Article

Screening and falls in community hospital emergency rooms in the 12 months following implementation of MEDFRAT

1686 Correspondence / American Journal of Emergency Medicine 38 (2020) 1679-1694

RE: Sublingual buprenorphine Vs IV or IM morphine in acute pain: A systematic review and meta-analysis

To the Editor,

We write to request retraction of our recently published manuscript Sublingual buprenorphine versus intravenous or intramuscular morphine in acute pain: A systematic review and meta-analysis of randomized control tri- als. (American Journal of Emergency Medicine 37 (2019) 381-386). Al- though we submitted the manuscript in good faith, upon reflection we believe that the paper has not clearly or fully disclosed that it better rep- resents a subset of a previously published manuscript in the British Jour- nal of Anaesthesia (White LD, Hodge A, Vlok R, Hurtado G, Eastern K, Melhuish TM. Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomized controlled trials. (Br J Anaesth. 2018; 120: 668-678). The papers pre- sented in our meta-analysis are a subset of those in our previous review in the British Journal of Anaesthesia, and do not present additional infor- mation beyond our previously published work.

We apologize to the editors and readers of the American Journal of Emergency Medicine for not having fully explained the duplication at the time of submission.

Sincerely,

Ruan Vlok

Wagga Wagga Rural referral hospital, Wagga Wagga, Australia

Correspononding author.

E-mail address: [email protected].

Gun An

University of Queensland, School of Medicine, Australia

Matthew Binks Thomas Melhuish

University of New South Wales, Faculty of Medicine, Australia

Leigh White

University of Queensland, School of Medicine, Australia Sunshine Coast University Hospital, Department of Anaesthetics, Australia

31 October 2019

https://doi.org/10.1016/j.ajem.2019.10.046

Screening and falls in community hospital emergency rooms in the 12 months following implementation of MEDFRAT

Falls continue to be a Public health problem. They are the leading cause of morbidity and mortality in US adults aged 65 years and older and a 2014 survey found that 28.7% of older adults reported having fallen at least once in the previous 12 months [1]. Much has been writ- ten about falls prevention in the community and inpatient settings, but less has been written about preventing falls in emergency departments. We previously published about our experience implementing the Memorial Emergency Department Fall Risk assessment tool (MEDFRAT) in the context of the Iowa Model of evidence-based practice to Promote Quality Care to decrease falls in emergency rooms at Essentia Health, a large, predominantly rural Health care delivery sys- tem [2]. MEDFRAT is nursing-administered, built into the electronic medical record, and includes potential falls interventions that can be implemented by the nurses [3-4]. It comprises six questions from

which a total score and falls risk levels are generated. Listening sessions prior to MEDFRAT implementation with nurses at the hospitals identi- fied challenges with some of the possible nursing interventions to de- crease falls risk, including a lack of doors for door signs and a shortage of beds that could be lowered to the floor for high falls risk patients.

The purpose of this paper is to evaluate our experience in the first 12 months after implementation of MEDFRAT with the following spe- cific aims: 1) document the frequency of MEDFRAT use by hospital; 2) document the fall prevention interventions used at each hospital; and

3) describe the outcomes of patients who fell. This project was reviewed by the Institutional Review Board at Essentia Health and determined to be quality improvement, not human subjects research.

Descriptive analyses were conducted with SPSS(R) version 23. We quan- tified the percent of patients for whom MEDFRAT was used and the percent of those patients who scored low-risk and moderate/high risk.

The table includes a comparison of falls risk assessment completion and falls in a 12-month period prior to implementation of MEDFRAT and in the 12 months immediately after MEDFRAT implementation. Three falls risk questions were used prior to MEDFRAT: 1) Is this visit is result of a fall?

2) Does the patient have gait and/or balance impairment? and 3) Does the patient have cognitive impairment/confusion and/or disorientation? Falls risks questions within the electronic health record were used for 57% of patients prior to MEDFRAT implementation, compared with 69% of pa- tients using the MEDFRAT tool after its implementation (p b .001). The gen- der distribution was similar in both time periods (54% female). The average number of ED visits per person (1.6) was also similar in the pre and post pe- riods; MEDFRAT results are reported per visit where individuals can con- tribute multiple times to the numerator and denominator. There was a significant increase in both the percentage of patients with a mental health diagnosis (11.6% and 12.6%) and the length of stay (3.1 h and 3.2 h). There was a non-significant increase in the absolute number of falls (p = .499). The severity of falls increased (p = .007), with 85% of falls in the pre- MEDFRAT time frame resulting in no harm, compared with 59% in the post-MEDFRAT time period (Table 1).

MEDFRAT use varied by hospital, ranging from b1% to 95% of patients being assessed for falls risk with MEDFRAT. Among patients with an available MEDFRAT score (interventions were ordered in some cases where a score was not available), 91.5% were low fall risk, 4.7% were moderate fall risk, and 4.2% were high fall risk. In decreasing order, the nursing interventions selected to prevent falls in low falls risk pa- tients were: placing a call light within reach of the patient (72.9%), plac- ing the bed in a low position (71.4%), 1-hour rounding (42.2%), non-skid socks (10.8%), and falls risk signs placed outside doors (2.5%). For me- dium/high falls risk patients, the nursing interventions selected, in de- creasing order, were: bed in low position (100%), call light within easy reach (98.9%), 1-hour rounding (54.2%), assistance with toileting (47.9%), moving the patient closer to the nurses’ station (30.7%), non- skid socks (27.1%), falls risk signs on doors (13.4%), and a bed alarm (12.0%). We discovered in our listening sessions prior to implementa- tion that not all possible interventions noted in MEDFRAT are available at all sites, such as doors on the rooms.

We were pleased to see an increase in the use and documentation of falls risk assessment and selection of nursing interventions to decrease falls with MEDFRAT implementation. Unfortunately, this increased use did not result in a decrease in falls and the falls that did occur were more likely to result in Patient harm. This could be due to the increased length of stay in the emergency department and/or the increase in mental health diagnoses. We have demonstrated that we could successfully integrate MEDFRAT in our electronic health record. Further qualitative research is indicated from these quantitative results. The large increase in falls from a bed needs to be studied to understand the surrounding circumstances; additional beds that can be lowered to the floor could help to decrease these falls. The low use of MEDFRAT in four of the 12 hospitals also needs to be explored further through discussions with nurses at those facilities to understand and assist with any barriers to MEDFRAT use.

Correspondence / American Journal of Emergency Medicine 38 (2020) 16791694 1687

Table 1

Overall pre- and post-MEDFRAT descriptive statistics and fall information (adults aged 18 and up)

Pre-MEDFRAT

Post-MEDFRAT

p

9/1/2015-8/31/2016

12/1/2016-11/30/2017

Unique persons

64,983

65,302

Female (%)1

34,779 (53.5%)

35,041 (53.7%)

0.613

Mean ED visits per person (SD), range2

1.63 (1.62), 1-48

1.62 (1.58) 1-65

0.217

total ED visits

Mean patient age at ED visit (SD), range2

106,107

45.93 (20.11) 18-106

105,462

47.17 (20.28) 18-108

b0.001

Mental health diagnosis at ED visit1

12,320 (11.6%)

13,311 (12.6%)

b0.001

ED boarder at ED visit1

656 (0.6%)

818 (0.8%)

b0.001

Mean ED length of stay in hours (SD), range2

3.13 (9.37), 0.01-2451.78

3.20 (6.92), 0.03-830.87

b0.001

Fall risk screen received1 MEDFRAT received1

60,008 (56.6%)

n/a

n/a

72,949 (69.2%)

b0.001

Mean MEDFRAT score (SD), range

n/a

0.69 (1.65)

Low fall risk (0-2)

n/a

63,978 (91.5%)

Moderate fall risk (3-4)

n/a

3021 (4.7%)

High fall risk (5-14)

n/a

2959 (4.2%)

Visits receiving MEDFRAT intervention

n/a

53,930

Falls education given

n/a

12,686

Total reported falls in an ED1

40

46

0.499

Fall severity:3,4

0.012

No harm

34 (85.0%)

27 (58.7%)

Harm – Temporary- Intervention or Treatment needed

6 (15.0%)

15 (32.6%)

Harm – Temporary- Initial or Prolonged hospitalization Needed

0 (0.0%)

4 (8.7%)

Fall description

n/a

While being assisted to a wheelchair

1 (2.5%)

0 (0.0%)

Balance/gait

13 (32.5%)

0 (0.0%)

Behavior

2 (5.0%)

0 (0.0%)

From bed

5 (12.5%)

14 (30.4%)

From chair

0 (0.0%)

3 (6.5%)

From stretcher

0 (0.0%)

2 (4.3%)

From toilet/commode

1 (2.5%)

6 (13.0%)

From wheelchair

1 (2.5%)

1 (2.2%)

Unknown/Found on floor

1 (2.5%)

1 (2.2%)

While ambulating

3 (7.5%)

13 (28.3%)

While standing

11 (27.5%)

6 (13.0%)

Other (Please specify):

Crutch slipped on dry floor

1 (2.5%)

0 (0.0%)

Patient lowered self to floor when ambulating

1 (2.5%)

0 (0.0%)

30-day readmissions2

19 (47.5%)

25 (54.3%)

0.526

Mean days from ED admission to time of fall (SD), range2

0.55 (2.63), -0.01-16.69

0.16 (0.19), 0.00-0.89

0.091

Hospital mortality5

0 (0.0%)

1 (2.2%)

1.000

Post discharge 30-day mortality5

0 (0.0%)

1 (2.2%)

1.000

n/a = Not applicable. SD = Standard deviation.

1 Chi-square.

2 Mann-Whitney U.

3 Fisher’s Exact Test.

4 Categories “Harm – Temporary- Intervention or Treatment needed” and “Harm – Temporary- Initial or Prolonged Hospitalization Needed” were combined for cross tab analysis.

5 Not fall-related.

Funding

This work was supported by Essentia Health St. Mary’s Medical Cen- ter Foundation.

Catherine A. McCarty PhD, MPH, MSB University of Minnesota Medical School, Duluth Campus, Duluth, MN, USA Corresponding author at: University of Minnesota Medical School, 219 Medical School, 1035 University Drive, Duluth, MN 55812, USA.

E-mail address:[email protected]

Melissa L. Harry PhD, MSW

Essentia Institute of Rural Health, Duluth, MN, USA

Theo A. Woehrle MPA

Essentia Institute of Rural Health, Duluth, MN, USA

Laura A. Kitch APRN, CNS

Essentia Health St. Mary’s Medical Center, Duluth, MN, USAc

16 March 2020

https://doi.org/10.1016/j.ajem.2019.12.053

References

  1. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged >=65 Years —

    United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993-8.

    McCarty CA, Woehrle TA, Waring SC, Taran AM, Kitch LA. Implementation of the MEDFRAT to promote quality care and decrease falls in community hospital emer- gency rooms. J Emerg Nurs 2018;44:280-4.

  2. Flarity K, Pate T, Finch H. Development and implementation of the Memorial Emer- gency Department Fall Risk Assessment Tool. Adv Emerg Nurs J 2013;35:57-66.
  3. Scott RA, Oman KS, Flarity K, Comer JL. Above, beyond, and over the side rails: evalu- ating the new Memorial Emergency Department Fall-Risk-Assessment Tool. J Emerg Nurs 2018;44:483-90.

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