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Three Part Question

IN [patients presenting to the Emergency Department/Clinical Decision Unit] TO [identify early interventions] For [the prevention of falls]

Clinical Scenario

A 50-year old patient presenting to ED falls in the department and sustains fracture of the wrist. What steps could be taken to reduce the number of falls in patients presenting to the ED/CDU?

Search Strategy

Electronic database utilized for the search were: MEDLINE, CINAHL, EMBASE, Google Scholar and the Cochrane Library, PubMed, Ovid. Also searched the grey literature and went through reference lists to identify relevant additional literature. Bibliographies of all relevant publications were also cross-referenced. The search included all publications in English language until December 2015.
A literature search was conducted to identify articles discussing ‘(early) intervention for falls Prevention in A&E/ acute care/ED’
Inclusion Criteria: Age > 18 years; A&E/ED; CDU; Acute Care Settings
Exclusion Criteria: Age <18 years; Non-acute care settings; Nursing home / Rehabilitation Centre; Falls attributed to specific disease / condition

Search Outcome

The search identified 187 citations, of which 8 publications were finally selected. Further 3 publications were excluded from this as they were conference proceedings and review letters.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Huey-Ming Tzeng 2015 USA	560 staff participants; 5 US healthcare systems; 68 Study units; 10 specialty areas	Study Design: A multihospital survey: Across 5 US hospitals (July 2011 – February 2012) Aim: To identify perceived top 10 highly effective falls prevention measures by specialty in acute hospitals	Effective Interventions	Perceived most effective to least effective: 1. Low positioned bed; locked bed brakes; Mental state assessment; 2. Transparency of falls & related injuries shared across units. ; 3. 1-1 support when in toilet; 4. Maintain call light within reach; Bedrails up; 5. Non-slip footwear; 6. Use of sitter; complete risk assessment once a shift; de-cluttering; 7. Standardized patient education; toileting regime; Patient to demonstrate call light use; Availability of bedside commode; Increased observation & surveillance; A visual identification system for patient at risk of falling 8. Reduce tripping hazard 10. Use of patient’s routine assistive device	Survey. Low response rate (25.81%). Perceived effective measures without statistical collaboration. Not validated in ED/CDU.
Alexander D 2013	Falls as reason for presentation; Age > 70; altered mental status; impaired mobility; nursing judgment of falls risk	Study Design: Introduction of new intervention Aim: Introduction of falls risk assessment tool at triage for early identification & intervention	Introduction of KINDER 1 falls risk assessment tool	Suggested to be useful, however not validated yet.	Interventional study in early stages of implementation; Insufficient data to validate its outcome or usefulness Age specific Falls assessment tool based on questions that are normally asked in our ED No preventive interventions
Terry P Haines 2013 Australia	1206 Patients; acute and rehabilitation inpatients. Inclusion: Age > 60 years; Admissions to cute wards (orthopedic, respiratory medicine, general medicine); Admissions to sub-acute wards (geriatric assessment & rehabilitation; neurological rehabilitation); Cognitively intact (SPMSQ score >8) compared to cognitively impaired subgroup analysis	Study Design: Economic evaluation from a multicenter randomized control trial Aim: Identify circumstances where patient education may be cost-effective in falls prevention	If the proportion of cognitively intact patients falling on the wards is 4% greater than that of the cognitively impaired, the provision of a complete program is likely to be effective		Age specific; Non-ED setting; Intensive multimedia program – questionable applicability to ED; Required additional human resources and time to carry out the program – questionable feasibility to ED setting; Does not take into account patients with transient impaired cognition patients in the acute setting
J Coussemen 2008	3948 Patients; 8 studies: Based in geriatric & rehabilitation units; single acute geriatric/rehabilitation units	Study Design: Systematic review & Metanalysis ; 1996-2001 Aim: Evaluate effectiveness of falls prevention interventions in acute & non-acute hospitals Interventions: Variety of interventions: Vitamin D supplements; Identity bracelets; Carpeted floors; Bed alarms; Education; Physiotherapy; Falls alert signs; Medication review; Eyesight Review	No evidence of effectiveness of falls prevention interventions identified		Heterogeneity of patient population; No specific interventions tested; No focus on ED -only 1 of 8 studies focused on acute admissions (but medical and rehab only); Heterogeneity of interventions, trials included range from single intervention to 2 or more.
S Gates 2008 United Kingdom	6397 patients; Study Populations: all studies focus on patients aged > 65 years	Study Design: Systematic Review & Metanalysis (till March 2007); Studies included: 6 in ED; 13 in non-ED settings Aims: (1) Assessment of risk factors for falling; (2) Treatments to address these risk factors Interventions: Drugs; Environment; Assistive devices; Knowledge; Exercise (supervised/ and unsupervised); Referral	Non-specific vague management		Mean quality score of study 23.8; Clinically diverse trials; Age specific (>65 years); Heterogeneity of assessment criteria; While 6 studies recruited patient from ED, none of the assessments/interventions were carried out in the ED; Heterogeneity of patient characteristics ;Tedious assessment methodology; Non-specific vague management

Comment(s)

There is an obvious lack of studies in the ED setting and full falls screening in the ED has not been validated. Most of the literature is focused on the older population with pre-existing co-morbidities. While there are several universal and other methods for falls prevention, none have been validated in the ED , nor are they focused on the entire adult ED population regardless of age, gender, or reason for presentation.

Clinical Bottom Line

Falls in the acutely ill patient are multifactorial and not restricted to those older than 75 years of age. There is an obvious need to conduct studies aimed at the prevention of falls and early interventions for the acutely unwell patients presenting to the ED, regardless of age, gender and underlying cause.

References

1. Huey-Ming Tzeng, Chang-Yi Yin Perceived to 10 highly effective interventions to prevent adult inpatient fall injuries by specialty area: a multihospital nurse survey Journal: Applied Nursing Research 2015; 28:10-17
2. Alexander D, Kinsley TL, Waszinski C Journey to a safe environment: fall prevention in an emergency department at a level 1 trauma centre J Emerg Nurs. 2013 Jul:39(4):346-52
3. Haines T P, Hill A-M, Hill K D, Brauer S G, Hoffman T, et al. Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial BMC Medicine 2013: 11:135
4. Coussement J, De Paepa L, Schwendimann, Denhaerynck K, Dejaeger E, Milisen K Interventions for preventing falls in acute and chronic care hospitals. A systematic review and meta-analysis J Am Geriatr Soc 2008. Jan;56(1):29-36
5. S Gates, S E Lamb, J D Fisher, M W Cooke, Y H Carter Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and metanalysis BMJ 2008 Jan 19:336:130-3