SGEM#89: Preventing Falling to Pieces

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Date: October 5th, 2014

Guest Skeptic: Dr. Chris Carpenter. Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. C0-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules. @SAEMEBM

The goal of the SGEM continues to be to cut the knowledge translation window down from over ten years to less than one year. There are about 3,800 biomedical publications every day on PUBMED alone. Bastian et al published in PloS 2010 that there are about 75 RCT and 11 Systematic reviews released daily. They asked the question “How could anyone every keep up”?

The answer is no one could possibly keep up. No wonder it takes so long for high quality clinically relevant evidence to reach the bedside. A study by Morris et al in 2011 called discusses how it can take an average of 17 years for research evidence to reach clinical practice.

Seventeen years is more than 10 years as we are always quoting on the SGEM. But we are going to try and shorten that KT window to less than 1 week using the power of Social Media.

The SGEM has entered into an arrangement with Society of Academic Emergency Medicine (SAEM) and the Canadian Association of Emergency Physicians (CAEP) to achieve that goal. SAEM publishes the Academic Emergency Medicine (AEM) Journal and CAEP publishes the Canadian Journal of Emergency Medicine (CJEM). I am calling SGEM Hot Off the Press, or SGEM HOP

A paper that has been submitted, peer-reviewd, and ultimately accepted for AEM/CJEM is going to be picked. We will select these papers in conjunction with the Editorial Boards of each journal.
The SGEM will then put a skeptical eye upon the manuscript using the BEEM critical appraisal tool. This is an instrument with published reliability and validity – the only such instrument that I am aware of in any specialty.
One of the authors of the paper will be invited to discuss their work. This will be in order to defend the strengths/weakness/limitations/clinical application of the ideas and data that they propose.
We will do a special SGEM Hot Off the Press podcast that will be posted the week the journal gets published. In essence, this is KT at the speed of social media!
You the audience will get a chance to respond via the blog, twitter or on Facebook. Where else do you have this interactive opportunity to compliment or criticize research with the ear of the original author and the publishing editors?
Another exciting component will be a summary of the SGEM critical appraisal because top social media feedback will be published in a subsequent issue of each journal. This process will leverage the content from original publication, secondary review, podcast dissemination, and social media interactivity and follow-up.

I am very excited about this new series. Just like Swami and the SGEM Classic episodes I hope the SGEM: Hot Off the Press episodes will be just as popular.

Case: 84-year-old woman (Mrs. C) who lives independently and alone in her own home presents to the emergency department via ambulance with a standing level fall. She was bending over to pick up a letter that had dropped off her desk, lost her balance and hurt her left, non-dominant arm. After the fall she was afraid to stand and could not reach her telephone so she laid on the floor calling for help until a neighbor heard her and called 911. She notes infrequent falls at home with no prior injurious falls. Her past medical history includes hypertension and a remote history of breast cancer, but she does not take anti-platelet or anticoagulant medications. An appropriate physical exam is performed and reveals an isolated left shoulder injury. The x-ray of her left shoulder is negative for any fracture. She is diagnosed with a minor contusion and provided with some acetaminophen. The daughter-in law arrives to take her home, but asks if Mrs. C is at risk for further falls in the future.

Question: Can healthcare personnel accurately identify subsets of geriatric adults at increased risk of falls or injurious falls in the months following an episode of emergency department care?

Background: In the geriatric population (all those over age 65), standing level falls are the #1 cause of traumatic mortality.

A fall can be defined as an unintentional, sudden descent to a lower level. This can be a fall from a bed or chair to the ground or down some stairs to a lower level of the home. In the vast majority of cases, we are not talking about falls from roofs or ladders.

For community dwelling adults over the age of 65 about 1/3 will suffer a standing-level fall. By the time you people reach 80 years of age that increases to half or 50%. Many of these people who fall end up in the ED.

These falls cause a lot of morbidity. They can cause contusions, lacerations and fractures. Fractures can obviously be any bony structure, but commonly include the spine, hip, pelvis, ankle, wrist and humerus. There are about 300,000 hip fractures every year in the US and by 2014 will probably have doubled.

These injuries must cost a lot of health care dollar. In the USA standing-level falls cost about $19 billion a year.

As mentioned earlier, falls are the leading cause of traumatic mortality in this age group. Older adults who are admitted to the hospital after a fall (the sickest subset) will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year.

Reference: Carpenter CR, Avidan MS, Wildes T, et al. Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review, Acad Emerg Med 2014

Population: Original prognostic research describing community-dwelling, non-critically ill geriatric adults after an episode of emergency department care.
Intervention: Falls and injurious falls risk stratification at 1- to 6-months evaluated in emergency department settings
Control: None
Outcome: Prognostic accuracy (sensitivity, specificity, likelihood ratios) for individual risk factors and prediction instruments to predict falls in the months following an episode of emergency department care.

Authors’ Conclusions: “This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk”.

Quality Check List for Systematic Review:

The diagnostic question is clinically relevant with an established criterion standard. Yes. Comment: Geriatric falls represent the leading cause of traumatic mortality in older adults. Fall risk assessment is advocated as a geriatric emergency medicine core competency and quality improvement target. It is a key component of Geriatric Emergency Department Guidelines recently approved by the American College of Emergency Physicians, American Geriatrics Society, Society for Academic Emergency Medicine, and Emergency Nurses Association.
The Search for studies was detailed and exhaustive. Yes. Used a medical librarian and followed the MOOSE statement and PRISMA guidelines.
The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes. QUADAS-2 was used to evaluate the overall quality of the trial data
The assessment of the studies were reproducible. Yes
Three was low heterogeneity for estimates of sensitivity or specificity. No
The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision making models. Yes

Key Results: 601 manuscripts with five papers met the inclusion criteria for a full review. Two articles did not include data to do a 2×2 table. This left you three ED-based studies with 767 patients.

Two of the studies were prospective (660 patients) and one was retrospective (107). The two prospective studies contained 29 individual predictors. These predictors included past falls, number of medications used, self-reported dementia or depression, use of canes or walkers, ability to drive, sense of imbalance, and many others, as well as simple objective physical tests like the chair stand, chair sit, ability to raise feet while walking and turn 180º, and visual and auditory acuity.

The incidence of falls at 6 months was 31% for those who presented with a chief complaint of falls. The incidence of falls was about half (14%) if the chief complaint was something else.

The best positive likelihood ratio (+LR) was found in one of the two studies and had a result of 6.55 (95% CI 1.41-30.38). However, when that was combined in the meta-analysis gave a +LR of 2.54 (95% CI 1.62-3.98).

The best negative likelihood ratio (-LR) was if the patient could cut their own toenails –LR 0.57 (95% CI 0.38-0.86).

We described the Tiedemann and Carpenter fall-risk prediction instruments. Both instruments use a simple scoring system based upon two to four fall-risk factors. A Tiedmann score of three had a +LR 3.76 and a –LR 0.46 In contrast, the Carpenter score of >1 gave a similar +LR score, but proved much more useful to distinguish subsets at lower risk of falls with –LR of 0.11.

We opine that “although our results fail to provide a definitive fall screening strategy, the quantitative summary estimates of fall incidence and risk factor accuracy and reliability provide an evidence basis on which clinicians, nursing leaders, administrators, educators, policy-makers, and researchers can build.”

Clearly there is a need to figure out who is a greater risk in this geriatric population. These types of falls cause significant morbidity/mortality, cost a lot of money, and we simply lack the resources to treat every older adult as high-risk for future falls.

Risk assessment in aging adults is advocated by multiple professional organizations and licensing bodies. Nonetheless, geriatric patients rarely receive guideline directed care for falls following an episode of ED care.

Multiple barriers exist between contemporary ED management of community-dwelling senior citizens and optimal injurious falls prevention. The first and most prominent obstacle is the lack of ED-validated risk stratification instruments to distinguish low-risk from non-low-risk for falls. If we cannot identify the “at-risk”, how can we efficiently and cost-effectively proactively work to prevent future falls? Funding agencies need to recognize this conundrum, too.

There are some non-EM guidelines committees and prominent funding agencies opine that fall-risk stratification risk factors and instruments from office-based settings, hospital wards, and nursing homes ought to extrapolate to the ED. However, evidence based medicine proponents argue that validation in the ED is essential. The current meta-analysis from the Academic Emergency Medicine Evidence Based Diagnostics series takes an essential first step toward this objective.

One limitation of this study was its English only search. This was due to lack of funding resources. The English search did identified 601 abstracts to review. Dr. Carpenter did attended the International Association of Gerontology and Geriatrics meeting in Seoul Korea in June 2013. This meeting brought together the world’s medical and non-medical experts in the care of an aging population. He sought expertise in ED-based falls prevention, cognitive assessment, frailty, and functional vulnerability during my week in Korea. Dr. Carpenter also serve as the Chair of the American College of Emergency Physicians Geriatric Section and founding member of the International Consortium for Emergency Geriatrics. Based upon these exposures and leadership positions, he is not convinced that there is a novel EMERGENCY DEPARTMENT based fall-risk stratification protocol somewhere else in the world.

Why limit the systematic review to only the English language? My research lab lacks funding or capacity to translate hundreds of abstracts in dozens of languages to find the few manuscripts that might require translation. Remember that our English-language only search identified 601 abstracts to review. In addition, I attended the International Association of Gerontology and Geriatrics meeting in Seoul Korea in June 2013. This meeting brought together the world’s medical and non-medical experts in the care of an aging population. I sought expertise in ED-based falls prevention, cognitive assessment, frailty, and functional vulnerability during my week in Korea. I also serve as the Chair of the American College of Emergency Physicians Geriatric Section and founding member of the International Consortium for Emergency Geriatrics. Based upon these exposures and leadership positions, I’m not convinced that there is a novel EMERGENCY DEPARTMENT based fall-risk stratification protocol somewhere else in the world.
Limited search of the “grey” literature? We did conduct a hand search of unpublished abstracts in Academic Emergency Medicine and Annals of Emergency Medicine. Admittedly, we could have hand-searched various other scientific assembly research abstracts including the Journal of the American Geriatrics Society, Canadian Association of Emergency Physicians, and the European Society for Emergency Medicine.
Where you disappointed in the quantitative conclusions of this systematic review? I was disappointed for clinicians and educators seeking a definitive answer on the question. However, I strongly feel the results are still useful. More importantly, this research ought to serve as a siren song to emergency medicine investigators and funding agencies that we need to devote more time, energy, and resources to solving older adult acute care questions. If we cannot accurately identify older adults at increased risk for the #1 cause of traumatic mortality, what else are we missing: dementia, delirium, frailty, functional decline, etc.?
Why do you think that these results are still useful? We explored 29 commonly referenced risk factors across two prospective ED-based studies. None of the risk factors, including objective tests of function like the elements of the “get-up-and-go test”, accurately predicted falls at 6-months. However, two risk prediction instruments were described. One (Carpenter Rule) significantly reduced the post-ED fall risk with a negative likelihood ratio 0.11 (95% CI 0.06-0.20).
Why do you think you got unsatisfactory results? The reasons are likely multifactorial. Falls represent a complex relationship between an aging individual’s senescent physiology interacting with intrinsic and extrinsic stressors. The risk of falls for an individual are neither static from day-to-day nor comparable to the next patient of similar age and illness severity. Furthermore, existing trials did not use STARD criteria, including the lack of an explicit and uniformly accepted definition of “falls”. Future trials must do so, while employing more definitive gold standards for fall occurrence, including smart-phone fall detectors.

The Bottom Line: Persons 65 years or older are an increasing percentage of the total population. These people fall, get injured and even die. We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.

Case Resolution: This lovely 84yo woman (who was my grandmother in 1995) is treated conservatively for her minor contusions and is discharged home with her daughter-in law. She is advised to follow- up with her PCP in the next week and return to the ED if she has increasing pain, decreasing function or is otherwise concerned. Of concern, Sirois et al noted that 15% of these patients (community dwelling geriatric standing level fall, discharged home from the ED with minor injuries) will experience significant functional decline at 3-months

Dr. Chris Carpenter

Clinical Application: ED-based fall-risk screening for older adults should use the most accurate risk-stratification instruments available until better tools are developed and validated in ED settings. Using other instruments like STRATIFY or HENDRICH II in the ED leaves clinicians, patients, payers, and policy-makers without valid, evidence-based estimates of post-ED fall risk. Funding agencies and researchers should more aggressively pursue more definitive and clinically useful fall-risk stratification.

What Do I Tell Patients/Families: Standing level falls are very common and can even cause death in people over age 65. There is about 1/3 chance your mother-in law will fall again in the next 6 months. Unfortunately, there is no single fall risk factor that we know of that can predict who will or will not fall. However, there is some information I can give you to try and prevent another fall. Click on this link to get the document downloaded. SGEM falling to pieces Figures

Keener Kontest: Last weeks winner was Loice Swisher from Ambler PA. She knew the major adverse effects of procainamide to watch for were cardiac in nature. Specifically watching for hypotension and prolonged QRS and QT intervals. The infusion should be stoped if the QRS or QT prolongs by more than 50% from baseline.

Listen to the podcast for this weeks Keener question. Sent your answer to TheSGEM@gmail.com. Put “keener” in the subject line. The first correct answer will receive a cool sceptical prize.

Upcoming Conferences: SkiBEEM January 26th-28th in Sun Peaks BC

Stay tuned for the next episode of the SGEM-HOP with Dr. Chris Bond and the Canadian Journal of Emergency Medicine.