Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
University College Dublin School of Medicine and Medical Science, Dublin, Ireland.
Ann Emerg Med. 2020 Dec;76(6):730-738. doi: 10.1016/j.annemergmed.2020.06.020. Epub 2020 Sep 30.
Falls are a major cause of mortality and morbidity in adults aged 65 years and older and a common chief complaint in the emergency department (ED). However, the rate of missed opportunities to diagnose and intervene in modifiable fall-risk factors in the ED is unknown. We hypothesize that although ED providers (defined as ED attendings, residents, and advanced care providers) excel at assessing and ruling out injury, they miss the opportunity to identify a large portion of the modifiable risk factors that contribute to a patient's fall. Our objective is to quantify the number of missed opportunities to identify and reduce fall-risk factors in older adult ED patients presenting after a fall.
This secondary analysis used data from a prospective cohort study of older patients at a single academic urban ED. The original study investigated the standard ED evaluation after a fall in older adults. All patients in the original study had a falls evaluation conducted at their ED visit by trained research assistants; this served as the standard fall evaluation. We reviewed the charts of study patients and identified modifiable fall-risk factors. We then determined the number of missed opportunities to intervene in these risk factors during the ED encounter; the primary outcome was the percentage of missed opportunities to identify risk factors in older ED patients who fell.
We found that of the 400 patient charts reviewed, 349 patients had a modifiable risk factor for falling. Of those patients with known modifiable risk factors, the ED team missed identifying the factors in 335 patients (96%). The most commonly missed fall-risk factors were visual acuity (147/154; 96%) and the use of high-risk medications (245/259;95%). Gait abnormalities had the lowest rates of missed modifiable risk factors, at 56% of patients (109/196). When a modifiable risk factor was identified and intervened in, it was most commonly done in the ED observation unit by a physician or physical therapist, and often consisted of an outpatient referral or primary care physician follow-up.
Providers frequently fail to identify and intervene in modifiable fall-risk factors in older adult patients presenting to the ED after a fall; this is a missed opportunity. Addressing the risk factors that contributed to the fall during a fall-related ED visit may minimize fall risk and promote safer mobility.
跌倒在 65 岁及以上的成年人中是导致死亡率和发病率的主要原因，也是急诊科（ED）常见的主要主诉。然而，ED 中未能诊断和干预可改变的跌倒风险因素的发生率尚不清楚。我们假设，尽管 ED 提供者（定义为 ED 主治医生、住院医师和高级护理提供者）擅长评估和排除伤害，但他们错过了识别导致患者跌倒的大部分可改变风险因素的机会。我们的目标是量化在因跌倒而就诊的老年 ED 患者中识别和降低跌倒风险因素的机会数量。
这是一项对单家学术性城市 ED 中老年人进行的前瞻性队列研究的二次分析。原始研究调查了老年人跌倒后的 ED 标准评估。原始研究中的所有患者在 ED 就诊时都由经过培训的研究助理进行了跌倒评估；这是标准的跌倒评估。我们查阅了研究患者的病历并确定了可改变的跌倒风险因素。然后，我们确定了在 ED 就诊期间干预这些危险因素的机会数量；主要结果是在跌倒的老年 ED 患者中识别风险因素的机会百分比。
我们发现，在审查的 400 份病历中，有 349 名患者有跌倒的可改变风险因素。在已知有可改变的跌倒风险因素的患者中，ED 团队在 335 名患者（96%）中未能识别这些因素。最常见的漏诊跌倒风险因素是视力（147/154；96%）和使用高危药物（245/259；95%）。步态异常漏诊的可改变跌倒风险因素率最低，为 56%的患者（109/196）。当识别出可改变的风险因素并进行干预时，最常见的是由医生或物理治疗师在 ED 观察单元进行，通常包括门诊转诊或初级保健医生随访。
提供者经常未能识别和干预老年患者跌倒后就诊于 ED 时的可改变跌倒风险因素；这是一个错失的机会。在与跌倒相关的 ED 就诊期间处理导致跌倒的风险因素可能会降低跌倒风险并促进更安全的活动能力。
