Follow up of Fallers Presenting to Emergency Department
Hunter New England Area Health Service
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Falls injury is painful, debilitating and costly. This project is an innovative and highly relevant health promotion activity aiming to reduce the rate of falls injury and subsequent representation.
Each month around 320 people 50 years and over, with a fall associated with their presentation, are discharged home from the three Greater Newcastle Sector Emergency Departments.
Operating independently of Emergency Departments and using data trawling, a process was developed to stream patients into risk groups and referral pathways. Appropriate community dwelling patients presenting to Greater Newcastle Sector Emergency Departments were phoned within a week of discharge to encourage participation in falls prevention strategies.
Around 48% of people initially contacted accepted the offer of intervention. Follow-up indicates good compliance.
Increase the uptake of falls prevention strategies in fallers over age 50 presenting to Emergency Department and discharged home, through a process of screening and safe referral over the phone.
Nature of the problem
Falls injury is associated with increasing age, and is debilitating and costly. The need to engage the community in falls injury prevention strategies is clearly enunciated in state and national health priorities. Current rates of participation by older people are low.
Fallers presenting to Emergency Department have their presenting problem such as the laceration treated however the underlying cause of the fall may not be addressed.
Referral for falls prevention strategies is ad hoc and knowledge about which services are appropriate and safe to refer to is limited.
The need for appropriate screening and safe referral processes, not reliant on busy Emergency Department staff was identified.
Extent of the problem
Trawling the Emergency Department Epidemiology Outcomes Report and other existing data sources, with the parameters of over fifty years and not admitted; and using clinical judgement to stratify risk, three month’s data showed:
- 968 people 50+years with a fall associated with their presentation were discharged home from the three Greater Newcastle Sector Emergency Departments of whom:
- 720 were excluded (see table 1)
- 248 eligible for phone coaching.
|Table 1. Reasons for exclusion from phone coaching|
|Syncope and collapse||183|
|From Residential Aged Care Facility||101|
|Out of Area||41|
|Referred to other services||35|
|Complex medical issues||33|
|Alcohol related fall||27|
|Follow-up of previous fall||19|
|Fall from ladder||16|
|Admitted to other hospital||15|
|Work related fall||13|
We concluded that around 25% of people over age 50 presenting to a Greater Newcastle Sector Emergency Department and discharged home were suitable to include in a phone coaching model.
Planning and implementing solutions
Under the governance of Hunter New England Falls Injury Prevention Among Older People Advisory Committee Community Working Party, a registered nurse with experience in falls injury prevention and an enrolled nurse from the Hunter New England Referral Information Centre embarked on this project in May 2008.
Consultation with the Hunter Urban Division of General Practice, the coordinators of Heartmoves and Active over 50s as well as the John Hunter Hospital Emergency Senior Clinical Team took place. Consultation with the community occurred as a natural inclusion since the project involved direct contact with members of the community.
Inclusion criteria were determined to be; community dwelling people, 50 years and over, who were discharged home from an Emergency Department after presenting with a fall and who had no complications.
Fallers who were hospitalised were excluded because they were more likely to have complications.
Falls phone coaching is simply a telephone conversation aimed at encouraging a person to change their behaviour in relation to participation in strength and balance exercise.
- Mapping services suitable for safe referral. These were Hunter New England services or other programs that provided appropriate pre-program health screening and included:
- Falls Clinics
- Community Allied Health
- Active Over 50s
- Home-based exercises.
- Developing questionnaires and flowcharts to stream patients into risk categories and then on to appropriate services.
- Working with the Information Technology team, a falls-specific query from the Emergency Department triage report text field was developed which reduced manual data trawling.
- Identifying appropriate resources to send out.
- Developing an organisation unit in the Community Health Information Management Enterprise electronic record which allowed data entry, process monitoring and sharing of information with other Hunter New England health care providers.
Early in the process we commenced phoning patients and refining exclusion criterion, questionnaires, flowcharts, referral letters and referrals processes as we progressed.
After the initial three month set-up, staffing was reduced to 0.5 full time equivalent enrolled nurse, and a leaner and more cost effective model commenced.
Outcomes and evaluation
In qualitative terms the response from the community has overwhelmingly been one of surprise and support. Even those who declined the offer of an intervention were pleased that the Area Heath Service had followed up their Emergency Department presentation. People felt valued.
Quantitative data for the period May 2008 to April 2009
- 397 patients were eligible for phone call
- 191 accepted initial offer of an intervention (48% acceptance rate)
|Actual rate of uptake of initial acceptors after 3 weeks follow-up (2009 data)||89%|
|Age range of those eligible who accepted the offer of intervention||50 to 64yrs||16%|
|65 to 79yrs||30%|
|Age range of those eligible who declined the offer of intervention||50 to 64yrs||46%|
|65 to 79yrs||31%|
|Referrals points of acceptors||Falls Clinics||50 patients||26%|
|Active Over 50s and Heartmoves||37 patients||19%|
|Other Community Based Services||7 patients||4%|
|Home Based Exercises||97 patients||51%|
Data includes 9 Indigenous patients 45+yrs – eight did not meet inclusion guidelines and one currently being followed up.
The initial aim of the project, to increase the uptake of falls prevention strategies, is clearly achieved.
Sustaining the change
The project moves forward in the following ways:
- Measuring compliance at 6 months to evaluate the longer-term impact of coaching.
- Evaluating cost effectiveness by measuring the number of people whose behaviour has changed in regard to exercise against the resources required to effect that change.
- Consideration of moving process to the Referral Information Centre which may be more efficient.
- Preliminary discussion re refining the exclusion process and utilising the same data system that generates electronic discharge summaries to facilitate further automation.
Patient stories in regard to the project are currently being collected.
The approach to data trawling for specific issues such as falls has been shown to be effective and could be readily extended to other conditions which may be amenable to phone coaching.
Opportunities for expansion to the whole of Hunter New England Health and the development of safe referral pathways for some of the exclusion groups should be explored.
- Ian O’Dea, Service Manager/Director of Nursing Rankin Park Centre
- Robyn Walker, Nurse Unit Manager Rankin Park Centre
- Anthony Lewis, Enrolled Nurse Rankin Park Centre Day Hospital
- Ena Fisher, Enrolled Nurse Referral Information Centre
- Consultancy: Hunter New England Falls Injury Prevention Among Older People Advisory Committee
Service Manager/DON, Rankin Park Centre
Hunter New England Area Health Service
Phone: 02 4921 4899