The risk of falls increases as we age. Unfortunately, so does the risk of injury, morbidity, and mortality following a fall. Falls risk is considered a geriatric syndrome, with multi-factorial causes. Falls are a the #1 cause of trauma-related mortality in older adults, and a major cause of ED visits, hospital admissions, and admission to nursing facilities. Often, a patient at high risk for falls is not identified until after they have suffered an injury. Orange County EMS developed a system to help identify patients who were at high risk for falls, perform a comprehensive home visit, and connect those individuals with appropriate services to help reduce the rate of future falls and help those patients maintain their independence and functionality in their home environment.
See below for references
- The MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008 Online calculator
- Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273(3):1348–1353. https://www.ncbi.nlm.nih.gov/pubmed/7715059
- Haentjens P, Magaziner J, Colon-Emeric CS, et al. Meta-analysis: Excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390 https://www.ncbi.nlm.nih.gov/pubmed/20231569
- Peck et al. Death after discharge: predictors of mortality in older brain injured patients. J Trauma Acute Care Surg 77;6, 2014 https://www.ncbi.nlm.nih.gov/pubmed/25248061
- CDC TBI facts and stats http://www.cdc.gov/traumaticbraininjury/index.html
- National Council on Aging Fall Prevention Facts and Statistics https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/
- Falls in Older Persons: Risk Factors and Prevention. https://www.ncbi.nlm.nih.gov/books/NBK235613/
- Zia et al. Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk. Postgrad Med 2015127 (3) https://www.ncbi.nlm.nih.gov/pubmed/25539567
- AHRQ Statistical Brief #268: Outpatient prescription anticoagulants utilization and expenditures for the US civilian noninstitutionalized population age 18 and older, 2007
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Congrats David and Christina for tackling the challenging topic of older adult falls and fall-related injuries. Using pre-hospital personnel to reduce falls and fall injuries is a fascinating concept. I was hoping that your podcast would acknowledge and discuss some of the most applicable published pre-hospital and ED falls research. Accordingly, here are a few unanswered questions that I have after listening to your podcast.
1) One recent systematic review of pre-hospital fall prevention interventions demonstrated no consistent benefit (see http://pmid.us/26755748). In your opinion, why did these prior studies fail to prevent falls or injurious falls? How can future pre-hospital fall investigators adapt prior interventions to increase the likelihood of success?
2) You mentioned during your podcast a couple of times that your pre-hospital intervention is unfunded. Implementation research indicates that a favorable funding environment is one essential ingredient to overcome inertia and develop sustainable, easily disseminated interventions for almost anything (see http://pmid.us/28264797 and http://pmid.us/25773739 and http://pmid.us/25393182). How do you foresee EMS systems that lack funding to develop pre-hospital falls programs (even those that link to existing falls services) do so? Who are the key opinion leaders within their communities that they’d need to reach to initiate funding streams?
3) What is the role of the GEMS program to educate EMS providers about falls (and more generally about the uniqueness of geriatric patients, see http://www.naemt.org/education/GEMS/GEMS.aspx)?
4) Your study used CDC fall prediction instruments, but most of these have never been tested in ED settings and those that have do not accurately predict falls (see http://pmid.us/25293956). Why did you choose to use the CDC instrument rather than evaluate ED instruments that might be more applicable for EMS settings?
Again, thanks for an important episode. I hope that GEMCast addresses the many challenges and complexities of geriatric falls again!
Chris Carpenter, MD, MSc
SAEM Academy of Geriatric Emergency Medicine President
Washington University in St. Louis
Chris, thank you, as always, for your expertise weighing in and for your thoughtful and well-read comments!
1. I’m not sure. His program is still working on getting quantitative results in terms of the outcomes. However, it likely has to do with (i) the population – they had already selected for people who were willing to have an in-home eval, so they may have been more motivated to follow through with the interventions. (ii) the interventions through the center on aging are very good, and may be more thorough than what other studies have offered.
2. They initially did this program in their extra time, on a volunteer basis. Now that they have seen that it works, they have received some small funding for it. Funding may be very dependent on location and major payer (eg a hospital system ACO may be interested). It is hard to get funding until you can show it is effective. They also worked with several MBA students who used this as their master’s project to help develop the system etc.
3. GEMS has a great opportunity to educate EMS providers about falls. In terms of what to do with high risk falls patients, that is more complicated, as it will depend on the specific resources available to each community/county.
4. I think the CDC fall prediction was simple, and quick to use, and they were primarily looking at patients who had called for a fall or a recurrent fall or a lift assist, so they were already targeting a high risk population. Other screening tools (as long as they are quick and easy to administrate either to a patient who has just fallen or in the back of an ambulance) would likely also work well.