A High-yield Fall Risk and Adverse Events Screening Questions From the Stopping Elderly Accidents, Death, and Injuries (STEADI) Guideline for Older Emergency Department Fall Patients.

OBJECTIVES: The objectives were to examine whether responses to the Stopping Elderly Accidents, Death, and Injuries (STEADI) questions responses predicted adverse events after an older adult emergency department (ED) fall visits and to identify factors associated with such recurrent fall. METHODS: We conducted a prospective study at two urban, teaching hospitals. We included patients aged ≥ 65 years who presented to the ED for an accidental fall. Data were gathered for fall-relevant comorbidities, high-risk medications for falls, and the responses to 12 questions from the STEADI guideline recommendation. Our outcomes were the number of 6-month adverse events that were defined as mortality, ED revisit, subsequent hospitalization, recurrent falls, and a composite outcome. RESULTS: There were 548 (86.3%) patients who completed follow-up and 243 (44.3%) patients experienced an adverse event after a fall within 6 months. In multivariate analysis, seven questions from the STEADI guideline predicted various outcomes. The question "Had previous fall" predicted recurrent falls (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.52 to 3.97), the question "Feels unsteady when walking sometimes" (OR = 2.34, 95% CI = 1.44 to 3.81), and "Lost some feeling in their feet" predicted recurrent falls. In addition to recurrent falls risk, the supplemental questions "Use or have been advised to use a cane or walker," "Take medication that sometimes makes them feel light-headed or more tired than usual," "Take medication to help sleep or improve mood," and "Have to rush to a toilet" predicted other outcomes. CONCLUSION: A STEADI score of ≥4 did not predict adverse outcomes although seven individual questions from the STEADI guidelines were associated with increased adverse outcomes within 6 months. These may be organized into three categories (previous falls, physical activity, and high-risk medications) and may assist emergency physicians to evaluate and refer high-risk fall patients for a comprehensive falls evaluation.

Revisits within 48 Hours to a Thai Emergency Department.

Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients' charts. 86/172 (50%) were male and the mean age was 38 ±â€Š5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (50.0%)], illness-related factors [61/172 (35.5%)], and patient-related factor [25/172 (14.5%)], respectively. Among revisits classified as physician-related factors, 40/86 (46.5%) revisits were due to misdiagnosis and 36/86 (41.9%) were due to suboptimal management. Abdominal pain [27/86 (31.4%)] was the majority of physician-related chief complaints, followed by fever [16/86 (18.6%)] and dyspnea [15/86 (17.4%)]. Conclusion. Misdiagnosis and suboptimal management contributed to half of the 48-hour repeat ED visits in this Thai hospital.

Serious conditions for ED elderly fall patients: a secondary analysis of the Basel Non-Specific Complaints study.

OBJECTIVE: Falls among older adults are a public health problem and are multifactorial. We sought to determine whether falls predict more serious conditions in older adult patients presenting to the emergency department (ED) with a "nonspecific complaint" (NSC). A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall. METHODS: This study was a secondary analysis of a prospective delayed-type cross-sectional diagnostic study that included a 30-day follow-up. We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a NSC and had an Emergency Severity Index score of 2 or 3. We then compared the serious conditions among older adults who presented to the ED with a fall with those who did not fall in a cohort of patients with NSC. RESULTS: We had 1111 patients enrolled in our study; 518 (47%) of them had fallen. We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P=.74). In multiple logistic regression analysis, falls did not predict serious conditions or 30-day mortality among all NSC patients. Among fall patients, male sex, diuretic use, and generalized weakness predicted serious conditions. CONCLUSION: Fall patients share many features with nonfall NSC patient. However, falls did not increase the risk of serious conditions. Falls in the elderly could be considered under the broader entity of NSC.

Is there such a thing as a mechanical fall?

OBJECTIVES: The term mechanical falls is commonly used in the emergency department (ED), yet its definition and clinical implications are not established. It may be used to attribute falls to extrinsic factors in the environment exonerating clinicians from conducting a thorough assessment of the fall's underlying intrinsic causes. We conducted this study to determine how clinicians assess "mechanical" and "nonmechanical" falls; we explored conditions, fall evaluation, and outcomes associated with these diagnoses. METHODS: This study was a secondary analysis of a retrospective study at 1 urban ED. Data were obtained from medical records of patients aged 65 years and older who presented to the ED for a fall. We compared the associated conditions/causes, the ED fall evaluation, mortality, ED revisits, subsequent hospitalizations, and recurrent falls between the 2 terms. RESULTS: We had a sample size of 350 patients: 218 (62.3%) with "mechanical falls" and 132 (37.7%) with nonmechanical falls. There was little difference among associated conditions between the 2 fall labels other than mechanical falls had more associated environmental causes but fewer syncope causes. However, more than a quarter of nonmechanical falls had associated environmental factors as well. Similarly, there was little difference in the fall evaluation, ED revisit rates, recurrent falls, subsequent hospitalizations, and death between the 2 groups. CONCLUSIONS: The term mechanical fall is unclear, inconsistently used, and not associated with a discrete fall evaluation and does not predict outcomes. We propose eliminating the term because it inaccurately implies that a benign etiology for an older person's fall exists.

The prevalence, risk factors and short-term outcomes of delirium in Thai elderly emergency department patients.

BACKGROUND: We sought to determine the prevalence of delirium in a Thai emergency department (ED). The secondary objective was to identify risk factors and short-term outcomes in delirious elderly ED patients. METHODS: This was a prospective cross-sectional study in the ED of an urban tertiary care hospital. Patients aged ≥65 years who presented to the ED were included. We excluded patients who had severe dementia, were not responsive to verbal stimuli, had severe trauma and were blind, deaf, aphasic or unable to speak Thai. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit. We collected 30-day mortality rate, hospital length of stay and revisit rate as short-term outcomes. RESULTS: We had a final sample size of 232 patients; 27 (12%) were delirious in the ED, of which 16 (59%) were not recognised to be delirious by the emergency physician. Multivariable logistic regression analysis showed dementia (adjusted OR (AOR) 13.1; 95% CI 2.9 to 59.6), auditory impairment (AOR 4.8; 95% CI 1.6 to 13.8) and ED diagnosis of metabolic derangement (AOR 6.5; 95% CI 1.6 to 26.8) were associated with delirium in the ED. Delirium was associated with a higher mortality rate than those without delirium (15% vs 2%, p=0.004). CONCLUSIONS: In one middle-income country, elderly ED patients were delirious >10% of the time. Delirium was underdiagnosed and was associated with an increased 30-day mortality rate. Delirium screening needs to be improved, potentially focusing on high-risk patients.

Knowledge and practices of Thai emergency physicians regarding the care of delirious elderly patients.

BACKGROUND: The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients. METHODS: We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand. RESULTS: We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium. CONCLUSIONS: Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.