SEARCH

SEARCH BY CITATION

Keywords:

  • practice guidelines;
  • accidental falls—prevention and control;
  • aged;
  • emergency medicine;
  • geriatric assessment

Abstract

  1. Top of page
  2. Abstract
  3. References

Objective: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. Methods: A pre—post-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. Results: During the two years of the study, 1,140 preintervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the “get up and go test” (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. Conclusions: The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls.

References

  1. Top of page
  2. Abstract
  3. References
  • 1
    Eliastam M.. Elderly patients in the emergency department. Ann Emerg Med. 1989; 18: 12229.
  • 2
    Beland F., Lemay A., Philibert L., Maheux B., Gravel G.. Elderly patient's use of hospital-based emergency services. Med Care. 1991; 29: 40818.
  • 3
    Campbell A. J., Reinken J., Allan B. C., Martinez G. S.. Falls in old age: a study of frequency and related clinical factors. Age Ageing. 1981; 10: 26470.
  • 4
    Blake A. J., Morgan K., Bendall M. J., et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing. 1988; 17: 36572.
  • 5
    Nelson R. C., Amin M. A.. Falls in the elderly. Emerg Med Clin N Am. 1990; 8: 30924.
  • 6
    O'Loughlin J. L., Robitaille Y., Boivin J. F., Suissa S.. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993; 137: 34254.
  • 7
    Campbell A. J., Borrie M. J., Spears G. F., Jackson S. L., Brown J. S., Fitzgerald J. L.. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing. 1990; 19: 13641.
  • 8
    Baker S. P., Harvey A. J.. Fall injury in the elderly. Clin Geriatr Med. 1985; 1: 50112.
  • 9
    Sattin R. W., Lambert Huber D. A., DeVito C. A., et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol. 1990; 131: 102837.
  • 10
    Sorock G. S.. Falls among the elderly: epidemiology and prevention. Am J Prev Med. 1988; 4: 2828.
  • 11
    Tinetti M. E., Speechley M., Ginter S. F.. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988; 319: 17017.
  • 12
    Ryynanen O. P., Kivela S. L., Honkanen R., Laippala P., Soini P.. Incidence of falling injuries leading to medical treatment in the elderly. Public Health. 1991; 105: 37386.
  • 13
    McNamara R. M., Rousseau E., Sanders A. B.. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med. 1992; 21: 796801.
  • 14
    Jones J. S., Rousseau E. W., Schropp M. A., Sanders A. B.. Geriatric training in emergency medicine residency programs. Ann Emerg Med. 1992; 21: 8259.
  • 15
    Witzke D. B., Sanders A. B.. The development and evaluation of a geriatric emergency medicine curriculum. The SAEM Geriatric Emergency Medicine Task Force. Acad Emerg Med. 1997; 4: 21922.
  • 16
    Baraff L. J., Della Penna R., Williams W., Sanders A.. Practice guideline for the emergency department management of falls in community dwelling elderly patients ≥65 years of age. Ann Emerg Med. 1997; 30: 4809.
  • 17
    Fink A., Kosecoff J., Chassin M., Brook, R. H.. Consensus methods: characteristics and guidelines for use. Am J Public Health. 1984; 74: 97983.
  • 18
    Hadorn D. C., McCormick K., Diokno A.. An annotated algorithm approach to clinical guideline development. JAMA. 1992; 267: 3314.
  • 19
    STATA Statistical Software, Release 5.0. College Station TX : State Corporation, 1997.
  • 20
    Eddy D. M.. Clinical policies and the quality of clinical practice. N Engl J Med. 1982; 307: 3437.
  • 21
    McDonald C. J., Overhage J. M.. Guidelines you can follow and can trust: an ideal and an example. JAMA. 1994; 271: 8723.
  • 22
    Toepp M. C., Kuznets N., Herrara S. P.. Directory of practice parameters: titles, sources, and updates. Chicago , IL : American Medical Association, 1996.
  • 23
    Soumerai S. B., Avorn J. A.. Principles of educational outreach (“academic detailing”) to improve clinical decision making. JAMA. 1990; 263: 54956.
  • 24
    Schriger D. L.. Emergency medicine clinical guidelines: we can make them, but will we use them Ann Emerg Med. 1996; 27: 6557.
  • 25
    Grimshaw J. M., Russell I. T.. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993; 342: 131722.
  • 26
    Grilli R., Lomas J.. Evaluating the message: the relationship between compliance rate and the subject of a practice guideline. Med Care. 1994; 32: 20213.
  • 27
    Legorreta A. P., Christian-Herman J., O'Connor R. D., Hasan M. M., Evans R., Leung K. M.. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med. 1998; 158: 45764.
  • 28
    Wigder H. N., Arai D. A., Narasimhan K., Cohan S.. ACEP chest pain policy: emergency physician awareness. Ann Emerg Med. 1996; 27: 6069.
  • 29
    Lewis L. M., Lasater L. C., Ruoff B. E.. Failure of a chest pain clinical policy to modify physician evaluation and management. Ann Emerg Med. 1995; 25: 914.
  • 30
    Schriger D. L., Baraff L. J., Rogers W. H., et al. Implementation of clinical guidelines using a computer charting system: effect on the initial care of health care workers exposed to body fluids. JAMA. 1997; 278: 158590.
  • 31
    Goebel L. J.. A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic. Joint Commission. J Qual Improv. 1997; 23: 196202.
  • 32
    Stuck A. E., Aronow H. U., Steiner A., et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med. 1995; 333: 11848.
  • 33
    Rubenstein L. Z., Josephson K. R., Wieland G. D., English P. A., Sayre J. A., Kane R. L.. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984; 311: 166470.
  • 34
    Stevens V. J., Hornbrook M. C., Wingfield D. J., Hollis J. F., Greenlick M. R.. Recruitment and intervention for a falls prevention project: the study of accidental falls in the elderly. In: WeindruchR., HadleyE. C., OryM. G. (eds). Reducing Frailty and Falls in Older Persons. Springfield , IL : Charles C Thomas, 1991, pp 27792.
  • 35
    Rubenstein L. V., Calkins D. R., Young R. T., et al. Improving patient function: a randomized trial of functional disability screening. Ann Intern Med. 1989; 111: 83642.
  • 36
    Hornbrook M. C., Stevens V. J., Wingfield D. J., Hollis J. F., Greenlick M. R., Ory M. G.. Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist. 1994; 34: 1623.
  • 37
    Williams M. E., Williams T. F., Zimmer J. G., Hall W. J., Podgorski C. A.. How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial. J Am Geriatr Soc. 1987; 35: 10718.