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Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement
ARTICLE IN PRESS International Emergency Nursing ■■ (2015) ■■–■■
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement Hamid Reza Hatamabadi MD (Associate Professor) a,b, Shima Sum PhD (Assistant Professor) c,*, Ali Tabatabaey MD (Assistant Professor) d, Mohammad Sabbaghi MD (Assistant Professor) b a
Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Emergency Department, Emam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran c Community Medicine, Babol University of Medical Sciences, Mazandaran, Iran d Emergency Department, Qom University of Medical Sciences and Health Services, Qom, Iran b
A R T I C L E
I N F O
Article history: Received 13 December 2014 Received in revised form 9 May 2015 Accepted 17 May 2015 Keywords: Fall Clinical management Emergency department
A B S T R A C T
Introduction: Falls are a major source of injury in the elderly and their incomplete management is a cause for concern by health systems. The present study looks at the current state of managing fall victims in Iran and offers suggestions for improvement. Methods: This was a clinical care audit comparing the state of current care with an institutionally approved optimum. Patients aged 60 years and over presenting with a fall were evaluated and deficiencies in their care were recorded and categorized. These were presented to an expert panel, where the Delphi method was used to come up with a list of actions to address the deficiencies. Furthermore an educational program was implemented based on these suggestions. Chi-squared and t-test were used to evaluate the efficacy of this program in improving treatment. Linear regression analysis was used to find factors affecting care. Results: Overall 431 cases were reviewed. The most common errors during clinical examination were: not performing Romberg test (92.75%) and lack of physiotherapy consultation (82.75%). The educational program had a modest effect on improving the clinical audit processes (β = 3.79; P < 0.001) and medical interventions (β = 2.004; P = 0.002); however, performing the correct diagnostic tests was worse after the program (β = −1.21; P = 0.008). Conclusion: There is a wide gap between the care services delivered in the management of falls and international standards. Therefore, measures should be adopted to close this gap. Education may have a modest positive effect in this regard. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Falls are responsible for much of the injury related morbidity and mortality in the elderly, and the resultant fractures are a major source of economic burden in this population (Marks, 2010). One-third of individuals over 65 and more than half those over 80 years of age suffer at least one fall-related injury each year (Akyol, 2007; Moore et al., 2010). The importance of falls as a source of elderly trauma and its economic burden has been documented around the world (Goodwin et al., 2010; Kwan et al., 2011; Moore et al., 2010; Pfortmueller et al., 2014). Falling is the leading mechanism of injury in the elderly, and is responsible for 70% of all elderly trauma in Iran (Ghodsi et al., 2003). In general, the annual incidence of fall-related injuries in Iran is 143.5 for men and 88.2 for women in 100,000 of
* Corresponding author. Community Medicine, Babol University of Medical Sciences, Mazandaran, Iran. Tel.: +98 1132190560; fax: +98 1132199936. E-mail address: [email protected] (S. Sum).
the population. The numbers increase significantly in individuals over 80 years of age, reaching 848.3 and 854.7 per 1000 in males and females respectively (Abolhassani et al., 2006). The incidence of falls and the resultant complications is on the rise with an increase in the elderly population and this increase will continue unless measures are adopted to improve the services delivered to at risk populations (Hatamabadi et al., 2014). Effective fall prevention can reduce serious fall-related injuries, emergency department visits, hospitalizations, nursing home placements, and functional decline (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). Organized and systematic services based on national standards and evidence-based guidelines can decrease complications, prevent subsequent falls and even decrease mortality and morbidity significantly (Kannus et al., 2005; Moreland et al., 2003). One of the most important considerations in delivering services to elderly patients suffering from fall-related injuries is the quality of the services with emphasis on correct patient evaluation and determination of risk factors which increase susceptibility to falling.
http://dx.doi.org/10.1016/j.ienj.2015.05.001 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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Unfortunately the chance to offer such interventions in the emergency department is often missed by doctors and nurses (Paniagua et al., 2006; Pfortmueller et al., 2014). Proper treatment and offering standard instructions in order to prevent future falls are an integral part of a holistic approach to treatment of falls and their resultant fractures (Kannus et al., 2005). Reports show that in the elderly who undergo comprehensive geriatric evaluations the odds of mortality or morbidity are low and there is a rapid improvement in their cognitive functioning (Feder et al., 2000). The elderly commonly seek treatment in the emergency department (ED) following falls, especially due to traumatic injuries after falling. While ED physicians and nurses focus on possible traumatic injuries, often the critical “teachable moment” after injury is lost. The ED is the best place to diagnose functional disorders leading to and resulting from falls, and ED personnel have the most important role in proper patient referral (Bell et al., 2000; Lee et al., 2012; Shaw et al., 2003). However, current data indicate that a significant percentage of elderly patients are discharged from ED without a proper diagnosis and follow-ups (Goodwin et al., 2010), thus leading to a wide gap between the services offered and international standards and guidelines (Barker et al., 2009; Kalula et al., 2006; Salter et al., 2006). Therefore, it is necessary to revise the therapeutic measures taken up by emergency physicians and nurses in the management of fall victims in an attempt to close the gap with international standards (Goodwin et al., 2010). The present study aims to design a clinical audit to identify the deficiencies, and to present domestic guidelines and suggestions to improve patient care in fall victims. Finally, the authors tested the efficacy of implementing the suggestions through an interventional educational program, on improving the quality of the services delivered. 2. Materials and methods This was a three step quasi-experimental study aiming to assess the level of care provided to elderly fall victims, to make suggestions for improving care, and then to assess the effectiveness of these suggestions. Graph 1 presents a summary of the study steps. The study protocol was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. The first step was a prospective clinical audit of the care provided to elderly fall victims. All patients over 60 years of age who presented to the ED at the Imam Hussein Teaching Hospital in Tehran, Iran with a complaint of falling between January 2012 and December 2012 were included in the study. The care provided to
Aim
Final evaluation
improvement in treatment status and prevention of re-occurrence
Table 1 Summary of audit questionnaire. Demographic information • Age, gender, marital status, educational level, etc. Admission information • type of admission, initial diagnosis, the patient’s ability to present information, stability of the clinical status Important events leading to fall • Location and time of the fall, loss of consciousness, type of the activity leading to the fall, barriers, etc. Patient history • Past medical history, drug history, social history, history of falls and movement limitations etc. Review of systems Physical examination • Including (but not limited to) vital signs, full neurologic examination, cerebellar examinations, Romberg test, visual acuity, evaluating for hearing loss, etc. Evaluation of daily functions • Ability of patient to perform daily activities Evaluation of psychosocial functions • Cognitive abilities based on the mini–mental state examination (MMSE), signs of depression, anxiety, or other psychiatric disorders Diagnostic tests • Complete blood count, Blood Urea, electrolytes, Electrocardiography, etc. Treatment interventions • Including (but not limited to) proper consults, correction of medications, admission, etc. Preventive measures • Patient education, improvement of living environment, etc.
patients was monitored over a 24 hour period and compared with an institutionally approved guideline of optimal care derived from scientific literature. An eleven-part questionnaire was devised to facilitate data extraction (Table 1). This checklist evaluates the delivery of diagnostic and therapeutic services and also steps taken to prevent accidents in future. Initial care for all victims was provided by junior emergency medicine residents and nursing staff. The clinicians providing the care in the ED were not aware of the audit taking place. Descriptive data alongside errors and deficiencies in the management of each patient were recorded. The second step was a qualitative study aiming to generate expert suggestions to improve patient care for elderly fall victims. To achieve this aim the Delphi method was used, which is a widely accepted method used to identify innovative and reliable ideas to prepare proper data for decision-making processes (Linstone and Turoff, 1975). The results of the first step were presented to a panel of
Techniques to achieve the aim Re-evaluation of the performance of the clinical team using a clinical audit and comparison of the data with data before educational intervention Instructing physicians in patient management and presentation of guidelines, at discharge, to improve the environment and prevent falling again
Suggestions of guidelines to improve the therapeutic services delivered
Use of Delphi method and holding sessions with specialists
Identification of deficiencies in the management of the elderly referred to the emergency unit with fall injuries
Evaluation of the performance of the medical team using a clinical audit
Graph 1. The aims of the study and the guidelines to achieve them.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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experts, consisting of geriatricians and emergency medicine specialists, through a second questionnaire. Specific shortcomings in patient care revealed in the audit were outlined, and experts were asked for their suggestions on how to overcome each deficiency. Before use, the questionnaire was submitted to an emergency medicine specialist and a geriatrician and its inter-rater reliability of responses was assessed (Κ = 0.81). Subsequently the responses received in the first round were analyzed and a revised questionnaire containing the suggestions offered in the first round was resubmitted to the expert panel. After the second-round responses were evaluated, the final report was prepared by the team and the draft was discussed and finalized in a live expert panel. In the third step of the study, educational interventions were offered to emergency physicians based on the suggestions generated in step 2 of the study. The educational sessions were held in two 2-hour sessions. The teaching material was based on suggestions made by the expert panel and focused on the institutionally approved treatment guideline. In order to evaluate the efficacy of these educational interventions, the same audit techniques and questionnaires were used to evaluate the management of the elderly suffering from fall injuries in the month following the educational program. The data before and after the educational intervention were compared to reveal any significant improvements in care.
Data were analyzed with SPSS 21.0. Chi-squared test was used to compare diagnostic-therapeutic measures before and after educational intervention. This was done to evaluate the efficacy of this intervention in improving the management of fall victims. In addition, the performance of the treating clinicians in the following fields was evaluated separately: clinical examinations, diagnostic tests, and therapeutic measures. To this end, each of these fields was scored (each correct action received one point). The independent t-test was used to compare these scores before and after the educational program was carried out and to evaluate its effect on the performance of physicians in the management of fall-related injuries. Subsequently a multivariate backward regression model was designed to determine if the educational intervention was actually responsible for the improvement in care and to eliminate the effect of any potential confounders. Statistical significance was defined at P < 0.05 for all the analyses. 3. Results Overall 431 patients were included in the study. The first step of the study included 400 patients presenting with fall-related injuries during the period of one year. In the third step of the study, 31 patients were included within the period of one month following educational interventions.
Table 2 Expert panel suggestions for preventing medical errors in the clinical evaluation and diagnostic tests. Strategy Registration of the patient’s demographic data Registration of clinical and admission data Registration of important moments in the process of care Taking a history
Evaluation of body systems
Clinical examinations
Functional and peripheral examination Evaluation of body function
Psychosocial evaluation
Laboratory tests a b c d e
3
The guidelines suggested – Demographic data; status of health insurance policy; supplementary insurance policy; coverage by a family physician – Type of admission; a history of previous admissions; duration of hospitalization; fall-related factors; level of consciousness; the patient’s ability to provide information; stability of the patient’s clinical state at the time of admission; drugs taken at the time of admission; the principal diagnosis – The time of arrival at the emergency department; admission into the hospital; examination by a specialist; request for consultation; report of evaluation and the interventions made by other medical teams (physiotherapist, nurse etc.) – Registration of data on how the fall occurred; the time of the incident; location of the incident; loss of consciousness, type of the activity and the patient’s status at the time of the incident; a history of falling and movement limitations; evaluation of walking, standing and sitting (if possible); the duration of execution of the “stop and go” test; the usual mode of walking, including a history of using walking aides; the clinical symptoms and signs associated with the incident – Other items: the methods of carrying out daily activities (ADL); the method of the use of tools necessary for carrying out daily activities before the incident (IADL); recent changes in drug regimen; use of alcohol; physical barriers at home; living alone or with others; support by the family; medical-surgical and psychiatric history; confined to home or not – General evaluation: the outcomes of the incident; chronic pain; stability of body status; stability of the mood – Neurologic evaluation and the motor system: visual acuity; hearing acuity; walking and balance; confusion and vertigo; structure and function of joints; history of osteoarthritis of the lower extremity – Cardiopulmonary evaluation: angina pectoris; syncope; asthma – Evaluation of the digestive system: nausea; vomiting; diarrhea; constipation; control of defecation; hemorrhage – Evaluation of urinary system: urinary incontinence – General examinations: vital signs; weight; height – Musculoskeletal examination: examination of the shoulders; hip joint; knee; foot – Cardiopulmonary examinations: heart sounds; orthostatic hypotension; evaluation of peripheral pulse – Neurologic examinations: cognitive function; MMSE; vision; hearing; the seventh cranial nerve; the cranial nerves III, IV and V; muscle tonicity; the strength of lower and upper extremities, Romberg test; cerebellar test; examination of cranial nerves; deep tendon reflexes; proprioception and sense of vibration – Judgment and self-protection: the ability to carry out daily activities; adequacy of support by the family in carrying out daily activities; description of details of how to use the necessary tools to carry out daily activities; adequacy of support by the family to use the necessary tools to carry out daily activities – Evaluation of pain – Decreased exercise tolerance due to asthma, tiredness etc. The maximum tolerance of walking distance – Motor coordination; the ability to stand up from a sitting position on the ground; state of balance based on The Berg Balance Scale; the patient’s need for accessory equipment; the ability to use the stairs; the ability to walk out of home; the ability to walk on different levels of the house – Socioeconomic status: the network for social supports of the elderly (family structure, organizations and the individual’s role); the family’s understanding and expectations; the state of social support network other than the relatives; the effect of the incident on the individual’s self-image; the effect of the incident on the individual’s inter-personal relationships; the effect of the incident on the patient’s family; the effect of the incident on the patent’s social environment – The necessity of requesting the following laboratory tests for all the patients with a falling incident: CBCa, BUNb/creatinine, Electrolytes, ALPc, Albumin, Calcium, Blood glucose, Vitamin B 12, Uric acid, TSHd , ECGe
Complete blood count. Blood urea nitrogen. Alkaline Phosphatase. Thyroid stimulating hormone. Electrocardiogram.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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The deficiencies recognized in the first step were divided into 3 general categories: deficiencies in the clinical evaluation of patients, deficiencies in laboratory tests, and finally deficiencies in therapeutic interventions. Then the deficiencies were listed separately for each subgroup and submitted to the expert panel. Tables 2 and 3 present the suggestions offered by the expert panel. Tables 4 and 5 present the frequency of each deficiency before and after the educational intervention. As shown in Tables 4 and 5 the most common medical errors in clinical examinations consisted of lack of performing the Romberg test (92.75% before intervention vs. 35.4% after intervention, P < 0.001), failure to perform cerebellar examinations (93.75% before intervention vs. 41.9% after intervention, P < 0.001), failure to examine cranial nerves (88.75% before intervention vs. 14.2% after intervention, P < 0.001), not examining deep tendon reflexes (95.0% before intervention vs. 42.2% after intervention, P < 0.001), no syncope work up (94.0% before intervention vs. 96.8% after intervention, P = 0.99), failure to rule out arrhythmias (80.75% before intervention vs. 48.4% after intervention, P < 0.001) and lack of attention to possible hemorrhage (83.25% before intervention vs. 24.9% after intervention, P < 0.001). The most frequent deficiencies in selecting the correct diagnostic tests consisted of not checking Alkaline phosphates (ALP) serum levels (66.4% before intervention vs. 74.2% after intervention, P = 0.43), albumin serum levels (59.25% before intervention vs. 74.2% after intervention, P = 0.13), Thyroid stimulating hormone (TSH) serum levels (78.25% before intervention vs. 80.6% after intervention, P = 0.75) and not performing an Electrocardiogram (ECG) (85.5% before intervention vs. 71.09% after intervention, P = 0.03). The most frequent medical interventions neglected by the physicians were lack of a proper action to improve the patient’s mental status (51.6% before intervention vs. 32.59% after intervention, P = 0.08), failure to recognize and intervene for visual problems (59.25% before intervention vs. 48.4% after intervention, P = 0.24),
lack of a physiotherapy consult (82.75% before intervention vs. 93.55% after intervention, P = 0.12) and lack of a nutritionist consult (61.75% before intervention vs. 83.99% after intervention, P = 0.01). After holding expert panel with specialists and preparation of suggestions to improve the management of patients presenting to the ED with fall-related injuries, educational sessions were offered to the physicians based on these suggestions. In the month following this intervention, 31 patients who met similar inclusion criteria as the patients in step one were included in the final step of the study. These patients were found to be homogenous to the patients included before the educational intervention in relation to demographic and baseline data. As shown in Tables 4 and 5, after the intervention the physicians’ performance improved in two categories (clinical examination and medical interventions), with no improvements in laboratory tests category. As mentioned in the methods section, a collective score was calculated for each category. The ranges of scores for clinical examinations, diagnostic tests and therapeutic intervention were 0–22, 0–10 and 0–16, respectively. The mean scores of physicians for correct implementation of clinical examinations before and after educational interventions were 10.01 ± 31.3 and 14.03 ± 2.3, respectively (P < 0.001). In addition, the scores of physicians’ performance in choosing correct diagnostic tests before and after educational intervention were 5.5 ± 2.3 and 4.6 ± 2.4, respectively (P = 0.053). It should be pointed out that the scores of physicians’ performance in adopting correct therapeutic measures before and after educational intervention were 9.5 ± 3.4 and 11.4 ± 3.2, respectively (P = 0.004). Based on these findings, one can conclude that the educational intervention resulted in an improvement in the performance of physicians in relation to clinical evaluation and therapeutic measures; however, it resulted in a minor decrease in their ability to choose correct diagnostic tests. In order to modify the effects of potential confounding factors a multivariate backward linear regression model was designed.
Table 3 Expert panel suggestions for preventing medical errors in therapeutic interventions and measures to prevent repeat falls. Strategy Therapeutic interventions
Implementation of the protocol to prevent the patient from falling again
Planning for the patient’s discharge
The suggested guidelines – General interventions: offering specialized interventions; offering technique interventions; control of the patient’s living environment; use of personal protection tools; evaluation of the patient’s ability to take medicine; evaluation of the care available based on the patient’s report – Cognitive status: evaluation and in the case of any abnormality, the diagnosis of the problem; evaluation of the individual’s ability to give personal consent for treatment; drug therapy – Mental state: evaluation and if there is any abnormality, diagnosis of the problem; drug therapy – Balance: evaluation and if there is any abnormality, diagnosis of the problem; rehabilitation in the ward (or referral for rehabilitation); presentation of exercise programs at home (by a physiotherapist) – The power of the lower extremity: evaluation and if there is any abnormality, diagnosis of the problem; determination of nutritional status or presence of malabsorption; follow-up of the patient’s rehabilitation (if necessary); presentation of exercise programs at home – Osteoarthritis in the lower extremity: evaluation and if present, diagnosis and prescription of analgesics; rehabilitation in the ward (or referral for rehabilitation); presentation of exercise programs at home (by a physiotherapist) – Integrity of bones: evaluation and in the case of any abnormalities, diagnosis and prescription of calcium, vitamin D and other necessary medicines to protect the bones – The health of the cardiovascular system: evaluation and in the case of any abnormality, diagnosis of the problem; in case of cardiac insufficiency before the incident or presence of risk factors, drug therapy is indicated – Vision: evaluation and in case of any problems, diagnosis; if the problem has not been previously evaluated by an ophthalmologist, consultation is indicated – Medications: evaluation and if the drug regime has been evaluated, the results of drug therapy and its effect should be evaluated; prescription of new drugs if necessary – Evaluation of risk factors for falling – Evaluation of history: headache; confusion; syncope; patient’s history in relation to the history of medicines the patient had been taking previously and polypharmacy; evaluation of the history of osteoporosis – Evaluation of the risk of patient falling again – Use of preventive measures – If the incident happens again in the hospital, the patient should be placed on a bed, if possible, and the physician or the nurse should be called upon; the incident should be recorded and reported accurately, with registration in the patient’s medical record. – Determination of a strategy: holding meeting sessions and Expert panel between specialists in order to plan therapeutic interventions Organizing care: The patient and his/her family should be informed about his/her clinical status; a physician should take the responsibility to take care of the patient constantly; the tools and equipment for taking care of the patient should be available for the patient; the patient should be referred to the center necessary (rehabilitation centers and social workers) – Registration of a summary of procedures to discharge the patient
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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Table 4 The most common medical errors in the clinical and diagnostic evaluation of patients referred to the emergency department, with a complaint of falling. Error
Before intervention (N = 400)
Deficiency in documentation of History Evaluation of vertigo 175(43.75%) Evaluation of angina pectoris 155(38.75%) Evaluation of asthma 224(56.0%) Evaluation of syncope, if any 376(94.0%) Presence of arrhythmia 323(80.75%) Nausea and vomiting 200(50.0%) Diarrhea and constipation 280(70.2%) Control of defecation 103(25.75%) Hemorrhage 333(83.25%) Urinary incontinence 300(75.0%) Deficiency in clinical examinations Documentation of vital signs 16(4.0%) Measurement of weight 74(17.2%) measurement of height 75(18.75%) Palpation of peripheral pulses 136(34.1%) Measurement of orthostatic 233(58.4%) hypotension Examination of cranial nerves 355(88.75%) Examination of deep tendon reflexes 380(95.0%) Romberg test 371(92.75%) Cerebellar test 375(93.75%) Examination of the hip joint 106(26.6%) Examination of the knee 100(25.0%) Examination of the foot 97(24.25%) No request for the following laboratory tests 2(0.5%) CBCa BUNb/creatinine 8(2.0%) c ALP 266(66.5%) Albumin 237(59.25%) Calcium 237(59.25%) Blood glucose 170(42.5%) Uric acid 157(39.25%) TSHd 313(78.25%) Electrolytes 67(16.75%) e ECG 341(85.5%) a b c d e
After intervention (N = 31)
P
13(41.9%) 14(45.2%) 14(45.2%) 30(96.8%) 15(48.4%) 15(48.4%) 10(20.1%) 8(25.8%) 13(24.9%) 18(58.1%)
0.84 0.48 0.24 0.99 <0.001 0.86 <0.001 0.99 <0.001 0.054
1(3.2%) 0(0.0%) 1(3.2%) 3(9.7%) 17(54.8%)
0.99 0.005 0.029 0.005 0.7
14(14.2%) 14(45.2%) 11(35.4%) 13(41.9%) 10(32.3%) 7(22.6%) 6(19.35%)
<0.001 <0.001 <0.001 <0.001 0.53 0.99 0.66
0(0.0%) 0(0.0%) 23(74.2%) 23(74.2%) 20(64.5%) 12(38.7%) 22(70.9%) 25(80.6%) 20(64.5%) 22(71.0%)
0.99 0.99 0.43 0.13 0.7 0.68 0.001 0.75 <0.001 0.03
Complete blood count. Blood urea nitrogen. Alkaline Phosphatase. Thyroid stimulating hormone. Electrocardiogram.
Table 5 The most common medical errors in therapeutic interventions inpatients referred to the emergency department, with a complaint of falling. Error
Before intervention (N = 400)
After intervention (N = 31)
Adoption of no medical interventions in the following cases Cognitive function 89(22.25%) 7(22.6%) Mental state 207(51.6%) 11(32.5%) Balance 139(34.75%) 7(22.6%) Integrity of bones 90(22.5%) 3(9.7%) Function of the lower extremity 13(28.75%) 5(16.1%) Cardiovascular health 97(24.25%) 6(19.35%) Visual apparatus 237(59.25%) 15(48.4%) Proper drug intervention 111(27.75%) 6(19.35%) Recommendation of aides 127(31.75%) 6(19.35%) Recommendation of safety equipment 147(36.75%) 8(25.8%) Recommendation of exercise 178(44.5%) 7(22.6%) programs at home Instructions in measures to prevent 186(46.5%) 8(25.8%) falling again Instructions, at discharge, in methods 186(46.5%) 9(29.0%) to improve the home environment Physiotherapy consultation 331(82.75%) 29(93.55%) Nutritional consultation 247(61.75%) 26(83.9%) Other consultations 119(29.75%) 1(3.2%)
P
0.96 0.08 0.17 0.095 0.14 0.54 0.24 0.31 0.15 0.25 0.02 0.026 0.06 0.12 0.01 0.002
5
Table 6 The results of multivariate linear regression analysis. Variable
Beta
t
P
Correct performance during clinical examinations Educational intervention 3.79 7.4 <0.001 Instability of the patient’s clinical state 1.76 6.63 <0.001 Chronic pain 1.505 4.63 <0.001 Fall-related complications 1.2 3.73 <0.001 Performance in ordering correct laboratory tests Educational intervention −1.21 −2.67 0.008 An increase in trauma severity 0.88 3.85 <0.001 Instability of the patient’s clinical state 0.52 2.2 0.03 Chronic pain 0.85 3.62 <0.001 Performance of physicians in selecting correct medical interventions Educational intervention 2.004 3.14 0.002 Chronic pain −.0834 −0.52 0.012
Factors such as patients’ educational level, severity of trauma, use of alcohol, patients’ mood stability, patients’ clinical stability at presentation, affliction with chronic pain and the complications of falls were entered into the model. The results of the analysis are presented in Table 6 in the three sections under study, including clinical examination, diagnostic tests and therapeutic interventions. The results of the analysis showed that educational intervention resulted in promotion of the quality of care in relation to clinical evaluations (β = 3.79; P < 0.001) and therapeutic interventions (β = 2.004; P = 0.002). However, education had a negative effect on choosing correct diagnostic tests (β = −1.21; P = 0.008). 4. Discussion The present study was the first attempt in Iran to design a clinical audit regarding the management of elderly fall-related injuries. The study revealed several important findings: 1) There are significant deficiencies in the diagnosis and treatment of fall victims; 2) In many cases proper actions were not taken to prevent future falls; 3) A list of expert suggestions were generated through the Delphi method to overcome these shortcomings; 4) It was shown that providing clinicians with instructions in the context of guidelines and educational material can help improve the care provided to fall victims. Studies have indicated a wide gap between the service offered and standard guidelines. Kalula et al. showed that the management of fall-related injuries was not favorable. The use of alcohol and drug abuse was recorded in only 20% of cases, while pulse rate and orthostatic blood pressure were evaluated in only 2% of patients. Furthermore, none of the elderly were referred to a geriatrician, physiotherapist or work therapist after falls (Kalula et al., 2006). Youde et al. (2009) concluded that the care delivered to the elderly after they fall is inconsistent with standards and often not delivered on time. Salter et al. (2006) showed in a clinical audit that less than 4% of elderly patients presenting with falls undergo evaluations and management based on standards. Therefore, measures should be adopted to decrease errors in the care of the elderly suffering from fall-related injuries. The suggestions offered by the expert panel were one of the most important strengths of the present study. Similar guidelines have been implemented around the world and it has been shown that prevention programs improve outcomes (Feder et al., 2000, Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). In our setting, implementing the suggested guidelines resulted in a modest improvement in the quality of services delivered during clinical examinations and therapeutic interventions; however, it had no effect on the adoption of correct diagnostic techniques. The fact that only a modest improvement was observed may be a result of the complexity and length
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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of the suggestions. Often emergency physicians and nurses do not find the time to follow in detail such recommendations. For this purpose a straightforward clinical pathway, derived from the points suggested here, would be a more feasible approach and may improve the level of care more significantly. In this study we found shortcomings in various aspects of patient care. History taking and physical examination are important steps for recognition of repeat fallers, internal risk factors (neurologic deficits, visual problems, cognitive and psychological disorders, urinary or fecal incontinence, etc.) and external risk factors (polypharmacy, psychotropic or diuretic medications, inadequate lighting, slippery surfaces, etc.) for future falls (Feder et al., 2000; Galvez-Barron et al., 2013; Grenier et al., 2014; Kwan et al., 2011; Stubbs et al., 2014; Tariq et al., 2013; Wu et al., 2013). The authors believe that our results reflect the clinicians’ focused approach to the fallen patient in the ED without a proper attitude toward prevention. For instance while vital signs were recorded for over 95% of the patients, orthostatic changes were missing in close to 60% of the cases. We also found that the results of the Romberg test were not recorded in close to 93% of the patients. This is in spite of the fact that guidelines have recommended all older adults should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance even if they don’t present with this complaint (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). These rates may be due to the fact that many patients who come to the ED with a fall may not be able to stand because of their injuries. But we believe focusing on the traumatic injuries usually diverts attention away from performing a meticulous physical exam. Furthermore, evaluation of visual impairments as a possible cause of the fall was only performed in just over 40% of our population. Literature is inconsistent regarding the importance of this intervention. While some studies describe a protective effect (Foss et al., 2006; Harwood et al., 2005), others have challenged this finding (Cumming et al., 2007). Nonetheless our guidelines recommend that the eye exam should be noted and recorded for these patients and treatment offered. A worrisome finding in our study was that despite the elderly population and the obvious risk for cardiac-related fall events (Belita et al., 2013), an ECG was not ordered for over 85% of cases and this only mildly improved to 71% after the educational intervention. In most cases a clear “tripping” history was thought to be the reason for omitting this significant evaluation in the ED. During treatment, the most neglected medical intervention was failure to consult a physiotherapist. Earlier guidelines recommended exercise and balance training for all older people who have had recurrent falls, but current guidelines advocate exercise programs only for community-dwelling elderly (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). Goodwin et al. showed that clinical evaluations and referral of patients with hip fractures for participation in exercise and physiotherapy programs were done in 68% and 44% of the cases, respectively. These figures were even lower in injuries without hip fractures, with 28% and 22%, respectively (Goodwin et al., 2010). In our study we found that this intervention was neglected in over 82% of cases, reflecting the treating physician’s improper attitude toward this important intervention. Education of patients by clinicians, and education of clinicians through guidelines and educational programs has been advocated as a measure of improving care for the fallen patient (Feder et al., 2000, Moreland et al., 2003, Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011, Paniagua et al., 2006). In our study, implementation of such a program for emergency department personnel best improved the process of history taking and physical examination, while it had a negative effect on obtaining the correct tests. We believe that a clear
clinical pathway initiated as early as possible in the ED by the triage nurse may have a more significant outcome, and the effect of these two approaches should be evaluated in future studies. Furthermore, the authors insist that for such comprehensive approaches to be effective, they should not be left up to the judgment of each individual clinician. These interventions need to be coordinated by a person or team in the emergency department. This may be included into the role of the trauma nurse coordinator (Crouch et al., 2015) or a specific hospital nurse coordinator for fall victims. 4.1. Limitations This was a clinical audit and a before and after study. Physicians’ failure to document interactions with the patient, or performed clinical examinations may have contributed in underestimating the level of care provided during the clinical audit. The number of patients evaluated after the implementation of the educational program was considerably less than the number evaluated before which may impair the ability to fully analyze the effects of the program. Finally the effect of the program was only analyzed during the first month after the program. Whether the effect is a lasting one needs to be analyzed in future audits. 5. Conclusion In order to promote the quality of care services the authorities and policy-makers should be confident that the services delivered during the evaluation and treatment of elderly patients suffering from complications of falls are standard. Identification of patients at risk and interventions to reduce this risk should become an important part of the ED evaluation of fall victims. The results of this clinical audit reaffirm the wide gap between services delivered in the management of falls and accepted standards. Furthermore, educational intervention could only modestly improve the situation. Acknowledgements This article was based on a postgraduate thesis by Dr. Sabbaghi, which was successfully completed under the supervision of Dr. Hatamabadi and Dr. Sum. References Abolhassani, F., Moayyeri, A., Naghavi, M., Soltani, A., Larijani, B., Shalmani, H.T., 2006. Incidence and characteristics of falls leading to hip fracture in Iranian population. Bone. 39, 408–413. Akyol, A.D., 2007. Falls in the elderly: what can be done? International Nursing Review. 54, 191–196. Barker, A., Kamar, J., Morton, A., Berlowitz, D., 2009. Bridging the gap between research and practice: review of a targeted hospital inpatient fall prevention programme. Quality and Safety in Health Care. 18, 467–472. Belita, L., Ford, P., Kirkpatrick, H., 2013. The development of an assessment and intervention falls guide for older hospitalized adults with cardiac conditions. European Journal of Cardiovascular Nursing: Journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology. 12, 302–309. Bell, A.J., Talbot-Stern, J.K., Hennessy, A., 2000. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. The Medical Journal of Australia. 173, 179–182. Crouch, R., McHale, H., Palfrey, R., Curtis, K., 2015. The trauma nurse coordinator in England: a survey of demographics, roles and resources. International Emergency Nursing. 23, 8–12. Cumming, R.G., Ivers, R., Clemson, L., Cullen, J., Hayes, M.F., Tanzer, M., et al., 2007. Improving vision to prevent falls in frail older people: a randomized trial. Journal of the American Geriatrics Society. 55, 175–181. Feder, G., Cryer, C., Donovan, S., Carter, Y., 2000. Guidelines for the prevention of falls in people over 65. The Guidelines’ Development Group. BMJ (Clinical Research Ed.). 321, 1007–1011. Foss, A.J., Harwood, R.H., Osborn, F., Gregson, R.M., Zaman, A., Masud, T., 2006. Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age and Ageing. 35, 66–71.
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Moreland, J., Richardson, J., Chan, D., O’Neill, J., Bellissimo, A., Grum, R., et al., 2003. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology. 49, 93–116. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society. 59, 148–157. Paniagua, M.A., Malphurs, J.E., Phelan, E.A., 2006. Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention. The American Journal of Emergency Medicine. 24, 413–417. Pfortmueller, C.A., Kunz, M., Lindner, G., Zisakis, A., Puig, S., Exadaktylos, A.K., 2014. Fall-related emergency department admission: fall environment and settings and related injury patterns in 6357 patients with special emphasis on the elderly. TheScientificWorldJournal. 2014, 256519. Salter, A.E., Khan, K.M., Donaldson, M.G., Davis, J.C., Buchanan, J., Abu-Laban, R.B., et al., 2006. Community-dwelling seniors who present to the emergency department with a fall do not receive guideline care and their fall risk profile worsens significantly: a 6-month prospective study. Osteoporosis International. 17, 672–683. Shaw, F.E., Bond, J., Richardson, D.A., Dawson, P., Steen, I.N., McKeith, I.G., et al., 2003. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ (Clinical Research Ed.). 326, 73. Stubbs, B., Schofield, P., Binnekade, T., Patchay, S., Sepehry, A., Eggermont, L., 2014. Pain is associated with recurrent falls in community-dwelling older adults: evidence from a systematic review and meta-analysis. Pain Medicine (Malden, Mass.). 15, 1115–1128. Tariq, H., Kloseck, M., Crilly, R.G., Gutmanis, I., Gibson, M., 2013. An exploration of risk for recurrent falls in two geriatric care settings. BMC Geriatrics. 13, 106. Wu, T.Y., Chie, W.C., Yang, R.S., Kuo, K.L., Wong, W.K., Liaw, C.K., 2013. Risk factors for single and recurrent falls: a prospective study of falls in community dwelling seniors without cognitive impairment. Preventive Medicine. 57, 511–517. Youde, J., Husk, J., Lowe, D., Grant, R., Potter, J., Martin, F., 2009. The national clinical audit of falls and bone health: the clinical management of hip fracture patients. Injury. 40, 1226–1230.
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement Hamid Reza Hatamabadi MD (Associate Professor) a,b, Shima Sum PhD (Assistant Professor) c,*, Ali Tabatabaey MD (Assistant Professor) d, Mohammad Sabbaghi MD (Assistant Professor) b a
Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Emergency Department, Emam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran c Community Medicine, Babol University of Medical Sciences, Mazandaran, Iran d Emergency Department, Qom University of Medical Sciences and Health Services, Qom, Iran b
A R T I C L E
I N F O
Article history: Received 13 December 2014 Received in revised form 9 May 2015 Accepted 17 May 2015 Keywords: Fall Clinical management Emergency department
A B S T R A C T
Introduction: Falls are a major source of injury in the elderly and their incomplete management is a cause for concern by health systems. The present study looks at the current state of managing fall victims in Iran and offers suggestions for improvement. Methods: This was a clinical care audit comparing the state of current care with an institutionally approved optimum. Patients aged 60 years and over presenting with a fall were evaluated and deficiencies in their care were recorded and categorized. These were presented to an expert panel, where the Delphi method was used to come up with a list of actions to address the deficiencies. Furthermore an educational program was implemented based on these suggestions. Chi-squared and t-test were used to evaluate the efficacy of this program in improving treatment. Linear regression analysis was used to find factors affecting care. Results: Overall 431 cases were reviewed. The most common errors during clinical examination were: not performing Romberg test (92.75%) and lack of physiotherapy consultation (82.75%). The educational program had a modest effect on improving the clinical audit processes (β = 3.79; P < 0.001) and medical interventions (β = 2.004; P = 0.002); however, performing the correct diagnostic tests was worse after the program (β = −1.21; P = 0.008). Conclusion: There is a wide gap between the care services delivered in the management of falls and international standards. Therefore, measures should be adopted to close this gap. Education may have a modest positive effect in this regard. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Falls are responsible for much of the injury related morbidity and mortality in the elderly, and the resultant fractures are a major source of economic burden in this population (Marks, 2010). One-third of individuals over 65 and more than half those over 80 years of age suffer at least one fall-related injury each year (Akyol, 2007; Moore et al., 2010). The importance of falls as a source of elderly trauma and its economic burden has been documented around the world (Goodwin et al., 2010; Kwan et al., 2011; Moore et al., 2010; Pfortmueller et al., 2014). Falling is the leading mechanism of injury in the elderly, and is responsible for 70% of all elderly trauma in Iran (Ghodsi et al., 2003). In general, the annual incidence of fall-related injuries in Iran is 143.5 for men and 88.2 for women in 100,000 of
* Corresponding author. Community Medicine, Babol University of Medical Sciences, Mazandaran, Iran. Tel.: +98 1132190560; fax: +98 1132199936. E-mail address: [email protected] (S. Sum).
the population. The numbers increase significantly in individuals over 80 years of age, reaching 848.3 and 854.7 per 1000 in males and females respectively (Abolhassani et al., 2006). The incidence of falls and the resultant complications is on the rise with an increase in the elderly population and this increase will continue unless measures are adopted to improve the services delivered to at risk populations (Hatamabadi et al., 2014). Effective fall prevention can reduce serious fall-related injuries, emergency department visits, hospitalizations, nursing home placements, and functional decline (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). Organized and systematic services based on national standards and evidence-based guidelines can decrease complications, prevent subsequent falls and even decrease mortality and morbidity significantly (Kannus et al., 2005; Moreland et al., 2003). One of the most important considerations in delivering services to elderly patients suffering from fall-related injuries is the quality of the services with emphasis on correct patient evaluation and determination of risk factors which increase susceptibility to falling.
http://dx.doi.org/10.1016/j.ienj.2015.05.001 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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Unfortunately the chance to offer such interventions in the emergency department is often missed by doctors and nurses (Paniagua et al., 2006; Pfortmueller et al., 2014). Proper treatment and offering standard instructions in order to prevent future falls are an integral part of a holistic approach to treatment of falls and their resultant fractures (Kannus et al., 2005). Reports show that in the elderly who undergo comprehensive geriatric evaluations the odds of mortality or morbidity are low and there is a rapid improvement in their cognitive functioning (Feder et al., 2000). The elderly commonly seek treatment in the emergency department (ED) following falls, especially due to traumatic injuries after falling. While ED physicians and nurses focus on possible traumatic injuries, often the critical “teachable moment” after injury is lost. The ED is the best place to diagnose functional disorders leading to and resulting from falls, and ED personnel have the most important role in proper patient referral (Bell et al., 2000; Lee et al., 2012; Shaw et al., 2003). However, current data indicate that a significant percentage of elderly patients are discharged from ED without a proper diagnosis and follow-ups (Goodwin et al., 2010), thus leading to a wide gap between the services offered and international standards and guidelines (Barker et al., 2009; Kalula et al., 2006; Salter et al., 2006). Therefore, it is necessary to revise the therapeutic measures taken up by emergency physicians and nurses in the management of fall victims in an attempt to close the gap with international standards (Goodwin et al., 2010). The present study aims to design a clinical audit to identify the deficiencies, and to present domestic guidelines and suggestions to improve patient care in fall victims. Finally, the authors tested the efficacy of implementing the suggestions through an interventional educational program, on improving the quality of the services delivered. 2. Materials and methods This was a three step quasi-experimental study aiming to assess the level of care provided to elderly fall victims, to make suggestions for improving care, and then to assess the effectiveness of these suggestions. Graph 1 presents a summary of the study steps. The study protocol was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. The first step was a prospective clinical audit of the care provided to elderly fall victims. All patients over 60 years of age who presented to the ED at the Imam Hussein Teaching Hospital in Tehran, Iran with a complaint of falling between January 2012 and December 2012 were included in the study. The care provided to
Aim
Final evaluation
improvement in treatment status and prevention of re-occurrence
Table 1 Summary of audit questionnaire. Demographic information • Age, gender, marital status, educational level, etc. Admission information • type of admission, initial diagnosis, the patient’s ability to present information, stability of the clinical status Important events leading to fall • Location and time of the fall, loss of consciousness, type of the activity leading to the fall, barriers, etc. Patient history • Past medical history, drug history, social history, history of falls and movement limitations etc. Review of systems Physical examination • Including (but not limited to) vital signs, full neurologic examination, cerebellar examinations, Romberg test, visual acuity, evaluating for hearing loss, etc. Evaluation of daily functions • Ability of patient to perform daily activities Evaluation of psychosocial functions • Cognitive abilities based on the mini–mental state examination (MMSE), signs of depression, anxiety, or other psychiatric disorders Diagnostic tests • Complete blood count, Blood Urea, electrolytes, Electrocardiography, etc. Treatment interventions • Including (but not limited to) proper consults, correction of medications, admission, etc. Preventive measures • Patient education, improvement of living environment, etc.
patients was monitored over a 24 hour period and compared with an institutionally approved guideline of optimal care derived from scientific literature. An eleven-part questionnaire was devised to facilitate data extraction (Table 1). This checklist evaluates the delivery of diagnostic and therapeutic services and also steps taken to prevent accidents in future. Initial care for all victims was provided by junior emergency medicine residents and nursing staff. The clinicians providing the care in the ED were not aware of the audit taking place. Descriptive data alongside errors and deficiencies in the management of each patient were recorded. The second step was a qualitative study aiming to generate expert suggestions to improve patient care for elderly fall victims. To achieve this aim the Delphi method was used, which is a widely accepted method used to identify innovative and reliable ideas to prepare proper data for decision-making processes (Linstone and Turoff, 1975). The results of the first step were presented to a panel of
Techniques to achieve the aim Re-evaluation of the performance of the clinical team using a clinical audit and comparison of the data with data before educational intervention Instructing physicians in patient management and presentation of guidelines, at discharge, to improve the environment and prevent falling again
Suggestions of guidelines to improve the therapeutic services delivered
Use of Delphi method and holding sessions with specialists
Identification of deficiencies in the management of the elderly referred to the emergency unit with fall injuries
Evaluation of the performance of the medical team using a clinical audit
Graph 1. The aims of the study and the guidelines to achieve them.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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experts, consisting of geriatricians and emergency medicine specialists, through a second questionnaire. Specific shortcomings in patient care revealed in the audit were outlined, and experts were asked for their suggestions on how to overcome each deficiency. Before use, the questionnaire was submitted to an emergency medicine specialist and a geriatrician and its inter-rater reliability of responses was assessed (Κ = 0.81). Subsequently the responses received in the first round were analyzed and a revised questionnaire containing the suggestions offered in the first round was resubmitted to the expert panel. After the second-round responses were evaluated, the final report was prepared by the team and the draft was discussed and finalized in a live expert panel. In the third step of the study, educational interventions were offered to emergency physicians based on the suggestions generated in step 2 of the study. The educational sessions were held in two 2-hour sessions. The teaching material was based on suggestions made by the expert panel and focused on the institutionally approved treatment guideline. In order to evaluate the efficacy of these educational interventions, the same audit techniques and questionnaires were used to evaluate the management of the elderly suffering from fall injuries in the month following the educational program. The data before and after the educational intervention were compared to reveal any significant improvements in care.
Data were analyzed with SPSS 21.0. Chi-squared test was used to compare diagnostic-therapeutic measures before and after educational intervention. This was done to evaluate the efficacy of this intervention in improving the management of fall victims. In addition, the performance of the treating clinicians in the following fields was evaluated separately: clinical examinations, diagnostic tests, and therapeutic measures. To this end, each of these fields was scored (each correct action received one point). The independent t-test was used to compare these scores before and after the educational program was carried out and to evaluate its effect on the performance of physicians in the management of fall-related injuries. Subsequently a multivariate backward regression model was designed to determine if the educational intervention was actually responsible for the improvement in care and to eliminate the effect of any potential confounders. Statistical significance was defined at P < 0.05 for all the analyses. 3. Results Overall 431 patients were included in the study. The first step of the study included 400 patients presenting with fall-related injuries during the period of one year. In the third step of the study, 31 patients were included within the period of one month following educational interventions.
Table 2 Expert panel suggestions for preventing medical errors in the clinical evaluation and diagnostic tests. Strategy Registration of the patient’s demographic data Registration of clinical and admission data Registration of important moments in the process of care Taking a history
Evaluation of body systems
Clinical examinations
Functional and peripheral examination Evaluation of body function
Psychosocial evaluation
Laboratory tests a b c d e
3
The guidelines suggested – Demographic data; status of health insurance policy; supplementary insurance policy; coverage by a family physician – Type of admission; a history of previous admissions; duration of hospitalization; fall-related factors; level of consciousness; the patient’s ability to provide information; stability of the patient’s clinical state at the time of admission; drugs taken at the time of admission; the principal diagnosis – The time of arrival at the emergency department; admission into the hospital; examination by a specialist; request for consultation; report of evaluation and the interventions made by other medical teams (physiotherapist, nurse etc.) – Registration of data on how the fall occurred; the time of the incident; location of the incident; loss of consciousness, type of the activity and the patient’s status at the time of the incident; a history of falling and movement limitations; evaluation of walking, standing and sitting (if possible); the duration of execution of the “stop and go” test; the usual mode of walking, including a history of using walking aides; the clinical symptoms and signs associated with the incident – Other items: the methods of carrying out daily activities (ADL); the method of the use of tools necessary for carrying out daily activities before the incident (IADL); recent changes in drug regimen; use of alcohol; physical barriers at home; living alone or with others; support by the family; medical-surgical and psychiatric history; confined to home or not – General evaluation: the outcomes of the incident; chronic pain; stability of body status; stability of the mood – Neurologic evaluation and the motor system: visual acuity; hearing acuity; walking and balance; confusion and vertigo; structure and function of joints; history of osteoarthritis of the lower extremity – Cardiopulmonary evaluation: angina pectoris; syncope; asthma – Evaluation of the digestive system: nausea; vomiting; diarrhea; constipation; control of defecation; hemorrhage – Evaluation of urinary system: urinary incontinence – General examinations: vital signs; weight; height – Musculoskeletal examination: examination of the shoulders; hip joint; knee; foot – Cardiopulmonary examinations: heart sounds; orthostatic hypotension; evaluation of peripheral pulse – Neurologic examinations: cognitive function; MMSE; vision; hearing; the seventh cranial nerve; the cranial nerves III, IV and V; muscle tonicity; the strength of lower and upper extremities, Romberg test; cerebellar test; examination of cranial nerves; deep tendon reflexes; proprioception and sense of vibration – Judgment and self-protection: the ability to carry out daily activities; adequacy of support by the family in carrying out daily activities; description of details of how to use the necessary tools to carry out daily activities; adequacy of support by the family to use the necessary tools to carry out daily activities – Evaluation of pain – Decreased exercise tolerance due to asthma, tiredness etc. The maximum tolerance of walking distance – Motor coordination; the ability to stand up from a sitting position on the ground; state of balance based on The Berg Balance Scale; the patient’s need for accessory equipment; the ability to use the stairs; the ability to walk out of home; the ability to walk on different levels of the house – Socioeconomic status: the network for social supports of the elderly (family structure, organizations and the individual’s role); the family’s understanding and expectations; the state of social support network other than the relatives; the effect of the incident on the individual’s self-image; the effect of the incident on the individual’s inter-personal relationships; the effect of the incident on the patient’s family; the effect of the incident on the patent’s social environment – The necessity of requesting the following laboratory tests for all the patients with a falling incident: CBCa, BUNb/creatinine, Electrolytes, ALPc, Albumin, Calcium, Blood glucose, Vitamin B 12, Uric acid, TSHd , ECGe
Complete blood count. Blood urea nitrogen. Alkaline Phosphatase. Thyroid stimulating hormone. Electrocardiogram.
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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The deficiencies recognized in the first step were divided into 3 general categories: deficiencies in the clinical evaluation of patients, deficiencies in laboratory tests, and finally deficiencies in therapeutic interventions. Then the deficiencies were listed separately for each subgroup and submitted to the expert panel. Tables 2 and 3 present the suggestions offered by the expert panel. Tables 4 and 5 present the frequency of each deficiency before and after the educational intervention. As shown in Tables 4 and 5 the most common medical errors in clinical examinations consisted of lack of performing the Romberg test (92.75% before intervention vs. 35.4% after intervention, P < 0.001), failure to perform cerebellar examinations (93.75% before intervention vs. 41.9% after intervention, P < 0.001), failure to examine cranial nerves (88.75% before intervention vs. 14.2% after intervention, P < 0.001), not examining deep tendon reflexes (95.0% before intervention vs. 42.2% after intervention, P < 0.001), no syncope work up (94.0% before intervention vs. 96.8% after intervention, P = 0.99), failure to rule out arrhythmias (80.75% before intervention vs. 48.4% after intervention, P < 0.001) and lack of attention to possible hemorrhage (83.25% before intervention vs. 24.9% after intervention, P < 0.001). The most frequent deficiencies in selecting the correct diagnostic tests consisted of not checking Alkaline phosphates (ALP) serum levels (66.4% before intervention vs. 74.2% after intervention, P = 0.43), albumin serum levels (59.25% before intervention vs. 74.2% after intervention, P = 0.13), Thyroid stimulating hormone (TSH) serum levels (78.25% before intervention vs. 80.6% after intervention, P = 0.75) and not performing an Electrocardiogram (ECG) (85.5% before intervention vs. 71.09% after intervention, P = 0.03). The most frequent medical interventions neglected by the physicians were lack of a proper action to improve the patient’s mental status (51.6% before intervention vs. 32.59% after intervention, P = 0.08), failure to recognize and intervene for visual problems (59.25% before intervention vs. 48.4% after intervention, P = 0.24),
lack of a physiotherapy consult (82.75% before intervention vs. 93.55% after intervention, P = 0.12) and lack of a nutritionist consult (61.75% before intervention vs. 83.99% after intervention, P = 0.01). After holding expert panel with specialists and preparation of suggestions to improve the management of patients presenting to the ED with fall-related injuries, educational sessions were offered to the physicians based on these suggestions. In the month following this intervention, 31 patients who met similar inclusion criteria as the patients in step one were included in the final step of the study. These patients were found to be homogenous to the patients included before the educational intervention in relation to demographic and baseline data. As shown in Tables 4 and 5, after the intervention the physicians’ performance improved in two categories (clinical examination and medical interventions), with no improvements in laboratory tests category. As mentioned in the methods section, a collective score was calculated for each category. The ranges of scores for clinical examinations, diagnostic tests and therapeutic intervention were 0–22, 0–10 and 0–16, respectively. The mean scores of physicians for correct implementation of clinical examinations before and after educational interventions were 10.01 ± 31.3 and 14.03 ± 2.3, respectively (P < 0.001). In addition, the scores of physicians’ performance in choosing correct diagnostic tests before and after educational intervention were 5.5 ± 2.3 and 4.6 ± 2.4, respectively (P = 0.053). It should be pointed out that the scores of physicians’ performance in adopting correct therapeutic measures before and after educational intervention were 9.5 ± 3.4 and 11.4 ± 3.2, respectively (P = 0.004). Based on these findings, one can conclude that the educational intervention resulted in an improvement in the performance of physicians in relation to clinical evaluation and therapeutic measures; however, it resulted in a minor decrease in their ability to choose correct diagnostic tests. In order to modify the effects of potential confounding factors a multivariate backward linear regression model was designed.
Table 3 Expert panel suggestions for preventing medical errors in therapeutic interventions and measures to prevent repeat falls. Strategy Therapeutic interventions
Implementation of the protocol to prevent the patient from falling again
Planning for the patient’s discharge
The suggested guidelines – General interventions: offering specialized interventions; offering technique interventions; control of the patient’s living environment; use of personal protection tools; evaluation of the patient’s ability to take medicine; evaluation of the care available based on the patient’s report – Cognitive status: evaluation and in the case of any abnormality, the diagnosis of the problem; evaluation of the individual’s ability to give personal consent for treatment; drug therapy – Mental state: evaluation and if there is any abnormality, diagnosis of the problem; drug therapy – Balance: evaluation and if there is any abnormality, diagnosis of the problem; rehabilitation in the ward (or referral for rehabilitation); presentation of exercise programs at home (by a physiotherapist) – The power of the lower extremity: evaluation and if there is any abnormality, diagnosis of the problem; determination of nutritional status or presence of malabsorption; follow-up of the patient’s rehabilitation (if necessary); presentation of exercise programs at home – Osteoarthritis in the lower extremity: evaluation and if present, diagnosis and prescription of analgesics; rehabilitation in the ward (or referral for rehabilitation); presentation of exercise programs at home (by a physiotherapist) – Integrity of bones: evaluation and in the case of any abnormalities, diagnosis and prescription of calcium, vitamin D and other necessary medicines to protect the bones – The health of the cardiovascular system: evaluation and in the case of any abnormality, diagnosis of the problem; in case of cardiac insufficiency before the incident or presence of risk factors, drug therapy is indicated – Vision: evaluation and in case of any problems, diagnosis; if the problem has not been previously evaluated by an ophthalmologist, consultation is indicated – Medications: evaluation and if the drug regime has been evaluated, the results of drug therapy and its effect should be evaluated; prescription of new drugs if necessary – Evaluation of risk factors for falling – Evaluation of history: headache; confusion; syncope; patient’s history in relation to the history of medicines the patient had been taking previously and polypharmacy; evaluation of the history of osteoporosis – Evaluation of the risk of patient falling again – Use of preventive measures – If the incident happens again in the hospital, the patient should be placed on a bed, if possible, and the physician or the nurse should be called upon; the incident should be recorded and reported accurately, with registration in the patient’s medical record. – Determination of a strategy: holding meeting sessions and Expert panel between specialists in order to plan therapeutic interventions Organizing care: The patient and his/her family should be informed about his/her clinical status; a physician should take the responsibility to take care of the patient constantly; the tools and equipment for taking care of the patient should be available for the patient; the patient should be referred to the center necessary (rehabilitation centers and social workers) – Registration of a summary of procedures to discharge the patient
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Table 4 The most common medical errors in the clinical and diagnostic evaluation of patients referred to the emergency department, with a complaint of falling. Error
Before intervention (N = 400)
Deficiency in documentation of History Evaluation of vertigo 175(43.75%) Evaluation of angina pectoris 155(38.75%) Evaluation of asthma 224(56.0%) Evaluation of syncope, if any 376(94.0%) Presence of arrhythmia 323(80.75%) Nausea and vomiting 200(50.0%) Diarrhea and constipation 280(70.2%) Control of defecation 103(25.75%) Hemorrhage 333(83.25%) Urinary incontinence 300(75.0%) Deficiency in clinical examinations Documentation of vital signs 16(4.0%) Measurement of weight 74(17.2%) measurement of height 75(18.75%) Palpation of peripheral pulses 136(34.1%) Measurement of orthostatic 233(58.4%) hypotension Examination of cranial nerves 355(88.75%) Examination of deep tendon reflexes 380(95.0%) Romberg test 371(92.75%) Cerebellar test 375(93.75%) Examination of the hip joint 106(26.6%) Examination of the knee 100(25.0%) Examination of the foot 97(24.25%) No request for the following laboratory tests 2(0.5%) CBCa BUNb/creatinine 8(2.0%) c ALP 266(66.5%) Albumin 237(59.25%) Calcium 237(59.25%) Blood glucose 170(42.5%) Uric acid 157(39.25%) TSHd 313(78.25%) Electrolytes 67(16.75%) e ECG 341(85.5%) a b c d e
After intervention (N = 31)
P
13(41.9%) 14(45.2%) 14(45.2%) 30(96.8%) 15(48.4%) 15(48.4%) 10(20.1%) 8(25.8%) 13(24.9%) 18(58.1%)
0.84 0.48 0.24 0.99 <0.001 0.86 <0.001 0.99 <0.001 0.054
1(3.2%) 0(0.0%) 1(3.2%) 3(9.7%) 17(54.8%)
0.99 0.005 0.029 0.005 0.7
14(14.2%) 14(45.2%) 11(35.4%) 13(41.9%) 10(32.3%) 7(22.6%) 6(19.35%)
<0.001 <0.001 <0.001 <0.001 0.53 0.99 0.66
0(0.0%) 0(0.0%) 23(74.2%) 23(74.2%) 20(64.5%) 12(38.7%) 22(70.9%) 25(80.6%) 20(64.5%) 22(71.0%)
0.99 0.99 0.43 0.13 0.7 0.68 0.001 0.75 <0.001 0.03
Complete blood count. Blood urea nitrogen. Alkaline Phosphatase. Thyroid stimulating hormone. Electrocardiogram.
Table 5 The most common medical errors in therapeutic interventions inpatients referred to the emergency department, with a complaint of falling. Error
Before intervention (N = 400)
After intervention (N = 31)
Adoption of no medical interventions in the following cases Cognitive function 89(22.25%) 7(22.6%) Mental state 207(51.6%) 11(32.5%) Balance 139(34.75%) 7(22.6%) Integrity of bones 90(22.5%) 3(9.7%) Function of the lower extremity 13(28.75%) 5(16.1%) Cardiovascular health 97(24.25%) 6(19.35%) Visual apparatus 237(59.25%) 15(48.4%) Proper drug intervention 111(27.75%) 6(19.35%) Recommendation of aides 127(31.75%) 6(19.35%) Recommendation of safety equipment 147(36.75%) 8(25.8%) Recommendation of exercise 178(44.5%) 7(22.6%) programs at home Instructions in measures to prevent 186(46.5%) 8(25.8%) falling again Instructions, at discharge, in methods 186(46.5%) 9(29.0%) to improve the home environment Physiotherapy consultation 331(82.75%) 29(93.55%) Nutritional consultation 247(61.75%) 26(83.9%) Other consultations 119(29.75%) 1(3.2%)
P
0.96 0.08 0.17 0.095 0.14 0.54 0.24 0.31 0.15 0.25 0.02 0.026 0.06 0.12 0.01 0.002
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Table 6 The results of multivariate linear regression analysis. Variable
Beta
t
P
Correct performance during clinical examinations Educational intervention 3.79 7.4 <0.001 Instability of the patient’s clinical state 1.76 6.63 <0.001 Chronic pain 1.505 4.63 <0.001 Fall-related complications 1.2 3.73 <0.001 Performance in ordering correct laboratory tests Educational intervention −1.21 −2.67 0.008 An increase in trauma severity 0.88 3.85 <0.001 Instability of the patient’s clinical state 0.52 2.2 0.03 Chronic pain 0.85 3.62 <0.001 Performance of physicians in selecting correct medical interventions Educational intervention 2.004 3.14 0.002 Chronic pain −.0834 −0.52 0.012
Factors such as patients’ educational level, severity of trauma, use of alcohol, patients’ mood stability, patients’ clinical stability at presentation, affliction with chronic pain and the complications of falls were entered into the model. The results of the analysis are presented in Table 6 in the three sections under study, including clinical examination, diagnostic tests and therapeutic interventions. The results of the analysis showed that educational intervention resulted in promotion of the quality of care in relation to clinical evaluations (β = 3.79; P < 0.001) and therapeutic interventions (β = 2.004; P = 0.002). However, education had a negative effect on choosing correct diagnostic tests (β = −1.21; P = 0.008). 4. Discussion The present study was the first attempt in Iran to design a clinical audit regarding the management of elderly fall-related injuries. The study revealed several important findings: 1) There are significant deficiencies in the diagnosis and treatment of fall victims; 2) In many cases proper actions were not taken to prevent future falls; 3) A list of expert suggestions were generated through the Delphi method to overcome these shortcomings; 4) It was shown that providing clinicians with instructions in the context of guidelines and educational material can help improve the care provided to fall victims. Studies have indicated a wide gap between the service offered and standard guidelines. Kalula et al. showed that the management of fall-related injuries was not favorable. The use of alcohol and drug abuse was recorded in only 20% of cases, while pulse rate and orthostatic blood pressure were evaluated in only 2% of patients. Furthermore, none of the elderly were referred to a geriatrician, physiotherapist or work therapist after falls (Kalula et al., 2006). Youde et al. (2009) concluded that the care delivered to the elderly after they fall is inconsistent with standards and often not delivered on time. Salter et al. (2006) showed in a clinical audit that less than 4% of elderly patients presenting with falls undergo evaluations and management based on standards. Therefore, measures should be adopted to decrease errors in the care of the elderly suffering from fall-related injuries. The suggestions offered by the expert panel were one of the most important strengths of the present study. Similar guidelines have been implemented around the world and it has been shown that prevention programs improve outcomes (Feder et al., 2000, Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). In our setting, implementing the suggested guidelines resulted in a modest improvement in the quality of services delivered during clinical examinations and therapeutic interventions; however, it had no effect on the adoption of correct diagnostic techniques. The fact that only a modest improvement was observed may be a result of the complexity and length
Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001
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of the suggestions. Often emergency physicians and nurses do not find the time to follow in detail such recommendations. For this purpose a straightforward clinical pathway, derived from the points suggested here, would be a more feasible approach and may improve the level of care more significantly. In this study we found shortcomings in various aspects of patient care. History taking and physical examination are important steps for recognition of repeat fallers, internal risk factors (neurologic deficits, visual problems, cognitive and psychological disorders, urinary or fecal incontinence, etc.) and external risk factors (polypharmacy, psychotropic or diuretic medications, inadequate lighting, slippery surfaces, etc.) for future falls (Feder et al., 2000; Galvez-Barron et al., 2013; Grenier et al., 2014; Kwan et al., 2011; Stubbs et al., 2014; Tariq et al., 2013; Wu et al., 2013). The authors believe that our results reflect the clinicians’ focused approach to the fallen patient in the ED without a proper attitude toward prevention. For instance while vital signs were recorded for over 95% of the patients, orthostatic changes were missing in close to 60% of the cases. We also found that the results of the Romberg test were not recorded in close to 93% of the patients. This is in spite of the fact that guidelines have recommended all older adults should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance even if they don’t present with this complaint (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). These rates may be due to the fact that many patients who come to the ED with a fall may not be able to stand because of their injuries. But we believe focusing on the traumatic injuries usually diverts attention away from performing a meticulous physical exam. Furthermore, evaluation of visual impairments as a possible cause of the fall was only performed in just over 40% of our population. Literature is inconsistent regarding the importance of this intervention. While some studies describe a protective effect (Foss et al., 2006; Harwood et al., 2005), others have challenged this finding (Cumming et al., 2007). Nonetheless our guidelines recommend that the eye exam should be noted and recorded for these patients and treatment offered. A worrisome finding in our study was that despite the elderly population and the obvious risk for cardiac-related fall events (Belita et al., 2013), an ECG was not ordered for over 85% of cases and this only mildly improved to 71% after the educational intervention. In most cases a clear “tripping” history was thought to be the reason for omitting this significant evaluation in the ED. During treatment, the most neglected medical intervention was failure to consult a physiotherapist. Earlier guidelines recommended exercise and balance training for all older people who have had recurrent falls, but current guidelines advocate exercise programs only for community-dwelling elderly (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). Goodwin et al. showed that clinical evaluations and referral of patients with hip fractures for participation in exercise and physiotherapy programs were done in 68% and 44% of the cases, respectively. These figures were even lower in injuries without hip fractures, with 28% and 22%, respectively (Goodwin et al., 2010). In our study we found that this intervention was neglected in over 82% of cases, reflecting the treating physician’s improper attitude toward this important intervention. Education of patients by clinicians, and education of clinicians through guidelines and educational programs has been advocated as a measure of improving care for the fallen patient (Feder et al., 2000, Moreland et al., 2003, Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011, Paniagua et al., 2006). In our study, implementation of such a program for emergency department personnel best improved the process of history taking and physical examination, while it had a negative effect on obtaining the correct tests. We believe that a clear
clinical pathway initiated as early as possible in the ED by the triage nurse may have a more significant outcome, and the effect of these two approaches should be evaluated in future studies. Furthermore, the authors insist that for such comprehensive approaches to be effective, they should not be left up to the judgment of each individual clinician. These interventions need to be coordinated by a person or team in the emergency department. This may be included into the role of the trauma nurse coordinator (Crouch et al., 2015) or a specific hospital nurse coordinator for fall victims. 4.1. Limitations This was a clinical audit and a before and after study. Physicians’ failure to document interactions with the patient, or performed clinical examinations may have contributed in underestimating the level of care provided during the clinical audit. The number of patients evaluated after the implementation of the educational program was considerably less than the number evaluated before which may impair the ability to fully analyze the effects of the program. Finally the effect of the program was only analyzed during the first month after the program. Whether the effect is a lasting one needs to be analyzed in future audits. 5. Conclusion In order to promote the quality of care services the authorities and policy-makers should be confident that the services delivered during the evaluation and treatment of elderly patients suffering from complications of falls are standard. Identification of patients at risk and interventions to reduce this risk should become an important part of the ED evaluation of fall victims. The results of this clinical audit reaffirm the wide gap between services delivered in the management of falls and accepted standards. Furthermore, educational intervention could only modestly improve the situation. Acknowledgements This article was based on a postgraduate thesis by Dr. Sabbaghi, which was successfully completed under the supervision of Dr. Hatamabadi and Dr. Sum. References Abolhassani, F., Moayyeri, A., Naghavi, M., Soltani, A., Larijani, B., Shalmani, H.T., 2006. Incidence and characteristics of falls leading to hip fracture in Iranian population. Bone. 39, 408–413. Akyol, A.D., 2007. Falls in the elderly: what can be done? International Nursing Review. 54, 191–196. Barker, A., Kamar, J., Morton, A., Berlowitz, D., 2009. Bridging the gap between research and practice: review of a targeted hospital inpatient fall prevention programme. Quality and Safety in Health Care. 18, 467–472. Belita, L., Ford, P., Kirkpatrick, H., 2013. The development of an assessment and intervention falls guide for older hospitalized adults with cardiac conditions. European Journal of Cardiovascular Nursing: Journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology. 12, 302–309. Bell, A.J., Talbot-Stern, J.K., Hennessy, A., 2000. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. The Medical Journal of Australia. 173, 179–182. Crouch, R., McHale, H., Palfrey, R., Curtis, K., 2015. The trauma nurse coordinator in England: a survey of demographics, roles and resources. International Emergency Nursing. 23, 8–12. Cumming, R.G., Ivers, R., Clemson, L., Cullen, J., Hayes, M.F., Tanzer, M., et al., 2007. Improving vision to prevent falls in frail older people: a randomized trial. Journal of the American Geriatrics Society. 55, 175–181. Feder, G., Cryer, C., Donovan, S., Carter, Y., 2000. Guidelines for the prevention of falls in people over 65. The Guidelines’ Development Group. BMJ (Clinical Research Ed.). 321, 1007–1011. Foss, A.J., Harwood, R.H., Osborn, F., Gregson, R.M., Zaman, A., Masud, T., 2006. Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age and Ageing. 35, 66–71.
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Please cite this article in press as: Hamid Reza Hatamabadi, Shima Sum, Ali Tabatabaey, Mohammad Sabbaghi, Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.001