Prevention of falls in the Emergency Department (ED)/ Clinical Decision Unit (CDU)

Date First Published:
October 11, 2017
Last Updated:
October 11, 2017
Report by:
Dr Tamkeen Pervez , Specialty Registrar Emergency Medicine (St. Mary's Hospital London, Imperial College Healthcare NHS Trust)
Search checked by:
Dr Tamkeen Pervez, St. Mary's Hospital London, Imperial College Healthcare NHS Trust
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.
Search Details:
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
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):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Perceived to 10 highly effective interventions to prevent adult inpatient fall injuries by specialty area: a multihospital nurse survey Huey-Ming Tzeng, Chang-Yi Yin 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.
Journey to a safe environment: fall prevention in an emergency department at a level 1 trauma centre Alexander D, Kinsley TL, Waszinski C 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
Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial Haines T P, Hill A-M, Hill K D, Brauer S G, Hoffman T, et al. 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
Interventions for preventing falls in acute and chronic care hospitals. A systematic review and meta-analysis Coussement J, De Paepa L, Schwendimann, Denhaerynck K, Dejaeger E, Milisen K 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.
Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and metanalysis S Gates, S E Lamb, J D Fisher, M W Cooke, Y H Carter 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
Author Commentary:
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.
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
  2. Alexander D, Kinsley TL, Waszinski C. Journey to a safe environment: fall prevention in an emergency department at a level 1 trauma centre
  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
  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
  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