Abstract. Objective: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. Methods: A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. Results: During the two years of the study, 1,140 preintervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the ''get up and go test'' (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. Conclusions:The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls. Key words: practice guidelines; accidental falls-prevention and control; aged; emergency medicine; geriatric assessment. ACADEMIC EMERGENCY MEDICINE 1999; 6:1216-1223 T HE U.S. population is growing older, with the most rapid growth among the oldest of the old.1 As a result, an increasing proportion of ED patients will be older citizens.2 Falls are a substantial problem in individuals Ն65 years of age, occurring in 32% of those 65-74, 35% of those 75-84, and 51% of those Ն85 years of age each year.3-7 Falls directly or indirectly cause 12% of all deaths in elders. 5,8 Approximately 5% of falls in older persons result in fractures and another 5-10% result in serious injuries that necessitate medical care. 9-12Though there has been considerable progress made in the evaluation and treatment of frail older citizens, recent surveys have demonstrated that practicing emergency physicians (EPs) are often uncomfortable with these patients, and attribute this to inadequacies in training, research, and continuing education in geriatric emergency medicine. 13,14 To address this issue, the Society for Academic Emergency developed a curriculum and model of care for the emergency medical treatment of elder patients. 15In a parallel attempt to improve EPs' understanding of the special problems of elders, we developed a practice guideline for the ED evaluation and treatment of falls in older persons. We chose falls because we postu...

Abstract. Objective: To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes. Methods: The experimental design was a prepost-intervention comparison with one-year pre-and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters. Results: 1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture. Conclusions: The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures. Key words: practice guidelines; accidental falls-prevention and control; aged; emergency medicine; geriatric assessment; outcomes. ACADEMIC EMERGENCY MEDICINE 1999; 6:1224-1231 F ALLS are a substantial problem in individuals Ն65 years of age 1-5 and directly or indirectly cause 12% of all deaths in the elder population. 3,6 Recent surveys have demonstrated inadequacies in training, research, and continuing education in geriatric emergency medicine. 7,8 In an attempt to improve emergency physicians' (EPs') understanding of the special problems of elders, we developed a practice guideline for the ED evaluation and treatment of falls in older persons. We directed this intervention towards ambulatory, community-dwelling elders in whom a fall might be a sentinel event heralding a functional decline, in the hope that selected interventions might prevent future falls or other events that would lead to the need for medical interventions. The guideline has previously been described in detail. 9The effect of the guideline on the process of ED care is described in a companion article in this issue of Academic Emergency Medicine in which we demonstrated that a one-time educational intervention directed at EPs and nurses coupled with a practice guideline reminder sheet attached to patients' ED charts had a minimal effect on the process of care in the ED as measured by physician and nurse documentation.10 However, we postulated that there might be changes in th...