.18 These guidelines recommend multifactorial fall risk evaluations for well-known modifiable and nonmodifiable factors such as orthostatic hypotension,11,15,20–22 vision,11,21,23–27 hearing,25–27 balance and gait,11,15,20–22,28,29 medication,15,20–23,25,27–33 activities of daily living (ADLs) and instrumental ADLs (IADLs),15,27,34 cognition,11,15,21,25,27 depression,21 neurological and musculoskeletal function,21,23,27,34 muscle strength,15,20,22,23,35 alcohol use,15,25 certain comorbidities and health problems,21,32,34,36 review of lighting in the environment and other environmental hazards,15,21–25,28,29,37 fall history,11,15,27,28,30,36,37 exercise,20,24,25,29,30,38 behavior modification,20,23,37 feet,15,21 footwear,21 and assistive devices.21,27,37 Certain items from the guidelines on which our instrument was based were modified or omitted due to the availability of corresponding data within patient charts. Asking for falls within the prior 12 months was changed because certain nursing forms at our hospital asked about fall history in the previous 3 months, as well as a 3-month fall history timeline recommended by the study conducted by Baraff et al.15 We did not record any data relating to heart rate and blood pressure responses to carotid sinus stimulation as recommended, because that information was not readily available. We altered “change in mental status” into a more comprehensive “cognitive assessment.” The categories for “cause of fall” were taken from Baraff et al.’s ED practice guideline for elder falls.15 “Cause of fall” categories are further delineated in Baraff et al’s article (e.g., aging/functional decline includes weakness, poor balance, impaired proprioception or sensation, vision problems, and hearing problems). Data for “cause of fall” were taken from the “history of present illness” section of the physician note. If there was an attempt to explain the circumstances of the fall, but the reviewers could not fully understand those circumstances, the cause of fall was marked “unclear.” Some indication of the mechanism of the fall had to be present in the ED chart for a cause to be assigned to it. We included “sports or occupation” from the physician assessment of cause to the “environmental (extrinsic factors)” category of cause of fall, and moved “nutritional deficiency” from the physician assessment to the “other medical problems” category cause of fall. Categories presented in “causes of falls in older persons” that had no results were not reported. All other data were collected from any relevant note relating to patients’ care in the ED. All laboratory reference ranges were taken from the laboratory and hospital standard reference ranges. Hemoglobin was used as a surrogate for a full complete blood count (CBC). Orthostatic hypotension was defined as a ≥ 20 mm Hg drop in systolic blood pressure or a ≥ 10 mmHg drop in diastolic blood pressure.39 Diagnostic imaging was labeled abnormal only for acute abnormalities or new findings. We weighed comorbidities according to the Charlson comorbidity index.40 Our study initially focused on the concordance of care with the AGS guidelines due to the fact that no widely accepted ED-specific guidelines existed. However, the GEDG was released in 2013 after we had nearly finished our data collection. Given that the GEDG guidelines
ACADEMIC EMERGENCY MEDICINE • April 2015, Vol. 22, No. 4 • www.aemj.org
were ED-specific, we decided to abstract additional data to see how our ED evaluation compared to the GEDG. Data were collected on the rate at which 16 items recommended by the AGS and GEDG guidelines had been performed in the ED. We then categorized patients by the number of guideline variables performed and reported differences in demographic data and disposition. Data collection was performed by a physician and a research assistant. To establish reliability, a random sample of 5% of the 350 randomly selected charts was reabstracted and the results obtained by the two data collectors were compared. Data were collected and managed using REDCap electronic data capture tools.41 REDCap is a secure, Web-based application designed to support data capture for research studies (www.projectredcap.org). Data Analysis Data were summarized as mean standard deviation (SD) or percentages. We analyzed patient characteristics according to how many guideline items were performed. All analyses were performed using STATA (version 13.0), and a p-value of 0.99 0.815 >0.99
59 (53.5–64.1) 41 (35.4–45.9) 1 (0.3–2.9)
55 (44.2–64.8) 44 (34.2–54.8) 1 (0–5.6)
62 (54.4–69.0) 38 (30.5–45.1) 1 (0–3.0)
57 (44.7–68.6) 43 (31.4–55.3) 0 (0–5.0)
0.471 0.489 >0.99
94 (91.3–96.5) 6 (3.5–8.7)
93 (85.7–97.0) 7 (2.9–14.3)
94 (90.1–97.3) 6 (2.7–9.9)
96 (88.3–99.1) 4 (0.9–11.70)
0.683 0.683
38 32 20 11
(32.6–43.0) (26.9–36.9) (15.9–24.6) (7.6–14.3)
44 30 15 10
(34.2–54.8) (21.1–40.0) (8.9–24.2) (5.1–18.1)
37 30 23 10
(30.0–44.5) (23.3–37.0) (17.3–30.0) (6.0–15.3)
31 39 18 13
(20.2–42.5) (27.6–51.1) (10.0–28.9) (5.9–22.4)
0.181 0.34 0.275 0.833
52 33 12 1 0 0 1
(46.6–57.3) (28.2–38.3) (9.0–16.2) (0.3–2.9) (0–1.6) (0–1.6) (0.3–2.9)
63 28 5 2 0 0 2
(52.5–72.5) (19.2–37.8) (1.7–11.6) (0.2–7.2) (0–3.7) (0–3.7) (0.2–7.2)
46 37 15 1 1 1 0
(39.0–54.0) (30.0–44.5) (10.1–20.9) (0–3.0) (0–3.0) (0–3.0) (0–2.0)
51 31 15 3 0 0 0
(39.3–63.3) (20.2–42.5) (7.9–25.7) (0.3–9.7) (0–5.0) (0–5.0) (0–5.0)
0.032 0.262 0.042 0.224 >0.99 >0.99 0.118
Data are reported as % (95% CI) unless otherwise noted.
Table 2 ED Adherence to Guidelines
GEDG Guideline Location of fall Cause of fall Near/syncope/orthostasis Fall in the previous (XX time) Time spent on the floor or ground Melena Visual or neurological impairments
AGS Guideline
Our Instrument
Environmental hazards Postural hypotension Two or more falls in prior 12 months Other neurological impairments Visual acuity Heart rate and rhythm
Activities of daily living Difficulty with gait and/or balance Appropriate footwear Presence/absence of proximal motor strength
Difficulty with walking or balance Evaluate gait and balance Feet and footwear Muscle strength
ED Adherence, n (%)
Fell indoor/outdoor Cause of fall Orthostatic vital signs Was fall history asked about?
282 299 43 79
(81) (85) (12) (23)
Time of floor/ground noted Asked about recent melena Patient evaluated for sensory deficits Was baseline vision asked about ECG Evaluation of ADLs Evaluation of IADLs Gait evaluation Balance evaluation Foot problems Proximal motor strength evaluated
13 10 220 3 127 150 148 59 4 5 52
(4) (3) (63) (1) (36) (43) (42) (17) (1) (1) (15)
Muscle weakness
168 (48)
ADL = activities of daily living; AGS = American Geriatric Society; ECG = electrocardiogram; GEDG = Geriatric Emergency Department Guidelines; IADL = instrumental activities of daily living.
older, had a slightly higher Charlson comorbidity index score (which is weighted by age), and were discharged home much less frequently than patients who had fewer guideline recommendations performed. Older patients with more comorbid conditions may have received more thorough fall evaluations for several
reasons. They may have stayed in the ED longer so perhaps had more time to have consulting specialists evaluate them. Clinicians may also be biased to giving older patients with more illnesses more comprehensive evaluations. Last, older patients with more comorbid conditions may have presented with more severe acute
ACADEMIC EMERGENCY MEDICINE • April 2015, Vol. 22, No. 4 • www.aemj.org
465
Table 3 Disposition From the ED Number of Items Guideline Items Reported Discharge to place of preadmission residence Admit to hospital Transfer to observation Discharge to (new) nursing home
Overall (n = 350)
0–3 Items (n = 97)
4–6 Items (n = 181)
53 (48.4–58.7)
86 (77.0–91.90)
50 (42.2–57.2)
≥7 Items (n = 72) 19 (11.0–30.5)
Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines Gregory Tirrell, MS, Jiraporn Sri-on, MD, Lewis A. Lipsitz, MD, Carlos A. Camargo, Jr., MD, DrPH, Christopher Kabrhel, MD, MPH, and Shan W. Liu, MD, SD
Abstract Objectives: The objective was to examine whether the emergency department (ED) evaluation of older adult fallers is concordant with the Geriatric Emergency Department Guidelines. Methods: This study was a chart review of randomly selected older adult ED fall patients from one urban academic teaching hospital. Patients 65 years and older who had ED fall visits in 2012 and who had primary care physicians within our hospital network during the past 3 years were included. Transferred patients were excluded. The data collection instrument was adapted from ED fall evaluation recommendations. Results: There were 350 patients in this study. The mean (SD) patient age was 80.1 (8.8) years, 124 (35%) were male, 327 (93%) were white, and 298 (85%) were community dwelling. The range with which history and physical examination findings were concordant with fall guidelines was 1% to 85%. Cause and location of fall were the two most frequently reported history items (85 and 81%, respectively), while asking about baseline vision was only reported 1% of the time. Evaluating for sensory deficits and muscle strength were the two most frequently reported physical examinations (63 and 48%, respectively), while balance was evaluated with the lowest frequency (1%). Patients who received more guidelinerecommended evaluations were older with more comorbid conditions and were transferred to an observation unit or admitted to the hospital more frequently. Overall, more than half of these elderly patients (56%) were discharged from the ED to their place of preadmission residence. Conclusions: The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines. ACADEMIC EMERGENCY MEDICINE 2015;22:461–467 © 2015 by the Society for Academic Emergency Medicine
M
ore than 30% of adults aged 65 years and older in the United States fall annually.1 In 2005, there were an estimated 20,000 fatal falls and 7.9 million nonfatal falls in the United States, costing approximately $5.7 billion and $68.4 billion, respectively.2 Falls represent the most common reason for unintentional injury-related emergency department (ED) visits for all ages,3 producing 749,000 visits by older adults to the ED in 2009–2010.4 Adults aged 65 years and older
represent a growing portion of ED patients, and treating them requires more ED resources and incurs greater cost than caring for younger patients.5,6 Considering that the older adult population is estimated to double in the next 25 years,7 the appropriate ED evaluation of older adults who have fallen will become increasingly important to reduce morbidity and mortality among this population. There is a robust literature on the evaluation of older adult patients to prevent future falls.8–14 However, there
From the Department of Emergency Medicine (GT, JS, CAC, CK, SWL), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine (JS), Vajira Hospital, Navamindhadhiraj University, Bangkok, Thailand; the Division of Gerontology, Beth Israel Deaconess Medical Center (LL), Boston, MA; the Institute for Aging Research at Hebrew SeniorLife, Harvard Medical School (LL), Boston, MA; and the Department of Epidemiology (CAC), Harvard School of Public Health, Boston, MA. Received August 19, 2014; revisions received October 24 and November 7, 2014; accepted November 8, 2014. Funded by the Hartford Foundation’s Center of Excellence. The authors have no potential conflicts to disclose. Supervising Editor: Manish N. Shah, MD, MPH. Address for correspondence and reprints: Gregory Tirrell, MS; e-mail: [email protected]. A related article appears on page 478.
© 2015 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12634
ISSN 1069-6563 PII ISSN 1069-6563583
461 461
462
have been few studies regarding the evaluation of older adults who have fallen and present to the ED.15,16 Various fall guidelines exist, such as those published by the American Geriatrics Society (AGS) in 2001;8,10,15 however, there is a lack of widely accepted and implemented guidelines for the ED evaluation of older adult fallers.17,18 A previous study15 suggested a guideline for the evaluation and treatment of older adult fallers in the ED, but found no reduction in subsequent falls.19 Another study examined fall risk factors assessed in the ED, but did not specifically evaluate the rate of adherence to the guideline they used.16 The American College of Emergency Physicians, AGS, Emergency Nurses Association, and Society for Academic Emergency Medicine recently (2013) published a comprehensive guideline for the care of geriatric patients in the ED based on topics including staffing, necessary equipment in a geriatric ED, and standard procedures for the treatment of geriatric patients, among others.18 It is not known how well the current evaluation of older adult fallers in the ED is concordant with AGS and Geriatric Emergency Department Guidelines (GEDG) recommendations. In this study, we examined the extent to which the ED evaluation of older adult fallers is concordant with AGS and GEDG guidelines.8,18 METHODS Study Design This was a retrospective study in which we collected data through chart review of older adult patients who presented to an urban, Level I trauma center teaching hospital ED that averages 100,000 annual ED visits. The hospital’s institutional review board approved this study. Study Setting and Population We included all patients aged 65 and older who presented to the ED for falls between January 1, 2012, and December 31, 2012. This time period was chosen to exclude any seasonal bias in demographics of older adult fall patients or causes of falls. It was also the most recent complete calendar year at the time of data collection. We compiled a list of each patient aged 65 and older who presented to our ED, who had an admitting International Classification of Diseases, revision 9 (ICD9) “E” code of an accidental fall (E880–E886 and E888) and had been seen by a primary care physician affiliated with this hospital in the past 3 years (to improve the likelihood that we would be able to collect follow-up data after the patient’s discharge from the ED, as well as to improve the validity of patient comorbidities). We excluded patients who were transferred to our ED from other hospitals because these patients are more likely to have missing data and a higher likelihood of not following up within our network. We listed patients by ED visit dates and then selected patients based on a random-number generator. Study Protocol Our instrument was adapted from the recommendations of the AGS and the British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older
Tirrell et al. • EVALUATION OF OLDER ADULT ED PATIENTS
Persons, 2010,8 and the GEDG.18 These guidelines recommend multifactorial fall risk evaluations for well-known modifiable and nonmodifiable factors such as orthostatic hypotension,11,15,20–22 vision,11,21,23–27 hearing,25–27 balance and gait,11,15,20–22,28,29 medication,15,20–23,25,27–33 activities of daily living (ADLs) and instrumental ADLs (IADLs),15,27,34 cognition,11,15,21,25,27 depression,21 neurological and musculoskeletal function,21,23,27,34 muscle strength,15,20,22,23,35 alcohol use,15,25 certain comorbidities and health problems,21,32,34,36 review of lighting in the environment and other environmental hazards,15,21–25,28,29,37 fall history,11,15,27,28,30,36,37 exercise,20,24,25,29,30,38 behavior modification,20,23,37 feet,15,21 footwear,21 and assistive devices.21,27,37 Certain items from the guidelines on which our instrument was based were modified or omitted due to the availability of corresponding data within patient charts. Asking for falls within the prior 12 months was changed because certain nursing forms at our hospital asked about fall history in the previous 3 months, as well as a 3-month fall history timeline recommended by the study conducted by Baraff et al.15 We did not record any data relating to heart rate and blood pressure responses to carotid sinus stimulation as recommended, because that information was not readily available. We altered “change in mental status” into a more comprehensive “cognitive assessment.” The categories for “cause of fall” were taken from Baraff et al.’s ED practice guideline for elder falls.15 “Cause of fall” categories are further delineated in Baraff et al’s article (e.g., aging/functional decline includes weakness, poor balance, impaired proprioception or sensation, vision problems, and hearing problems). Data for “cause of fall” were taken from the “history of present illness” section of the physician note. If there was an attempt to explain the circumstances of the fall, but the reviewers could not fully understand those circumstances, the cause of fall was marked “unclear.” Some indication of the mechanism of the fall had to be present in the ED chart for a cause to be assigned to it. We included “sports or occupation” from the physician assessment of cause to the “environmental (extrinsic factors)” category of cause of fall, and moved “nutritional deficiency” from the physician assessment to the “other medical problems” category cause of fall. Categories presented in “causes of falls in older persons” that had no results were not reported. All other data were collected from any relevant note relating to patients’ care in the ED. All laboratory reference ranges were taken from the laboratory and hospital standard reference ranges. Hemoglobin was used as a surrogate for a full complete blood count (CBC). Orthostatic hypotension was defined as a ≥ 20 mm Hg drop in systolic blood pressure or a ≥ 10 mmHg drop in diastolic blood pressure.39 Diagnostic imaging was labeled abnormal only for acute abnormalities or new findings. We weighed comorbidities according to the Charlson comorbidity index.40 Our study initially focused on the concordance of care with the AGS guidelines due to the fact that no widely accepted ED-specific guidelines existed. However, the GEDG was released in 2013 after we had nearly finished our data collection. Given that the GEDG guidelines
ACADEMIC EMERGENCY MEDICINE • April 2015, Vol. 22, No. 4 • www.aemj.org
were ED-specific, we decided to abstract additional data to see how our ED evaluation compared to the GEDG. Data were collected on the rate at which 16 items recommended by the AGS and GEDG guidelines had been performed in the ED. We then categorized patients by the number of guideline variables performed and reported differences in demographic data and disposition. Data collection was performed by a physician and a research assistant. To establish reliability, a random sample of 5% of the 350 randomly selected charts was reabstracted and the results obtained by the two data collectors were compared. Data were collected and managed using REDCap electronic data capture tools.41 REDCap is a secure, Web-based application designed to support data capture for research studies (www.projectredcap.org). Data Analysis Data were summarized as mean standard deviation (SD) or percentages. We analyzed patient characteristics according to how many guideline items were performed. All analyses were performed using STATA (version 13.0), and a p-value of 0.99 0.815 >0.99
59 (53.5–64.1) 41 (35.4–45.9) 1 (0.3–2.9)
55 (44.2–64.8) 44 (34.2–54.8) 1 (0–5.6)
62 (54.4–69.0) 38 (30.5–45.1) 1 (0–3.0)
57 (44.7–68.6) 43 (31.4–55.3) 0 (0–5.0)
0.471 0.489 >0.99
94 (91.3–96.5) 6 (3.5–8.7)
93 (85.7–97.0) 7 (2.9–14.3)
94 (90.1–97.3) 6 (2.7–9.9)
96 (88.3–99.1) 4 (0.9–11.70)
0.683 0.683
38 32 20 11
(32.6–43.0) (26.9–36.9) (15.9–24.6) (7.6–14.3)
44 30 15 10
(34.2–54.8) (21.1–40.0) (8.9–24.2) (5.1–18.1)
37 30 23 10
(30.0–44.5) (23.3–37.0) (17.3–30.0) (6.0–15.3)
31 39 18 13
(20.2–42.5) (27.6–51.1) (10.0–28.9) (5.9–22.4)
0.181 0.34 0.275 0.833
52 33 12 1 0 0 1
(46.6–57.3) (28.2–38.3) (9.0–16.2) (0.3–2.9) (0–1.6) (0–1.6) (0.3–2.9)
63 28 5 2 0 0 2
(52.5–72.5) (19.2–37.8) (1.7–11.6) (0.2–7.2) (0–3.7) (0–3.7) (0.2–7.2)
46 37 15 1 1 1 0
(39.0–54.0) (30.0–44.5) (10.1–20.9) (0–3.0) (0–3.0) (0–3.0) (0–2.0)
51 31 15 3 0 0 0
(39.3–63.3) (20.2–42.5) (7.9–25.7) (0.3–9.7) (0–5.0) (0–5.0) (0–5.0)
0.032 0.262 0.042 0.224 >0.99 >0.99 0.118
Data are reported as % (95% CI) unless otherwise noted.
Table 2 ED Adherence to Guidelines
GEDG Guideline Location of fall Cause of fall Near/syncope/orthostasis Fall in the previous (XX time) Time spent on the floor or ground Melena Visual or neurological impairments
AGS Guideline
Our Instrument
Environmental hazards Postural hypotension Two or more falls in prior 12 months Other neurological impairments Visual acuity Heart rate and rhythm
Activities of daily living Difficulty with gait and/or balance Appropriate footwear Presence/absence of proximal motor strength
Difficulty with walking or balance Evaluate gait and balance Feet and footwear Muscle strength
ED Adherence, n (%)
Fell indoor/outdoor Cause of fall Orthostatic vital signs Was fall history asked about?
282 299 43 79
(81) (85) (12) (23)
Time of floor/ground noted Asked about recent melena Patient evaluated for sensory deficits Was baseline vision asked about ECG Evaluation of ADLs Evaluation of IADLs Gait evaluation Balance evaluation Foot problems Proximal motor strength evaluated
13 10 220 3 127 150 148 59 4 5 52
(4) (3) (63) (1) (36) (43) (42) (17) (1) (1) (15)
Muscle weakness
168 (48)
ADL = activities of daily living; AGS = American Geriatric Society; ECG = electrocardiogram; GEDG = Geriatric Emergency Department Guidelines; IADL = instrumental activities of daily living.
older, had a slightly higher Charlson comorbidity index score (which is weighted by age), and were discharged home much less frequently than patients who had fewer guideline recommendations performed. Older patients with more comorbid conditions may have received more thorough fall evaluations for several
reasons. They may have stayed in the ED longer so perhaps had more time to have consulting specialists evaluate them. Clinicians may also be biased to giving older patients with more illnesses more comprehensive evaluations. Last, older patients with more comorbid conditions may have presented with more severe acute
ACADEMIC EMERGENCY MEDICINE • April 2015, Vol. 22, No. 4 • www.aemj.org
465
Table 3 Disposition From the ED Number of Items Guideline Items Reported Discharge to place of preadmission residence Admit to hospital Transfer to observation Discharge to (new) nursing home
Overall (n = 350)
0–3 Items (n = 97)
4–6 Items (n = 181)
53 (48.4–58.7)
86 (77.0–91.90)
50 (42.2–57.2)
≥7 Items (n = 72) 19 (11.0–30.5)
