Effect of a Practice Guideline on the Process of Emergency Department Care of Falls in Elder Patients

Abstract

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...

Effect of a Practice Guideline for Emergency Department Care of Falls in Elder Patients on Subsequent Falls and Hospitalizations for Injuries

“…The 6-7% absolute increase in the proportion of subjects taking calcium and vitamin D supplements is equal to the change in ED prescribing of these supplements from 0% to 6.6% reported in the accompanying paper. 10 There was no significant difference in the proportions of subjects hospitalized with fractures when stratified by self-report of calcium and/or vitamin D supplements at the time of the follow-up telephone interview. Table 3 presents the self-reported falls that occurred during the year following the subject's ED visit.…”

“…10 However, we postulated that there might be changes in outcomes because our intervention also included an information sheet provided to the subjects and a one-time educational intervention directed at their primary care providers.…”

“…The methods of subject recruitment have been previously described in detail. 10 Patients were eligible for the study if they were Ն65 years of age and presented to one of three study EDs for a fall. Exclusion criteria were: falls caused by violent blow, loss of consciousness (fainting/syncope), new stroke or TIA, seizure, sport-or work-related activity, or other higher-risk activity normally associated with falls such as falling off a ladder, chair, fence, or tree.…”

“…9 The 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 the process of ED care as a result of the educational intervention not necessarily measured by review of charts of study subjects. There was some evidence of this as we showed a significant increase in the diagnoses of loss of consciousness, stroke, and transient ischemic attacks (TIAs) in the ED during the postintervention phase of the study.…”

Changing Clinical Practice in Geriatric Emergency Medicine

“…Whom to contact and how to provide access to the process, as well as how to capture the appropriate information for potential subjects, have not been easy tasks for potential sponsors. As the paper by Biros et al 2 in this issue of Academic Emergency Medicine delineates, there are as many possibilities for these activities as there are communities in which studies may be performed. No two study locations may pose the same concerns or difficulties in outreach.…”