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Research paper| Volume 26, ISSUE 1, P84-89, March 2023

Improving care for older patients visiting emergency departments. Are they receiving falls prevention guideline care?

Published:August 19, 2022DOI:https://doi.org/10.1016/j.auec.2022.08.003
Improving care for older patients visiting emergency departments. Are they receiving falls prevention guideline care?
Previous ArticleA scoping review of metaverse in emergency medicine
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      Abstract

      Background

      The primary objective was to examine whether the Emergency Department (ED) treatment of older adults who fall in Australia is concordant with falls prevention and management clinical guideline care recommendations.

      Methods

      A retrospective medical records audit was completed for patients 65years and older, who attended the ED with a fall and were discharged home. An audit tool was developed from local, national, and international falls clinical guidelines.

      Results

      One thousand and twenty-seven patients presented following a fall throughout 2020. One hundred and seven patient medical records were audited. Assessment of cognition (94%), medication review (76%) and use of a falls risk screen (76%) were commonly completed. Under half of the patients had a documented gait evaluation (40%) and review of vision (18%). Concordance with guideline care was more likely for older patients (p = 0.042), with higher levels of comorbidity (p = 0.013), who required care assistance (p = 0.008) and received treatment from a multidisciplinary team (p < 0.001) in an observation ward (p < 0.001).

      Conclusions

      Older patients with increased comorbidities and higher care needs had more falls guideline care recommendations documented. This was likely to occur when patients were moved to the observation ward where more comprehensive care by a multidisciplinary team could occur.

      Keywords

      1. Introduction

      Falls are the second leading cause of unintentional injury deaths worldwide [

      World Health Oragnisation. Falls: World Health Organisation (WHO), 2021 [Update 26 April 2021]. Available from: 〈https://www.who.int/news-room/fact-sheets/detail/falls〉.

      ,
      World Health Organisation
      Step Safely: Strategies for Preventing and Managing Falls across the Life-course.
      World Health Organisation (WHO),, 2021
      ]. The Emergency Department (ED) is often the first place that older people seek help after having a fall [
      • Nickel N.
      • Arendts G.
      • Lucke J.
      • Mooijaart S.
      Geriatric syndromes.
      in: Conroy S. Carpenter C. Banerjee J. Silver Book 2 Quality Urgent Care for Older People. British Geriatric Society. 2021
      〈https://www.bgs.org.uk/resources/silver-book-ii-geriatric-syndromes〉
      ]. In 2019, 32% of ED presentations in Western Australia were from adults aged over 65 years who had fallen [

      Injury Matters. 2021, Western Australian falls report: Incidence of falls-related fatalities, hospitalisations, emergency department attendances and ambulance attendances. Perth (AU): Injury Matters, Government of Western Australia Department of Health; 2021. Available from: 〈https://www.injurymatters.org.au/wp-content/uploads/2021/08/2021WAFallsReport.pdf〉.

      ]. A fall can lead to substantial consequences for older adults functioning and well-being. In the six months following a fall-related ED presentation, up to 52% of patients experience subsequent falls [
      • Harper K.J.
      • Arendts G.
      • Barton A.D.
      • Celenza A.
      Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis.
      Australas J Ageing. 2021; 40: 116-128
      ,
      • Harper K.J.
      • Barton A.D.
      • Arendts G.
      • Edwards D.G.
      • Petta A.C.
      • Celenza A.
      Controlled clinical trial exploring the impact of a brief intervention for prevention of falls in an emergency department.
      Emerg Med Australas. 2017; 29: 524-530
      ,
      • Barker A.
      • Cameron P.
      • Hill K.D.
      • et al.
      RESPOND—a patient-centred programme to prevent secondary falls in older people presenting to the emergency department with a fall: Protocol for a multicentre randomised controlled trial.
      Inj Prev. 2015; 21e1
      ] with 54% of these resulting in serious injury [
      • Lusardi M.M.
      • Fritz S.
      • Middleton A.
      • et al.
      Determining risk of falls in community dwelling older adults: A systematic review and meta-analysis using posttest probability.
      J Geriatr Phys Ther. 2017; 40: 1
      ]. Many also experience functional decline up to 12 months following a fall-related ED presentation [
      • Russell M.
      • Hill K.
      • Day L.
      • Oosterhuis T.
      • Blackberry I.
      • Dharmage S.C.
      Predictors of long‐term function in older community‐dwelling people who have presented to an emergency department after a fall: A cohort study.
      Australas J Ageing. 2015; 34: 47-52
      ,
      • Russell M.A.
      • Hill K.D.
      • Blackberry I.
      • Day L.L.
      • Dharmage S.C.
      Falls risk and functional decline in older fallers discharged directly from emergency departments.
      J Gerontol A Biol Sci Med Sci. 2006; 61: 1090-1095
      ,
      • Tan M.P.
      • Kamaruzzaman S.B.
      • Zakaria M.I.
      • Chin A.V.
      • Poi P.J.
      Ten-year mortality in older patients attending the emergency department after a fall.
      Geriatr Gerontol Int. 2016; 16: 111-117
      ,
      • Harper K.
      Allied Health Care Coordination Teams Preventing Falls in Older Adults Presenting to Emergency Departments.
      University of Western Australia,, Perth (Au)2020
      ]. Those more likely to attend the ED with a fall or fall-related problem are aged 80 years and older, require assistance with activities of daily living (ADL) and have sensory impairment [
      • Harper K.
      Allied Health Care Coordination Teams Preventing Falls in Older Adults Presenting to Emergency Departments.
      University of Western Australia,, Perth (Au)2020
      ,
      • Boyle N.M.
      Falls in Older People: Examining Risk Factors in Specific Subgroups and the Effectiveness of a Specialist-led Falls Prevention Intervention.
      University of Sydney,, Sydney (Au)2017
      ]. With 45% of older patients being discharged directly home [
      • Lowthian J.A.
      • McGinnes R.A.
      • Brand C.A.
      • Barker A.L.
      • Cameron P.A.
      Discharging older patients from the emergency department effectively: A systematic review and meta-analysis.
      Age Ageing. 2015; 44: 761-770
      ] it is essential that falls screening and prevention measures are initiated in the ED setting [
      • Harper K.J.
      • Barton A.D.
      • Arendts G.
      • Edwards D.G.
      • Petta A.C.
      • Celenza A.
      Controlled clinical trial exploring the impact of a brief intervention for prevention of falls in an emergency department.
      Emerg Med Australas. 2017; 29: 524-530
      ].
      A recent systematic review by Harper et al. [
      • Harper K.J.
      • Arendts G.
      • Barton A.D.
      • Celenza A.
      Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis.
      Australas J Ageing. 2021; 40: 116-128
      ] found that multifactorial falls prevention services initiated in the ED did not significantly reduce the proportion of future falls in older adults. However, multifactorial intervention did significantly reduce fall-related injuries and hospital admissions with low heterogeneity [
      • Harper K.J.
      • Arendts G.
      • Barton A.D.
      • Celenza A.
      Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis.
      Australas J Ageing. 2021; 40: 116-128
      ]. Current national and international falls clinical guidelines state that identifying falls risk factors and initiating interventions in the ED is crucial to reduce a patient’s risk of future falls [
      • Nickel N.
      • Arendts G.
      • Lucke J.
      • Mooijaart S.
      Geriatric syndromes.
      in: Conroy S. Carpenter C. Banerjee J. Silver Book 2 Quality Urgent Care for Older People. British Geriatric Society. 2021
      〈https://www.bgs.org.uk/resources/silver-book-ii-geriatric-syndromes〉
      ,
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ,
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ]. However, previous research has found low levels of staff adherence to provision and documentation of guideline care recommendations [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ,
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ].
      A study completed by Tirrell et al. [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ] found that fewer than 20% of older patients presenting after a fall had half of the guideline recommendations documented [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ]. In a similar study 17.5–25.8% of patients who presented to ED with a fall were asked the recommended Danish Health Authority (DHA) falls screening questions [
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ]. To date there have been no studies performed in Australia to evaluate adherence with falls prevention and management guidelines with older adult fallers presenting to ED. With the introduction of interdisciplinary allied health teams (such as Care Coordination Teams) and geriatric services to ED over the past 10–15 years, practice now provides more comprehensive care to older patients [
      • Harper K.J.
      • Arendts G.
      • Barton A.D.
      • Celenza A.
      Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis.
      Australas J Ageing. 2021; 40: 116-128
      ,
      • Johnson L.
      • Cusick A.
      Emergency departments: An emerging context of Australian allied health practice.
      J Allied Health. 2009; 38: 29E-35E
      ,
      • Waldron N.
      • Dey I.
      • Nagree Y.
      • Xiao J.
      • Flicker L.
      A multi-faceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls.
      BMC Geriatr. 2011; 11: 6
      ,
      • Cassarino M.
      • Robinson K.
      • Quinn R.
      • et al.
      Effectiveness of early assessment and intervention by interdisciplinary teams including health and social care professionals in the emergency department: Protocol for a systematic review.
      BMJ Open. 2018; 8 (Available from)e023464
      〈https://bmjopen.bmj.com/content/bmjopen/8/7/e023464.full.pdf〉
      ]. This study aims to examine whether this has impacted on the ED treatment for older adult fallers in an acute hospital ED and if their care is concordant with local, state, and international falls guideline care recommendations.

      2. Methods

      2.1 Study design

      A single-centred retrospective cross-sectional study was completed. Data was extracted from patient medical records for patients aged 65 years and older who presented to ED following a fall. Reporting adheres to the STROBE statement for observational studies [
      • von Elm E.
      • Altman D.G.
      • Egger M.
      • et al.
      The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies.
      Epidemiol. 2007; 18: 800-804
      ].
      The primary aim was to examine whether ED treatment for older adults who present to an acute hospital after a fall was concordant with falls prevention and management guideline care recommendations, including local hospital guidelines; Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals [
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ]; and the Geriatric Emergency Department Guidelines (GEDG) [
      American College of Emergency Physicians
      The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
      Geriatric Emergency Department Guideline. United States of America,, 2013
      〈https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf〉
      ]. The secondary aim was to examine factors associated with enhanced levels of adherence to support future practice.

      2.2 Setting

      The study was completed at a tertiary hospital in Perth, Western Australia. The ED has an aggregated annual presentation of approximately 75,000 patients with 35% (n = 26,250) of these over 65 years of age and 50% (n = 37,500) of patients discharged home from the ED.

      2.3 Participants

      Inclusion criteria consisted of patients aged 65 years and older who presented to the ED following a fall. A fall was defined as an event which resulted in a person coming to rest inadvertently on the ground or floor or other lower level [

      World Health Organization (WHO). Falls, 2021. Available from: 〈https://www.who.int/news-room/factsheets/detail/falls#:~:text=A%20fall%20is%20defined%20as%20an%20event%20which,be%20fatal%20or%20non-fatal%281%29%20though%20most%20are%20non-fatal〉.

      ]. Patients may have had any comorbidities or experienced a medical episode. Patients received treatment in the main department, fast track or observation ward by any health professional and were discharged home. Patients admitted to the hospital or transferred to another hospital were the only exclusion criteria for this study.
      Initial electronic data for all patients who presented following a fall between January 1, 2020 and December 31, 2020 were extracted from the Emergency Department Information System (EDIS). EDIS is an administrative and clinical database that tracks ED presentations in real time. Fields extracted included: patient age, treatment location and discharge point (main department, fast track or observation ward), arrival date and time, discharge date and destination, symptom code, symptom description, and ICD10.
      One investigator electronically interrogated the data extracted from EDIS for patients who had fallen. The cohort was narrowed to include only patients 65 years or older with a presenting problem, and ED diagnosis (ICD 10) or free-text complying with the fall’s definition. Patients who had fallen and were discharged from the ED were identified. As this was a descriptive observational study, a priori power calculation was not appropriate. A convenience sample, based on 10% of the presenting population for the study period, resulted in a final sample size of n = 107 eligible patients evenly distributed over the study period and proportionally stratified between treatment locations. Patients may have transferred through different treatment locations, however at the medical records audit, treatment location and single study enrolment were cross-checked.

      2.4 Audit tool and data variables

      An audit tool was developed and piloted by a trained occupational therapy clinical research assistant with patients meeting the inclusion criteria (Appendix 1) [
      • Vassar M.
      • Matthew H.
      The retrospective chart review: Important methodological considerations.
      J Educ Eval Health Prof. 2013; : 10
      ]. It included patient descriptor data and falls characteristics. Patient descriptors included patient demographics, living arrangements, level of independence with ADL, receipt of formal care services, Clinical Frailty Scale (CFS) [
      • Rockwood K.
      • Theou O.
      Using the clinical frailty scale in allocating scarce health care resources.
      Can Geriatr J. 2020; 23: 210-215
      ] and Charlson Comorbidity Index (CCI) [
      • Charlson M.E.
      • Carrozzino D.
      • Guidi J.
      • Patierno C.
      Charlson comorbidity index: a critical review of clinimetric properties.
      Psychother Psychosom. 2022; 91: 8-35
      ].
      Presenting falls characteristics included time and location of fall; activity when fall occurred; injuries sustained; loss of consciousness; number of falls in last 12 months; independence getting off the floor; experience of a long lie and pre-existing falls risk factors including orthostatic hypotension; foot problems; Parkinson’s disease; stroke; respiratory deficits; alcoholism; visual impairment; gait or balance impairments; depression; vertigo; number and types of medications.
      The audit tool assessed the care provided and adherence with the Australian Preventing Falls Best Practice Guideline [
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ] and the Geriatric Emergency Department Guideline [
      American College of Emergency Physicians
      The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
      Geriatric Emergency Department Guideline. United States of America,, 2013
      〈https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf〉
      ]. These guidelines recommend patients receive a multifactorial falls risk assessment for modifiable and non-modifiable risk factors (Table 1) [
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ,
      American College of Emergency Physicians
      The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
      Geriatric Emergency Department Guideline. United States of America,, 2013
      〈https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf〉
      ]. The Australian Preventing Falls Best Practice Guidelines aims to improve the safety and quality of care for older people and ensure a consistent approach to preventing falls using best practice in Australian Hospitals [
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ]. The guideline encompasses 11 items that address the use of a falls risk screen, syncope, vision, medications, balance and mobility review, cognitive impairment, continence, feet and footwear, dizziness and vertigo, environment and post fall management [
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      ].
      Table 1Level of adherence to ED falls prevention and management clinical care recommendations.
      Geriatric Emergency Department Guidelines
      American College of Emergency Physicians
      The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
      Geriatric Emergency Department Guideline. United States of America,, 2013
      〈https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf〉
      		Australian Hospital Guideline
      • Australian Commission on Safety and Quality in Health Care
      Preventing falls and harm from falls in older people: Best practice guideline for Australian community care, 2009.
      Australian Commission on Safety and Quality in Health Care (ACSQHC),, Sydney2009
      		Local Hospital GuidelineOur Audit ToolLevel of adherence, n (%)

      n = 107
      Falls risk assessment toolFalls risk screenUse of a falls risk screenUse of a falls risk screen81 (76%)
      Multidisciplinary TeamReferral to allied healthReferral to allied health40 (37%)
      Location of fallLocation of fall106 (99%)
      Cause of fallCause of fall69 (64%)
      Falls in previous (XX time)Falls in the previous 12 monthsFalls in previous 12 months34 (32%)
      Near/syncope/orthostaticSyncopeNear/syncope/orthostatic
      • •
        Orthostatic vital signs
      • •
        ECG
      		105 (98%)

      9 (8%)

      71 (66%)
      MelenaMelena0 (0%)
      Review of comorbiditiesReview of comorbidities107 (100%)
      Visual or neurological impairmentsVisionVisual screen Neurological impairments19 (18%)

      105 (98%)
      Alcohol use105 (98%)
      MedicationsMedicationsMedicationsMedications81 (76%)
      Activities of Daily Living reviewFunctional reviewActivities of Daily Living review

      Instrumental Activities of Daily Living review      		39 (36%)

      38 (35%)
      Balance and mobility reviewMobility impairmentGait evaluation

      Gross (n = 43)

      Detailed (n = 43)      		43 (40%)

      10 (23%)

      33 (77%)
      Presence/absence of proximal motor strengthLower limb strength testing

      Gross (n = 26)

      Detailed (n = 26)      		26 (24%)

      12 (46%)

      14 (54%)
      Lower limb sensation6 (6%)
      Cognitive impairmentCognitive impairmentCognition101 (94%)
      ContinenceUrinary/faecal urgency/retentionContinence89 (83%)
      Feet and footwearFeet and footwear100 (93%)
      Dizziness and vertigoVertigo105 (98%)
      EnvironmentDomestic environmental risks36 (39%)
      Post fall managementPost fall managementPost falls management
      • •
        Provision of education (n = 67)
      • •
        Post discharge referrals
      		32 (48%)

      39 (36%)
      Malnutrition27 (25%)
      Fear of falling4 (4%)
      Similarly, the Geriatric Emergency Department Guideline is a standardised set of care recommendations for the ED [
      American College of Emergency Physicians
      The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
      Geriatric Emergency Department Guideline. United States of America,, 2013
      〈https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf〉
      ]. This guideline identifies 14 items including a comprehensive assessment, identifying the cause and location of a fall and addressing falls risk factors. They recommend use of a falls risk assessment tool, treatment from a multidisciplinary team (MDT), and determining previous falls history.
      Our audit tool incorporated the two guideline’s recommendations and consisted of 25 items such as health professional/s involved, establishment of orthostatic vital signs and completion of an ECG, mobility and function review (including mobility aid and gait evaluation, strength and sensory assessment, ADL evaluation) and review of other falls risk factors including nutrition, melaena, cognition, continence, vision, feet and footwear, vertigo, environmental risk factors, fear of falling and use of a falls risk screening tool. Additional data collected included interventions completed, post discharge referrals and any identifiable barriers. Adherence was calculated for each item where either the guideline care recommendation was provided to the patient (yes) or it was not addressed (no).

      2.5 Data collection

      Data collection was supported by two investigators with cross-checks undertaken to ensure consistency. Data was collected and managed using REDCap electronic data capture tool. The project was registered with the Hospital Quality and Risk Department (QA33952) and deemed to be of negligible risk; as per the National Statement on Ethical Conduct in Human Research (5.1.22) the project was exempt from review by the ‘removed for peer review’ Human Research Ethics Committee. All data was deidentified and analysed in aggregate form.

      2.6 Data analysis

      Data was summarised using frequency distributions for categorical data and means and standard deviations for continuous data. The level of adherence for each care recommendation was calculated by identifying the number and proportion of patients who received the care recommendation in the ED. Group comparisons between patients seen in different ED treatment area, by different professionals or by level of adherence were completed using Chi-squared tests for categorical variables and t tests for continuous variables. Stata version 16.0 (StataCorp, College Station, TX) was used for data analysis.

      3. Results

      One thousand and twenty-seven patients presented to the ED with a fall throughout 2020. A sample of 107 patients underwent a full medical records audit using the audit tool to determine provision of documented falls management and prevention guideline care. Twenty patients received care in fast track, 47 in the main ED and 40 in the observation ward. Forty patients (37%) were seen by the multidisciplinary team consisting of medical, nursing, and allied health staff.

      3.1 Characteristics of older adult fallers

      The mean (SD) age of patients was 83.1 (9.4) years, 60 (56%) females, 75 (70%) community dwelling and 96 (96%) patients stated their primary language was English. Forty-eight patients (45%) were independent with ADL, either with or without aids, whilst 42 (39%) required assistance with personal activities of daily living (PADL) and instrumental activities of daily living (IADL), although for 17 (16%) it was not documented. The mean (SD) CCI was 5.9 (1.9).

      3.2 Presenting fall characteristics

      Medical record documentation indicated most patients sustained a fall indoors (n = 84, 78%) with the most common cause “unknown” (n = 38, 36%), followed by “mechanical” (n = 33, 31%). Seventeen (16%) had a documented loss of consciousness. The most common injuries sustained were lacerations (n = 44, 41%), followed by no documented injuries (n = 26, 24%) or bruising (n = 24, 22%). Patients tended to fall in the morning (n = 32, 30%) and evening (n = 31, 29%) whilst 13 patients (12%) did not have a time of fall documented (Table 2).
      Table 2Emergency department presenting fall characteristics.
      Fast trackMain departmentObservation ward
      (N = 20)(N = 47)(N = 40)p-value
      Location fall0.338
      Indoors15 (75.0%)38 (80.9%)31 (77.5%)
      Outdoors4 (20.0%)9 (19.1%)9 (22.5%)
      Unable to determine1 (5.0%)0 (0.0%)0 (0.0%)
      Fall cause0.252
      Mechanical9 (45.0%)13 (28.3%)11 (28.2%)
      Collapse2 (10.0%)2 (4.3%)2 (5.1%)
      Cardiac0 (0.0%)2 (4.3%)0 (0.0%)
      Unknown8 (40.0%)19 (41.3%)11 (28.2%)
      Alcohol related0 (0.0%)5 (10.9%)8 (20.5%)
      Other1 (5.0%)5 (10.9%)7 (17.9%)
      Time of fall0.225
      Morning (0601–1200)3 (15.0%)13 (27.7%)16 (40.0%)
      Afternoon (1201–1800)5 (25.0%)7 (14.9%)8 (20.0%)
      Evening (1801–2200)8 (40.0%)16 (34.0%)7 (17.5%)
      Overnight (2201–0600)0 (0.0%)6 (12.8%)5 (12.5%)
      Unable to determine4 (20.0%)5 (10.6%)4 (10.0%)
      Long lie on floor (greater than 1 h
      • Blackburn J.
      • Ousey K.
      • Stephenson J.
      • Lui S.
      Exploring the impact of experiencing a long lie fall on physical and clinical outcomes in older people requiring an ambulance: A systematic review.
      Int Emeg Nurs. 2020; 62 (Available from)101148
      〈https://www.sciencedirect.com/science/article/pii/S1755599X22000052〉
      )      		1 (5.0%)2 (4.3%)3 (7.5%)0.876
      Unknown14 (70.0%)29 (61.7%)23 (57.5%)
      Ability to get off floor post fall?4 (20.0%)6 (12.8%)7 (17.5%)0.760
      Unknown7 (35.0%)13 (27.7%)14 (35.0%)
      Injury0.731
      None documented3 (15.0%)9 (19.1%)14 (35.0%)
      Bruising5 (25.0%)12 (25.5%)7 (17.5%)
      Strain0 (0.0%)1 (2.1%)1 (2.5%)
      Lacerations9 (45.0%)20 (42.6%)15 (37.5%)
      Fractures3 (15.0%)5 (10.6%)3 (7.5%)
      Loss of consciousness2 (10.0%)9 (19.1%)6 (15.0%)0.632
      Falls in last 12 months0 (0.0%)11 (23.4%)23 (59.0%)< 0.001
      significantly different for all pairwise comparisons.
      Number of medications mean (SD)7.5 (4.3)5.9 (3.7)6.7 (3.7)0.1863
      Medications
      Antidepressants5 (25.0%)12 (25.5%)14 (35.0%)0.568
      Antipsychotics1 (5.0%)5 (10.6%)2 (5.0%)0.546
      Anticonvulsants1 (5.0%)5 (10.6%)3 (7.5%)0.723
      Benzodiazepine1 (5.0%)3 (6.4%)2 (5.0%)0.953
      Opioids/pain medications1 (5.0%)6 (12.8%)4 (10.0%)0.630
      Sleep aids0 (0.0%)0 (0.0%)0 (0.0%)
      Blood thinners8 (40.0%)15 (31.9%)20 (50.0%)0.230
      Use of mobility aid6 (30.0%)10 (21.3%)17 (42.5%)0.052
      * significantly different for all pairwise comparisons.

      3.3 Adherence to falls prevention and management clinical guidelines

      The range with which history and physical examination findings were concordant with guideline care recommendations was 0–99% (Table 3). Sixty-six (62%) had over half of the guideline care recommendations documented. Adherence levels greater than 75% were seen in thirty-two (30%) patients. Forty patients (37%) were seen by a multidisciplinary team. Eighty-one patients (76%) had a medication review documented and a falls risk screen completed. Assessment of baseline vision was documented for 19 patients (18%). Screening for postural hypotension occurred for 105 patients (98%), however nine (8%) patients had repeated blood pressures taken to establish orthostatic vitals. Documentation of lower limb sensation screening was completed for six patients (6%). Under half of the patients had a documented gait evaluation (n = 43, 40%), but of those completed 33 (77%) were detailed gait assessments. Thirty-three (85%) of these patients received treatment from a multidisciplinary team. Verbal falls prevention education was provided to 32 patients (48%) and 39 (36%) received referrals for follow-up community care (Table 1).
      Table 3Patient and services factors associated with adherence with core guideline recommendations.
      Level of adherence
      Factors<50%50–75%>75%
      (N = 41)(N = 34)(N = 32)p-value
      overall significant difference between groups.
      Sex
      Male20 (49%)14 (41%)13 (41%)0.727
      Female21 (51%)20 (59%)19 (59%)
      Age mean (SD)83.5 (9.6)80.1 (10.5)85.8 (6.8)0.042
      Lives alone
      No28 (68%)28 (82%)16 (50%)0.020
      Yes13 (32%)6 (18%)16 (50%)
      Charlson Comorbidity Index mean (SD)5.83 (1.76)5.24 (1.94)6.66 (2.10)0.013
      English primary language
      No5 (12%)3 (9%)3 (9%)0.874
      Yes36 (88%)31 (91%)29 (91%)
      Loss of consciousness with fall
      No36 (88%)29 (85%)25 (78%)0.519
      Yes5 (12%)5 (15%)7 (22%)
      Previous function
      Independent18 (62%)16 (55%)8 (25%)0.008
      Required care assistance11 (38%)13 (45%)24 (75%)
      Multidisciplinary team involvement1 (2%)7 (18%)32 (80%)< 0.001
      Location of ED seen< 0.001
      Fast track14 (70%)6 (30%)0 (0%)
      Main department21 (45%)16 (34%)12 (30%)
      Observation ward6 (15%)12 (30%)22 (55%)
      * overall significant difference between groups.

      3.4 Patient and service factors associated with adherence with core guideline recommendations

      Patients that were seen by a multidisciplinary team (n = 40) received a significantly (p = <0.001) higher proportion of guideline recommendations (79%) when compared to a sole discipline (n = 16, 45%). Patients in the observation ward (n = 40, 71%) had higher rates of adherence to guideline care recommendations compared to the main department (n = 47, 56%) and fast track (n = 20, 45%), p = <0.001. Significant factors associated with provision and documentation of greater than 75% of recommended care guidelines included being seen in the observation ward by a multidisciplinary team (p = <0.001), over 85 years of age (p = 0.042), higher CCI (mean = 6.66, SD = 2.1, p = 0.013) and requiring more assistance with ADL (p = 0.008) (Table 3).

      4. Discussion

      Previous retrospective medical audits have found poor staff adherence to best practice falls guideline care recommendations in the ED [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ,
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ]. However, this study found that over half of the falls guideline care recommendations were recorded in 62% of patients audited. Patients who received more guideline care recommendations documented were older, had a higher CCI, required more assistance with ADL, received multidisciplinary team input and were treated in the observation ward. This may indicate that patients at greater risk of falls were directed to and received guideline care.
      A retrospective study by Tirrel et al. [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ] audited 350 patient medical records against 16 guideline care recommendations and found fewer than 20% of older adults presenting to ED received guideline-based care. Similar to our study, those who were older, had a higher CCI, and lived in an aged care facility had greater adherence with the provision of recommended care [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ]. Lillevang-Johannsen et al. [
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ] also reviewed the completion of falls risk screening in the ED setting. During the three-month study period 2664 patients presented to two EDs with 1100 (41%) presenting with a fall. Low levels of risk screening for falls prevention and management were documented with less than 2% of patients asked all four falls risk screening questions.
      Previous studies [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ,
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ] surmised that staff may ask falls related questions but not document their findings, which is a limitation of retrospective audits. However, Lillevand-Johannsen et al. [
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ] noted less than 2.3% of patients had ongoing referrals and suspected this was not the case, instead inferring poor knowledge of the Danish Falls guidelines [
      • Lillevang-Johannsen M.
      • Grand J.
      • Lembeck M.
      • et al.
      Falls in elderly patients are not treated according to national recommendations.
      Dan Med J. 2017; 64: 1-5
      ]. Tirrel et al. [
      • Tirrell G.M.
      • Sri-on J.M.
      • Lipsitz L.A.
      • Camargo C.A.
      • Kabrhel C.M.
      • Liu S.W.
      Evaluation of older adult patients with falls in the emergency department: Discordance with national guidelines.
      Acad Emerg Med. 2015; 22: 461-467
      ] also made this correlation, suggesting widespread training would be required to make ED practice concordant. However, concordance may not be achieved if busy ED clinicians find it time consuming to conduct, which may be why our study showed concordance levels under 50% in the ED fast track.
      McEwan et al. [
      • McEwan H.
      • Baker R.
      • Armstrong N.
      • Banerjee J.
      A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department.
      Int J Emerg Med. 2018; 11: 33
      ] reported concordance with falls guideline care recommendations at two UK hospitals was 62% and 64% in a mixed methods study. Qualitative analysis identified that current workloads and lack of education and training impacted adherence to falls guidelines [
      • McEwan H.
      • Baker R.
      • Armstrong N.
      • Banerjee J.
      A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department.
      Int J Emerg Med. 2018; 11: 33
      ]. Parks et al. [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ] similarly found that ED clinicians reported a lack of knowledge and training about current guidelines, as well as lack of time and high workloads contributing to poor concordance [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ]. These papers indicated that education was required to improve awareness but reported that this necessitated senior staff involvement and collaboration [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ,
      • McEwan H.
      • Baker R.
      • Armstrong N.
      • Banerjee J.
      A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department.
      Int J Emerg Med. 2018; 11: 33
      ]. Support for specialist skill sets, including allied health professionals and geriatric specialists, were also suggested to improve the provision of guideline-based care in the ED [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ,
      • McEwan H.
      • Baker R.
      • Armstrong N.
      • Banerjee J.
      A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department.
      Int J Emerg Med. 2018; 11: 33
      ]. This was found in our study where allied health and geriatric services are available and identified greater adherence with gait evaluation (40% versus 17%) and proximal motor strength evaluation (24% versus 15%) compared to the audit completed by Tirrel, et al. (2015).
      As expected, higher levels of adherence to the falls guidelines were seen in the observation ward, where patients can stay up to 24 h. The ‘four-hour rule’ [
      • Boyle D.A.
      • Mason P.S.
      What has the 4-hour access standard achieved?.
      Br J Hosp Med. 2014; 75: 620-622
      ] affecting other areas of ED may have impacted the level of service provided. Parks et al. [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ] and McEwan et al. [
      • McEwan H.
      • Baker R.
      • Armstrong N.
      • Banerjee J.
      A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department.
      Int J Emerg Med. 2018; 11: 33
      ] both reported that the complexity of treating older adults who have fallen in a time pressured ED setting was a barrier to ensuring provision of guideline-based care. Parks et al. [
      • Parks A.
      • Eagles D.
      • Ge Y.
      • Stiell I.G.
      • Cheung W.J.
      Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.
      Emerg Med J. 2019; 36: 741-747
      ] also found that triaging and the location in which a patient is seen can impact on the level of falls assessment and intervention provided. Over 70% of patients in our study treated in the observation ward had over 75% of the recommendations documented. Southland et al. [
      • Southerland L.T.
      • Vargas A.J.
      • Nagaraj L.
      • Gure T.R.
      • Caterino J.M.
      An emergency department observation unit is a feasible setting for multidisciplinary geriatric assessments in compliance with the geriatric Emergency Department Guidelines.
      Acad Emerg Med. 2018; 25: 76-82
      ] supported the use of an ED observation ward for the assessment and treatment of older adult fallers. Their pilot study demonstrated that comprehensive geriatric assessments and multidisciplinary falls assessments can be completed in an ED setting without impacting length of stay or admission rate and care provided in the observation ward facilitated adherence with GEDG guidelines [
      • Southerland L.T.
      • Vargas A.J.
      • Nagaraj L.
      • Gure T.R.
      • Caterino J.M.
      An emergency department observation unit is a feasible setting for multidisciplinary geriatric assessments in compliance with the geriatric Emergency Department Guidelines.
      Acad Emerg Med. 2018; 25: 76-82
      ].
      Southland et al. [
      • Southland L.T.
      • Lo A.X.
      • Biese K.
      • et al.
      Concepts in practice: geriatric emergency departments.
      Ann Emerg Med. 2020; 75: 162-170
      ] also explored geriatric ED models of care. Four models were proposed including having a geriatric ED unit embedded into the main ED; geriatric practitioners where the entire ED screens geriatric patients and refers to geriatric nurse, nurse practitioner, allied health professionals, and/or geriatrician; geriatric champions who lead initiatives and care pathways but there is no dedicated geriatric service; and a geriatric-focused observation unit which is within the ED but not constrained by the 4 h rule [
      • Southland L.T.
      • Lo A.X.
      • Biese K.
      • et al.
      Concepts in practice: geriatric emergency departments.
      Ann Emerg Med. 2020; 75: 162-170
      ]. To date no research has explored which model of care improves adherence to falls guideline care recommendations. Our ED currently uses the second model of care, where all geriatric patients are screened and if necessary referred onto allied health professionals and/or a geriatrician. Future research could compare if different models of care impact on adherence to provision of guideline care recommendations and patient outcomes.
      Further research is required to measure the level of adherence with falls guideline care recommendations and the impact this has on outcomes such as falls occurrence after discharge from the ED or engagement in falls prevention activities. In addition, with almost half of patients being discharged home from ED [
      • Lowthian J.A.
      • McGinnes R.A.
      • Brand C.A.
      • Barker A.L.
      • Cameron P.A.
      Discharging older patients from the emergency department effectively: A systematic review and meta-analysis.
      Age Ageing. 2015; 44: 761-770
      ] the clinical implications from this study also need to be considered. Equity and consistency of service provision is required and should not be dependent on the location seen in the ED. O’Keefe et al. [
      • O'Keefe A.
      • O'Grady S.
      • Cronin F.
      • et al.
      Evaluation of an emergency department falls pathway for older people: A patient chart review.
      Int Emerg Nurs. 2020; 51 (Available from)100869
      〈http://www.sciencedirect.com/science/article/pii/S1755599X20300410〉
      ] proposed an ED falls pathway highlighting the effectiveness of early identification of older adults at risk of falls to facilitate falls assessment and intervention. This may be a possible solution to support consistency and the quality of service provision. It may also improve screening of falls risk factors where adherence was lower, such as vision, lower limb sensation and screening for fear of falling.

      4.1 Limitations

      This study was a retrospective medical records audit, therefore treating clinicians may have provided falls guideline recommendations but did not document these. Steps were taken to reduce bias such as developing and piloting the audit tool to support data extraction. This study was completed at a single site and therefore the results may not be generalisable to other ED. There were uneven sample sizes between fast track, the main department and the observation ward, however this was proportional to patients seen in these areas throughout 2020. Also, patients that were seen in the observation ward had a greater number of falls in the last 12 months (n = 23) than those in the main department (n = 11) and fast track (n = 0). However, the results of this study showed that those treated in the observation ward were older and had more comorbidities, reflecting the higher number of falls in this group.

      5. Conclusion

      This study has provided evidence regarding the implementation of falls prevention and management guidelines in a contemporary Australian ED setting and can support future service development. Overall, 62% patients had over half of the guideline recommendations documented. The level of implementation was comparable to international studies. Older patients with more comorbidities and greater dependence in ADL received more guideline care recommendations to reduce their future risk of falls. These patients were often treated in the observation ward by a multidisciplinary team.

      Funding

      Funding was granted from Sir Charles Gairdner and Osborne Park Health Care Group Research Advisory Committee (RAC) and the Charlies Foundation for Research to the amount of $5000.

      CRediT authorship contribution statement

      Melinda Williamson: Investigation, Writing − original draft. Annette Barton: Conceptualisation, Writing – review & editing. Deborah Edwards: Conceptualisation, Writing – review & editing. Claire Morrisby: Writing – review & editing. Angela Jacques: Formal analysis. Kristie Harper: Conceptualisation, Methodology, Writing − review & editing, Supervision.

      Conflict of interest statement

      None declared.

      Acknowledgements

      Thanks to the Sir Charles Gairdner Osborne Park Health Care Group Research Advisory Committee and the Charlies Foundation for Research for funding and supporting this research.

      Appendix A. Supplementary material

      .

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      Article info

      Publication history

      Published online: August 19, 2022
      Accepted: August 8, 2022
      Received in revised form: July 27, 2022
      Received: May 24, 2022

      Identification

      DOI: https://doi.org/10.1016/j.auec.2022.08.003

      Copyright

      Crown Copyright © 2022 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. All rights reserved.

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