The emergency department evaluation and outcomes of elderly fallers
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Background: Approximately one-third of community dwelling elderly people (age ≥65 years) falls each year contributing to over 2 million elderly emergency department (ED) visits for falls annually. The cost of care for fatal falls by elderly patients in the US was $179 million in 2000, and was $19 billion for non-fatal falls. The risk of falling increases with various risk factors including advancing age. Despite the frequency and costs associated with elderly falls, it is not clear what evaluation elderly fallers receive in the ED, after the ED, and the outcomes of the care provided. Objectives: We sought to examine the ED and post-ED workup of elderly fallers, and to compare this evaluation to that recommended by published ED fall evaluation and treatment guidelines. We also examined the disposition of these patients and the rate of adverse events which occurred within 1 year of discharge. Methods: This study was a retrospective chart review of elderly ED fall patients from one urban teaching hospital with >90,000 visits per year. Patients aged ≥65 years who had an ED visit in 2012 with fall related ICD-9 codes E880-886, E888 and who had been seen by a primary care physician (PCP) within our hospital network during the past 3 years were included. We excluded patients who were transferred to our hospital and subsequent visits related to the original fall. We randomly selected 350 eligible patients for chart review. We adapted our data collection instrument from published fall evaluation recommendations including the American Geriatric Society. Categorical data were presented as percentages and continuous data were recorded as mean with standard deviation (SD) if normally distributed or medians with inter-quartile ranges (IQR) if non-normally distributed. Results: A random sample of 450 charts were taken, 100 were subsequently excluded for erroneous identification. The average age was 80 (SD±9) years; 124 (35%) were male, with an average Charlson comorbidity index of 7.6 (SD 2.9). In terms of history, 251/350 (72%) took 5 or more medications, 144/350 (41%) had their visual acuity checked in the past 12 months, and 34/350 (10%) had fallen two or more times in the past 3 months. In the physical exam, only 43/350 (12%) had orthostatics done. 168/350 (48%) patients had their extremity strength recorded, of these 16/168 (10%) had decreased muscle strength. Only 128/350 (37%) patients had their gait recorded, of which 108/128 (84%) were noted to have an abnormal gait. Basic chemistry laboratory tests and hematology were sent on 199/350 (57%) of patients in the ED. X-rays were taken of 275/350 (79%) patients, and CTs were taken of 184/350 (53%) patients in the ED. 277/350 (79%) patients were discharged to their place of preadmission residence from the ED, ED observation unit, or hospital while 70/350 (20%) were discharged to a skilled rehab facility, all after being admitted to the hospital. 196/350 (56%) patients returned to the ED for any reason within 1 year of discharge, averaging 2.4 ± 1.9 visits. 161/350 (46%) patients were hospitalized within 1 year after discharge, averaging 2 ± 1.4 hospital admissions. 23 (7%) of patients died within 1 year after discharge. Conclusion: The comprehensive evaluation of falls for well-established risk factors and causes appears to be poor in this academic medical center ED. While results may not be generalizable to other EDs, the results suggest that standardized evaluation and treatment guidelines are needed.