The Emergency Department Stopping Elderly Accidents, Deaths, & Injuries Study

Abstract The Emergency Department Stopping Elderly Accidents, Deaths, and Injuries (ED-STEADI) study aims to determine if a bedside decision aid for fall prevention can increase patient participation in management options that decrease fall risk. The study also aims to determine if gender differences exist in the choices that are selected and in the accomplishment of these goals by using the decision aid. The population included patients at the Lehigh Valley Hospital Cedar Crest Emergency Department (ED) who were 65 years of age or older, being discharged home from the ED, able to speak English, competent and able to give consent, and had a mechanical fall risk. Interested patients who consented were enrolled in the study. Both the intervention and control arms were given an initial survey and performed two mobility tests. Those in the control arm then received a fall prevention pamphlet, while those in the intervention arm used a bedside decision aid to select interventions to decrease fall risk. Follow-up phone calls will be made 5 times over a one-year period to collect self-reported data about goal completion and fall history, and the data will be analyzed using logistic regression models. Thus far, of the 120 people screened, 7 (5.8%) patients enrolled. The home assessment checklist and medication review by the patient’s own physician were selected as the most common interventions to prevent falls while using the bedside decision aid. More data is needed to effectively determine the effect of the bedside decision aid on patient participation in fall prevention management options, to determine gender differences in choice of interventions selected using the bedside decision tool, and to determine whether gender differences exist pertaining to the goals truly accomplished by patients. The Emergency Department Stopping Elderly Accidents, Deaths, and Injuries Study Alarmingly, falls are one of the leading causes of fatal and nonfatal injuries among older adults (Center for Disease Control and Prevention [CDC], 2014a). Each year, 1 in 3 adults age 65 and older falls (Tinetti, 2003).20% to 30% of people who fall suffer moderate to severe injuries, including lacerations, hip fractures, and head traumas (Sterling, O’Connor, & Bonadies, 2001). These injuries make it extremely difficult for the aging to live independently and can increase risk of premature death. In 2011, 2.4 million nonfatal fall injuries among older adults were treated in emergency departments, and more than 689,000 of these patients were hospitalized (CDC, 2014a). Furthermore, it has been reported that falls account for 10% of all emergency department visits (Owens, Russo, Spector, & Mutter, 2009). Additionally, gender has been found to have a clear impact on fall risk. Men are more likely to die from a fall; however, women have been found to be 58% more likely than men to suffer a nonfatal fall injury (CDC, 2014a). The purpose of the ED- STEADI study is to determine if utilization of a bedside decision aid for mechanical fall prevention in the emergency department can increase patient participation in management options that decrease the patients’ fall risk. Furthermore, the study aims to determine if gender differences exist in choices that are selected by the patient from the given management options listed on the bedside decision aid, and if gender differences exist in the accomplishment of goals that were agreed upon by using the decision aid. It is hypothesized that the use of a bedside decision aid will increase patient participation in management options that decrease the patients’ fall risk. Moreover, it is hypothesized that men and women will select different management options listed on the decision aid and will accomplish different goals through utilization of the decision aid. Literature Review In response to the drastic number of traumatic falls suffered by older adults, many studies have been conducted to investigate the efficacy of isolated fall prevention strategies, including fall risk assessments, exercise programs, medication management, home hazard reduction, and multifactorial interventions that include two or more fall prevention strategies. One study published in the journal Age and Ageing evaluated the efficacy of a multifactorial assessment in preventing falls, which included medical intercessions, physiotherapy, and occupational therapy as interventions compared to conventional care (Davison, Bond, Dawson, Steen, & Kenny, 2005). Conclusively, the study demonstrated that multifactorial fall assessment and intervention reduced subsequent falls by 36% in adults over 65 without cognitive impairment (Davison, Bond, Dawson, Steen, & Kenny, 2005). Additionally, the 2012 Cochrane Review analysis on interventions for preventing falls in older people living in the community compared the rate of falls between intervention and control groups, and analyzed 159 trials comprised of 79,193 total participants (Gillespie et al., 2012). The study concluded that both group and home-based exercise significantly reduced the rate of falls and risk of falling, and determined both multifactorial interventions and gradual withdrawal of psychotropic medications additionally reduced rate of falls (Gillespie et al., 2012). Home safety modification interventions were effective in reducing the rate of falls and risk of falling, but were more effective for those already at higher risk for falling, and when delivered by an occupational therapist (Gillespie et al., 2012). Furthermore, the study concluded that an intervention to treat vision problems reduced falls that occurred outside in those of the intervention group that regularly took part in outside activities, but conversely increased outside falls in those that took part in little outside activity (Gillespie et al., 2012). Stevens et al. (2012) further examined how men and women differed in seeking medical care for falls. The study found women were significantly more likely than men to report falls, seek medical care, and discuss falls and fall prevention with a healthcare provider (Stevens et al., 2012). An additional study addressing differences for non-fatal unintentional fall related injuries among older adults concluded that rates for injury diagnoses were generally higher among women, most notably among fractures which were 2.2 times higher for women than for men (Stevens & Sogolow, 2005). For all parts of the body, women’s injuries exceeded those of men, and women were 1.8 times as likely to be hospitalized for fall-related injuries (Stevens & Sogolow, 2005). Thus, it is evident that interventions should be tailored to account for gender differences, and gender must be taken into account for developing and implementing targeted fall prevention strategies. Methodology The population being studied included all patients who presented to the Lehigh Valley Hospital Cedar Crest Emergency Department (ED) while a member of the research team was available to enroll patients who were 65 years of age or older, being discharged home from the ED, able to speak English, competent and able to give consent, and had a mechanical fall risk, meaning the patient had fallen in the last year, worried about falling, or admitted they felt unsteady when standing or walking. Eligible and interested patients were consented and randomly assigned to either control or intervention study arms. All subjects in both the control and intervention arms took an initial survey and performed the Timed Up and Go (TUG) Test and the 30 Second Chair Stand Test. Those in the control arm were then given the brochure “What YOU Can Do To Prevent Falls” (CDC, 2014b). Those in the intervention arm instead completed a bedside decision aid worksheet and selected fall prevention management options most valuable to them. Both arms will have follow-up phone calls at 6 weeks, 3 months, 6 months, 9 months, and 12 months after discharge to collect self-reported data about goal completion and fall history. Logistic regression models will be used to determine if the use of the bedside decision aid for fall prevention increased patient participation in management options that decreased their fall risk, to determine if men and women selected different management options listed on the decision aid, and to determine if men and women participated in different management options. Data and Results Between 6/4/2014 and 7/10/2014, 120 patients were screened at the Lehigh Valley Hospital Emergency Department Cedar Crest. Out of the 120 patients screened, 113 patients (94.2%) declined or were ineligible to enroll in the study, while 7 patients (5.8%) enrolled in the study. From the 7 patients enrolled, 71.4% (5 patients) were male, while 28.6% (2 patients) were female. Additionally, the mean age of the enrolled patients was 80, and ages of the enrolled patients ranged from 70 – 94. Refer to Tables 1, 2, & 3 for a more detailed representation of enrollment distribution, gender distribution, and age distribution respectively. Enrollment Distribution Total Screened 120 Screened Who Did Not Enroll 113 94.2% Enrolled 7 5.8% Table 1. Enrollment Distribution. This table presents the number and percentages of those who declined or were ineligible to enroll and of those who enrolled. Gender Distribution Total Screened (n=120) Male 51 42.5% Female 69 57.5% Screened Who Did Not Enroll (n=113) Male 46 40.7% Female 67 59.3% Enrolled (n=7) Male 5 71.4% Female 2 28.6% Table 2. Gender Distribution. This table presents the relative percentages of males and females from total patients screened, those who declined or were ineligible to enroll, and those who enrolled. Age Distribution Total Screened (n=120) Mean Age 78 Mean Male Age 76 Mean Female Age 79 Range 65 – 97 Screened Who Did Not Enroll (n=113) Mean Age 78 Mean Male Age 75 Mean Female Age 80 Range 65 – 97 Enrolled (n=7) Mean Age 80 Mean Male Age 81 Mean Female Age 79 Range 70 – 94 Table 3. Age Distribution. This table presents the mean age with regards to gender, and age ranges for total patients screened, those screened who declined or were ineligible to enroll, and those who enrolled. Common reasons as to why patients declined or were ineligible to enroll in the ED-STEADI study included pain, eventual admission to the hospital, and failing to admit to being a fall-risk. Refer to Table 4 for the primary reasons that patients declined or were ineligible to enroll, as classified by age group. Primary Reasons Patients Did Not Enroll By Age Group Ages 65-69 Intense Pain Not A Fall Risk Ages 70-74 Not A Fall Risk Ages 75-79 Admitted Mobility Restricting Health Issues Intense Pain Not A Fall Risk Ages 80-84 Admitted Ages 85-89 Mobility Restricting Health Issues Not Interested Memory/Psych Issues Ages 90-94 Admitted Ages 95-99 Memory/Psych Issues Doctor Did Not Consent Table 4. Primary Reasons Patients Did Not Enroll By Age Group. This table presents the most common reason(s) that individuals declined or were ineligible to enroll in the study, categorized by age group. (n=113) The 7 enrolled patients were given an initial survey to measure fall concern and functional decline. The patients were asked to rate the amount of difficulty on average that they had with physical activities, the amount of difficulty that they had with activities due to their health and whether or not they sought help with those activities, and the amount of concern that they had about performing certain activities. Refer to Tables 5, 6, & 7 for average scores on the aforementioned survey questions. Average Difficulty With Activities As Indicated On Initial Survey Stooping, Crouching, Kneeling 2.5 Lifting Or Carrying Objects Up To 10 lbs. 2.0 Reaching Arms Above Shoulder Level 1.5 Writing Or Grasping Small Objects 2.0 Walking A Quarter Of A Mile 2.5 Doing Heavy Housework 2.5 Table 5. Average Difficulty With Activities As Indicated On Initial Survey. This table presents the average difficulty with activities of the 7 enrolled patients as indicated on the initial survey. (n=7) 1=No Difficulty, 2=A Little Difficulty, 3=Some Difficulty, 4=A Lot of Difficulty, 5=Unable Average Difficulty With Activities Because Of Health/Physical Condition As Indicated On Initial Survey Shopping For Personal Items 1.0 Managing Money 2.0 Walking Across The Room 1.0 Doing Light Housework 1.0 Bathing Or Showering 1.0 Table 6. Average Difficulty With Activities Because Of Health/Physical Condition As Indicated On Initial Survey. This table presents the average difficulty with activities because of the enrolled patients’ health or other physical conditions and if the patients sought help for those activities as indicated on the initial survey. (n=7) 1=No Difficulty, 2=I Have Difficulty But Do Not Get Help, 3=I Have Difficulty So I Get Help, 4=I Don’t Do This Because Of My Health, 5=I Don’t Do This For Other Reasons Unrelated To My Health Average Concern As Indicated On Initial Survey Getting Dressed Or Undressed 1.5 Taking A Shower Or Bath 1.5 Getting In Or Out Of A Chair 2.0 Going Up Or Down Stairs 2.0 Reaching Above Head Or To Ground 1.5 Walking Up Or Down A Slope 1.5 Going To A Social Event 1.5 Table 7. Average Concern As Indicated On Initial Survey. This table presents the average concern of the 7 enrolled patients in performing activities as indicated on the initial survey. (n=7) 1=Not Concerned, 2=Somewhat Concerned, 3=Fairly Concerned, 4=Very Concerned Interestingly, the largest percentage of the population screened who did not enroll was between ages 65-69 (25%), while the largest percentage of the population who enrolled was between the ages of 70-74 (43%). Refer to Figures 1 and 2 for graphic representations of both the populations who declined or were ineligible to enroll and of those who enrolled, as classified by age group. Figure 1. Percent Of Population Who Did Not Enroll By Age Group. This figure refers to the percentages of screened patients who declined or were ineligible to enroll in the ED-STEADI study, categorized by age group. (n=113) Figure 2. Percent Of Population Who Enrolled By Age Group. This figure refers to the percentages of screened patients who actually enrolled in the ED-STEADI study, categorized by age group. (n=7) Additionally, Figure 3 demonstrates the most common reasons that patients declined or were ineligible to enroll in the study. 19% of the patients who declined or were ineligible to enroll in the study were eventually admitted to the hospital, while 18% stated they were not fall risks. Refer to figure 4 for a more detailed depiction of the reasons that patients declined or were ineligible to enroll, as categorized by gender. Figure 3. Reasons Patients Did Not Enroll. This figure refers to the reasons that patients declined or were ineligible to enroll in the ED-STEADI study. (n=113) Figure 4. Reasons Males And Females Did Not Enroll. This figure refers to the specific numbers of males and females who declined or were ineligible to enroll in the ED-STEADI study. (n=113) By 7/10/2014, 5 out of the 7 patients enrolled had completed the bedside decision aid as members of the intervention study arm. Thus far, the home assessment checklist and medication review by the patient’s own physician were selected as most common interventions to prevent falls while using the bedside decision aid. Refer to Figure 5 for a graphic assessment of the frequency of selected interventions by patients using the bedside decision aid. Figure 5. Interventions Selected By Enrolled Subjects. This figure refers to the frequency of interventions for fall prevention selected by the 5 patients in the intervention study arm when using the bedside decision aid. Note: none of the 5 subjects enrolled in the intervention arm selected to have his/her medication reviewed by a hospital pharmacist, receive a referral for occupational therapy, or have the ED decide which interventions to select. (n=5) Each of the 7 enrolled patients performed the Timed Up and Go (TUG) Test and the 30 Second Chair Stand Test. Figure 6 graphically depicts the time in seconds that it took for the enrolled patients to complete the Timed Up and Go Test (R2 = 0.39). Figure 7 graphically depicts the number of chair stands completed by the enrolled patients during the 30 Second Chair Stand Test (R2 = 0.63). Figure 6. Timed Up And Go Test Results. This figure refers to the time in seconds that it took for the 7 patients enrolled in the ED-STEADI study to complete the Timed Up and Go Test. An older patient who takes 12 or more seconds to complete the TUG test is at high risk for falling and is represented as a red data point on the graph (CDC, 2014b). (n=7) Figure 7. Thirty Second Chair Stand Test Results. This figure refers to the number of chair stands completed in 30 seconds by the 7 patients enrolled in the ED-STEADI study during the 30 Second Chair Stand Test. A below average score indicates a high risk for falling and is represented as a red data point on the graph (CDC, 2014b). Refer to CDC (2014b) for criteria for below average scores. (n=7) Discussion and Conclusion Between 6/4/2014 and 7/10/2014, 120 people were screened at the Lehigh Valley Hospital Cedar Crest Emergency Department, and 7 of these 120 (5.8%) enrolled (Table 1). 28.6% of patients who enrolled were female, while 71.4% were male (Table 2). The high rate of male enrollment, in contrast to the considerably higher number of women screened, may have been due to the fact that men were less likely to be admitted, have health or mobility issues, have memory or psychological problems, or be in intense pain as compared to women (Figure 4). 43% of the population who enrolled was between the ages of 70-74 (Figure 2), while those who declined or were ineligible to enroll were mainly between the ages of 65-69 (25%) and 75-79 (21%) (Figure 1). It is interesting to note that one primary reason patients declined or were ineligible to enroll between the ages of 65-74 was due to failure of patients to admit to being a fall risk, while those age 75 and older did not enroll primarily due to such issues including eventually being admitted to the hospital, having mobility-restricting health issues, having memory or psychological issues, and suffering from intense pain (Table 4). Therefore, it can be presumed that many of those ages 65-74 may have decided against enrollment because they did not yet view themselves as a fall risk, while those age 75 and older may have declined or been ineligible to enroll due to more serious medical issues that they suffered from. Overall, 19% of patients who did not enroll were eventually admitted, 18% did not admit to being a fall risk, and 13% suffered intense pain (Figure 3). However, a notably higher number of males did not enroll because they stated they were not fall risks, while a significantly higher number of females did not enroll because they were in intense pain or eventually admitted (Figure 4). As evident by the responses to the initial survey questions that the 7 enrolled patients were given, it is clear that patients had the most difficulty with stooping, crouching, or kneeling, walking longer distances, and performing heavy housework (Table 5). On average, patients also had the most difficulty managing money, although most did not receive help with this task (Table 6). Furthermore, patients were most concerned about the possibility of falling when getting in or out of a chair and when going up or down stairs (Table 7). 5 out of the 7 patients enrolled were randomly assigned to the intervention study arm, and used a bedside decision aid worksheet in order to identify what interventions for fall prevention were most valuable to them. The patient could choose none, one, or multiple intervention options. Overall, the two most common interventions chosen to prevent falls included the utilization of a checklist provided by the emergency department which provided patients with the information necessary to make their homes safer on their own, followed by medication review by the patients’ own doctors (Figure 5). The home modification checklist may have been the intervention selected most often because the home assessment checklist allowed patients to easily make their homes safer at their own convenience without needing to drive or find a ride to an appointment or being charged a copay. Home modification was also an easier goal to achieve than doing an exercise program or working with a physical therapist, especially for those who have limited mobility or already had a fear of falling. Others may have preferred to have their medications reviewed by their own doctor because an established relationship already existed between the patients and their doctors, and the patients may believe that their own doctors may better be able to review their medications, as these physicians best know the patients’ medical history. Level of mobility was evaluated for all enrolled patients by assessment of their performance during the Timed Up and Go (TUG) Test, in which the subjects were timed walking ten feet and back starting and ending in a seated position, and during the 30 Second Chair Stand Test, in which the number of chair stands were recorded during a 30 second period. According to the CDC (2014b), an older adult patient who takes 12 or more seconds to complete the TUG test is at high risk for falling, as is an adult who receives a below average score on the 30 Second Chair Stand Test. Refer to the CDC (2014b) for criteria for below average scores. The coefficients of determination for the TUG Test and 30 Second Chair Stand Test were 0.39 and 0.63 respectively; however, only 7 patients were enrolled, and thus graphically represented (Figure 6 & Figure 7). As anticipated, the time to complete the TUG test increase