Falling Behind? Understanding Implementation Science in Future Emergency Department Management Strategies for Geriatric Fall Prevention

Recently published consensus guidelines for geriatric emergency departments (EDs)1 provide a significant milestone for the nascent subspecialty of geriatric emergency medicine, but real-world challenges reside between guidelines and bedside practice. In this issue of Academic Emergency Medicine, Tirrell et al.2 report a 1-year chart review of 350 randomly selected elderly patients presenting to an urban academic ED following falls. Their primary objective was to determine the extent to which the documented ED evaluation adhered to the Geriatric Emergency Department Guidelines1 and the American Geriatric Society (AGS) guidelines. Only two of the 16 fall-risk evaluation items recommended by the guidelines were reported over 80% of the time: fall location and cause of fall. Most (13 of 16) were reported fewer than 50% of the time, and nine of these fewer than 25% of the time. Four patient-level characteristics were significantly associated with better guideline adherence: older age, more comorbid conditions, residing in an assisted living facility, and admission to either an inpatient or an observation unit. While these findings offer reassurance that individuals deemed at higher risk were more likely to undergo more comprehensive evaluations for falls, there is clearly a missed opportunity to perform more complete risk assessments that may provide critical secondary prevention for falls in individuals at lower risk. Falls represent an essential target for geriatric emergency medicine since falls are the leading cause of traumatic mortality in this age group and one-third of past fallers will fall again within 6 months, most of whom will be injured.3 Even falls without injury result in loss of mobility and social participation,4 and up to one-third of fallers discharged home from the ED experience trauma-related functional decline within 3 months.5 Nonetheless, most ED patients do not receive guideline-directed fall management.6 Disseminating research findings and consensus statements is one approach to reducing injurious falls,7 but as demonstrated in this study, is insufficient when used alone. The disconnect between what knowledge and action prevents fall-related morbidity and mortality leads to the overarching question, “Why does clinical practice lag behind research evidence, consensus statements, and professional society guidelines?” Understanding the answer will highlight challenges and opportunities for clinicians, educators, researchers, and policy-makers moving forward. The physician-level framework to qualify the leaks between knowledge and patient outcomes have been described as awareness, acceptance, applicability, ability, and remembering to act.8 In conjunction with representatives from the National Institutes of Health (NIH), implementation science experts recently published a framework for clinicians and researchers (and other key stakeholders) to understand the layers of complexity in moving from evidence to action in the planning, delivery, and evaluation stages (Figure 1).9 Using this new framework provides a construct upon which to explore the hypothetical causes for the results reported by Tirrell et al. while highlighting logical next steps. First, what is the evidence basis upon which ED fall investigators and guideline developers presuppose benefit exists? Prior studies on ED-based practice strategies to reduce elderly falls have yielded disappointing results. Baraff and colleagues10, 11 found that interventions in the ED can improve documentation and awareness of falls in elders, but do not improve subsequent fall or hospitalization risks. Furthermore, in assessing the preintervention time frame, scant evidence exists to imply that ED providers can accurately risk-stratify geriatric patients at increased risk for falls within 6 months.3 Better ED-based evidence to guide ED solutions will require ample funding opportunities to answer key questions, some of which the Society for Academic Emergency Medicine, AGS, and NIH have already formulated.3, 12 The second question arising from the NIH implementation science framework is whether the ED culture and clinical context is conducive to fall prevention efforts? Third, what proportion of ED staff adopt fall prevention efforts, is this knowledge uptake adaptable at the level of the patient or provider, and when adapted how does an investigator ensure fidelity of implementation so that what care is delivered is not a different intervention than that actually recommended? Even when ED fall-risk evaluation occurs, fewer than 15% of patients discharged from the ED receive follow-up instructions to address these issues, so just as publication in isolation of policy and guidelines is insufficient to modify clinician behavior, fall-risk knowledge alone and screening alone do not equate to evidence-based referrals.13 Fourth, does one ED's fall intervention fit other ED's resources, cultural capacity for change, and sustainability? An evolving understanding of the complexity of inter- and intraindividual fall risk make it unlikely that a one-time fall-risk assessment and one-size-fits-all fall prevention intervention will prove reproducibly effective, so further exploration of the ED-based science of predicting falls, preventing falls, and adapting clinician behavior to efficiently intervene upon higher-risk future fallers within the context of implementation science is essential moving forward.3 Tirrell et al.2 provide cautious optimism favoring an increased emphasis on geriatric emergency medicine in the contemporary ED, but their results are also a sobering reminder of the formidable task ahead. Their study represents a microcosm of the myriad challenges to improve health care delivery for any population: balancing the triple aim to enhance the experience of care while yielding better population health at lower costs14 versus the demand for efficient throughput via minimal ED length-of-stay to maximize patient volume and meet institutional metrics. Is the ED an appropriate environment for assessing the risk of occult geriatric syndromes? The evidence argues that it is. First, deferring geriatric evaluations and interventions to an inpatient service by admitting any older adult with complex medical conditions and risk factors is not the solution; in fact, unnecessary hospitalization is often the cause of adverse outcome, given the potentially detrimental effects of hospitalization, including loss of mobility and independence and the risks of nosocomial infections, delirium, and nursing home admission.15, 16 Second, the ED physician is paradoxically the only physician an individual patient may see in continuity. Data on adults with heart failure show that 80% requiring ED care were hospitalized,17 but 65% of those requiring rehospitalization at 30 days returned to the ED for reasons unrelated to heart failure,18 indicating that the ED physician is more likely than the primary care provider to see them at both health care encounters. The ED is by necessity one link to screen, evaluate, and risk-stratify older adults at risk for the many geriatric syndromes.1 This research provides a pragmatic perspective of from whence fall prevention research has come and where implementation science can now be used to move forward emergency medicine efforts to alleviate injurious falls. Recognizing the imperfect fit of the traditional ED model for potentially vulnerable subsets of older adults, geriatric ED guidelines were developed to optimize acute care of an aging population, but will require continued revisions as more research like this emerges.19 The bottom line is that enhancing the penetration of sustainable ED-based fall prevention protocols into heterogeneous health care settings with unpredictable resource availability and an unconvincing evidentiary basis is an ongoing challenge. To shift the paradigm toward more consistent fall management that adheres to guidelines, ED providers need scalable, adaptable, and measurable fall prevention models designed for communities with limited financial and human capital. Understanding the new dissemination and implementation framework will be essential for future ED fall researchers to advance the science of geriatric injury prevention.