P131: Emergency department falls risk management screening tool comparison

Introduction: Emergency Department (ED) fall risk screening has been newly implemented in Alberta based on Accreditation Canada requirements. Two existing inpatient tools failed to include certain ED risk conditions. One tool graded unconsciousness as no risk for falling, and neither considered intoxication or sedation. This led to the development of a new fall risk management screening tool, the FRM (Tool1). This study compared Tool1 with inpatient utilized Schmid Fall Risk Assessment Tool (Tool2) and the validated Hendrich II Fall Risk Model (Tool3). Methods: Patients (≥17 years old) in a tertiary care adult ED with any of the following; history of falling in the last 12 months, elderly/frail, incontinence, impaired gait, mobility assist device, confusion/disorientation, procedural sedation, intoxication/sedated, or unconscious were included. Forms were randomized to score patients using different paired screening tools: Tool1 paired with either Tool2 or Tool3. Percent agreement (PA) between the tools based on identification of a patient at either risk/no risk for falling; higher PA indicating more tool homogeneity. Results: A total of 928 screening forms were completed within our 8-week study period; 452 and 443 comparing Tool1 to Tool2 and Tool1 to Tool3, respectively. Thirty-two forms included only Tool1 scores, excluding them from comparative analysis. The average patient age (n=895) was 64.8±21.4 years. Tool1 identified 66.4% of patients at risk, whereas Tool2 and Tool3 identified only 19.2% and 31.4%, respectively. Tool1 and 2 had a PA of 50.2%, whereas Tool1 and Tool3 had a PA of 65.9%. Conclusion: The FRM tool had higher agreement with the validated assessment tool, identifying patients at risk for falling but better identified patients presenting with intoxication, need for procedural sedation and unconsciousness. The other tools generally miss these common ED conditions, putting these patients at risk. Validation and reliability assessments of the FRM tool are warranted.

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P036: A comprehensive quality improvement initiative to prevent falls in the emergency department

CJEM ◽

10.1017/cem.2017.238 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S90

Author(s):

P. Samuel ◽

J. Park ◽

F. Muckle ◽

J. Lexchin ◽

S. Mehta ◽

...

Keyword(s):

At Risk ◽

Emergency Department ◽

Quality Improvement ◽

Literature Review ◽

Fall Risk ◽

Screening Tool ◽

Risk Screening ◽

Constructive Feedback ◽

Patients At Risk ◽

Fall Risk Screening

Introduction: Patients from all population groups visit the emergency department (ED), with increasing visits by elderly patients. Patient falls in the ED are a significant safety concern, and they can lead to serious injuries and worse outcomes. Toronto Western Hospital’s ED Quality Improvement (QI) team identified as a problem our assessment and management of patients at risk for falls. The aim of this project was to develop a comprehensive and standardized approach to patients at risk of falls in the ED, including implementing timely interventions for fall prevention. Methods: A literature review of existing tools was completed to develop our own reliable and valid fall risk screening tool for ED patients. QI methods were used to devise a comprehensive strategy starting with detection at triage and implementation of action-driven steps at the bedside, through multiple PDSA cycles, randomized audits, surveys, and education. Repeated measurements were undergone throughout the project, as were staff satisfaction surveys. Results: The chart audits showed a five-fold increase in the completion rate of the fall risk screening tool in the ED by the end of the QI initiative (from 10% to 50%). Constructive feedback by an engaged team of nurses was used to iteratively improve the tool, and there was mostly positive feedback on it after various PDSA cycles were completed. The various component of this novel and useful ED-based falls screening tool and bundle will be presented in tables and figures for other leaders to replicate in their EDs. Conclusion: We developed a completely new ED-specific fall risk screening tool through literature review, front-line provider feedback, and iterative PDSA cycles. It was used for the identification, prevention, and management of ED patients with fall risk. We also contributed to a positive change in the culture of a busy ED environment towards the promotion of patient safety. Education and feedback continue to be provided to the ED nurses for reflective practice, and we hope to continue to improve our tool and to share it with other EDs.

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P120: Exploring the utility of the Hamilton early warning score at triage: pilot study in a Canadian emergency department

CJEM ◽

10.1017/cem.2016.295 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S118-S118

Author(s):

S. Skitch ◽

L. McInnis ◽

A. Vu ◽

B. Tam ◽

M. Xu ◽

...

Keyword(s):

At Risk ◽

Emergency Department ◽

Early Warning ◽

Tertiary Care ◽

Vital Signs ◽

Early Warning Score ◽

Critical Event ◽

Likelihood Ratios ◽

Discriminative Ability ◽

Patients At Risk

Introduction: Early warning scores (EWS) use vital signs to identify patients at risk of critical events as defined by unplanned intensive care unit (ICU) admission, cardiopulmonary resuscitation (CPR), or death. Systems that combine an EWS with a ICU outreach team can improve hospital survival and cardiac arrest rates. Although initially developed for use in ward patients, evidence suggests that EWS are useful in emergency department (ED) patients and may aid in the earlier identification of sepsis. The Hamilton Early Warning Score (HEWS) was recently developed as part of quality improvement process in our health system. The current study examined HEWS at ED triage among a cohort of patients who experienced a critical event during their hospitalization. HEWS were also evaluated as a predictor of sepsis. Methods: Patient were selected from a database of patients admitted to a medical or surgical ward at two tertiary care hospitals over a six-month period. Cases were patients who experienced a critical event during admission and were admitted via the ED. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match cases based upon burden of comorbid illness. Receiver operator curves (ROC) and likelihood ratios were used to evaluate HEWS at ED triage as a predictor of likelihood of critical deterioration and sepsis. Results: The sample included 845 patients of whom 267 experienced a critical event. The median time to occurrence of critical event from admission was 124 hours. ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting likelihood of experiencing a critical event 0.63 [95%CI: 0.58-0.67]. HEWS had fair discriminative ability for predicting likelihood of meeting criteria for sepsis 0.75 [95%CI: 0.71-0.80], and good discriminative ability for predicting likelihood of experiencing a critical event among patients meeting criteria for sepsis 0.80 [95%CI: 0.74-0.86]. Conclusion: This retrospective study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. This may be because deterioration commonly occurred days after admission. However, HEWS may have utility as tool for aiding earlier identification of critically ill septic patients. Prospective studies are needed to further delineate the utility of the HEWS in the ED.

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LO054: The emergency department usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium

CJEM ◽

10.1017/cem.2016.91 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S48-S49

Author(s):

C. Thompson ◽

A. Sandre ◽

S.L. McLeod ◽

B. Borgundvaag

Keyword(s):

At Risk ◽

Emergency Department ◽

Hip Fracture ◽

Functional Decline ◽

Assessment Method ◽

Assessment Tools ◽

Screening Tools ◽

Future Research ◽

Early Management ◽

Patients At Risk

Introduction: Delirium is an acute state of mental confusion that is a frequent complication in older adults with a hip fracture, and is often unrecognized by clinicians in the emergency department (ED). It is associated with prolonged hospitalization, functional decline, hospital readmission, and death. The Identification of Seniors At Risk (ISAR) and Confusion Assessment Method (CAM) are two standardized tools designed to facilitate prompt screening and detection of functional decline and delirium respectively amongst adults 65 and older. The objective of this study was to determine the ED usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium. Methods: This was a retrospective chart review of patients aged 65 and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. At this institution, both the ISAR and CAM are included in the standard ED nursing documentation and are intended to be completed for all patients over 65 years of age. Results: Of the 243 hip fracture cases included in this study, the ISAR and CAM scores were completed for 131 (53.9%) and 69 (28.4%) patients, respectively. There were 43 (17.7%) cases of recorded in-hospital acute delirium. Of the delirium cases, 20 (46.5%) had an ISAR assessment. Patients with an ISAR score of ≥3 were more likely to experience delirium compared to those with lower ISAR scores (28.3% vs 8.3%; Δ 20.0%, 95% CI: 6.6%, 34.9%). Of the 43 patients with delirium, 11 (25.6%) had a CAM score recorded. Patients with a positive CAM score (meeting 3 of 4 criteria in the diagnostic algorithm) were more likely to experience delirium compared to those with negative CAM scores (66.7% vs 11.1%; Δ 55.6%, 95% CI: 17.5%, 79.9%). Conclusion: Vigilant efforts are needed to ensure these screening tools are applied for all patients over the age of 65 presenting to the ED to improve the recognition and early management of delirium. Future research should focus on initiatives to improve delirium screening compliance by ED personnel.

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Association between Shock Index and Emergency Department Cardiac Arrest

Emergency Medicine International ◽

10.1155/2021/9138449 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Chao-Tung Chen ◽

Pei-Ming Wang ◽

Chao-Hsin Wu ◽

Chih-Wei Wei ◽

Tai-Lin Huang

Keyword(s):

At Risk ◽

Emergency Department ◽

Cardiac Arrest ◽

Hospital Mortality ◽

Screening Tool ◽

Vital Signs ◽

Shock Index ◽

Patients At Risk ◽

Injured Patients ◽

The Relationship

Background. In the emergency department (ED), early identification of patients at risk of cardiac arrest is paramount, especially in the context of overcrowding. The shock index (SI) is defined as the ratio of heart rate to systolic blood pressure. It is a tool used for predicting the prognosis of critically ill and injured patients. In this study, we have discussed the relationship between SI and cardiac arrest in the ED. Methods. Patients who experienced cardiac arrest in the ED were classified into two groups, SI ≥ 0.9 and < 0.9, according to their triage vital signs. The association between SI ≥ 0.9 and in-hospital mortality was analyzed in five different etiologies of cardiac arrest, including hypoxia, cardiac cause, bleeding, sepsis, and other metabolic problems. Results. In total, 3,313 patients experienced cardiac arrest in the ED. Among them, 1,909 (57.6%) had a SI of ≥0.9. The incidence of SI ≥ 0.9 in the five etiologies was 43.5% (hypoxia), 58.1% (cardiac cause), 56.1% (bleeding), 58.0% (sepsis), and 65.5% (other metabolic problems). SI was associated with in-hospital mortality (adjusted odds ratio (aOR), 1.6; 95% confidence interval (CI), 1.5–1.8). The aOR (CI) in the five etiologies was 1.3 (1.1–1.6) for hypoxia, 1.8 (1.6–2.1) for cardiac cause, 1.3 (0.98–1.7) for bleeding, 1.3 (1.03–1.6) for sepsis, and 1.9 (1.5–2.1) for other metabolic problems. Conclusion. More than half of the patients who experienced cardiac arrest in the ED had a SI ≥ 0.9. The SI was also associated with in-hospital mortality after cardiac arrest in the ED. SI maybe used as a screening tool to identify patients at risk of cardiac arrest in the ED and a predictor of mortality in those experiencing cardiac arrest in the ED.

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Pengembangan metode skrining gizi untuk pasien dewasa rawat inap

Jurnal Gizi Klinik Indonesia ◽

10.22146/ijcn.18217 ◽

2012 ◽

Vol 8 (4) ◽

pp. 188

Author(s):

Susetyowati Susetyowati ◽

Hamam Hadi ◽

Muhammad Hakimi ◽

Ahmad Husein Asdie

Keyword(s):

At Risk ◽

Screening Tool ◽

Nutritional Assessment ◽

Healing Process ◽

Screening Tools ◽

Nutrition Support ◽

Cross Sectional ◽

Nutrition Screening ◽

Patients At Risk ◽

Nutrition Screening Tool

Background: A comprehensive nutrition assessment needs to be done on all hospitalized patients. The accuracy of nutritional assessment are necessary to ensure the provision of optimal nutrition support for the patient to prevent iatrogenic malnutrition and speed up the healing process. The nutrition screening tools has limited ability to be used as a valid indicator for comprehensive nutritional assessment. Thus, it is necessary to develop a new nutrition screening tool.Objective: To develop a simple, quick and valid malnutrition screening tool that can be used to identify adult patients at risk of malnutrition.Methods: This is an observational study with cross sectional design. The subjects were 495 patients admitted to Sardjito General Hospital, excluding paediatric, maternity, and psychiatric patients. All patients were screened using the Nutrition Screening Tool of University Gadjah Mada (NST-UGM). The validity of the NST-UGM will be tested by measuring the sensitivity and specifi city value compared to Subjective Global Assessment (SGA).Result: The newly developed nutrition screening tool consisted of 6 questions with a cut-off of 0-2 classifi ed as not at risk of malnutrition and > 2 classifi ed as at risk of malnutrition. The sensitivity and specifi city value of the new screening tool compared with SGA were 91.28 and 79.78 respectively. Therefore, the convergent and predictive validity of NSTUGM was established. Conclusion: The NST-UGM is a simple, quick and valid tool which can be used to identify patients at risk of malnutrition.

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Identifying Foot and Ankle Patients at Risk to Fall Based on Patient Reported Outcomes Assessments

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00026 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0002

Author(s):

Judith Baumhauer ◽

Jack Teitel ◽

Allison McIntyre ◽

David Mitten ◽

Jeff Houck

Keyword(s):

At Risk ◽

Effect Size ◽

Fall Risk ◽

Patient Reported Outcomes ◽

The United States ◽

Foot And Ankle ◽

Falls Risk ◽

Orthopaedic Patients ◽

Patient Reported ◽

Patients At Risk

Category: Other Introduction/Purpose: Each year approximately 30-40% of people over the age of 65 fall. Approximately one half of these falls result in an injury with the estimated annual direct medical costs of $30 billion. Pain, mobility issues, neuropathy and post-operative weight bearing limitations make foot and ankle patients particularly vulnerable to falls. Current approaches to determine at risk patients are cumbersome and time consuming requiring performance testing and “hands on” clinical assessment. The efficiency of obtaining PRO, such as PROMIS, in the clinical arena has been well documented. The purpose of this study is determine if patient reported outcomes (PROMIS) can identify orthopaedic and specifically foot and ankle patients at risk to fall. Methods: Prospective patient reported outcomes (PROMIS CAT physical function, pain interference and depression and CMS fall risk assessment questions) and patient demographics were collected for all patients at each clinic visit from an academic orthopaedic multi-specialty practice between January 2015 and November 2017. Standardized yes/no validated self-reported fall risk questions include: “Have you fallen in the last year?” and “Do you feel you are at risk of falling?” Histograms, t-tests, confidence intervals and effect size were used to determine the fall risk “YES” patients were different than the “NO” for ALL orthopaedic patients and specifically foot and ankle patients. Logistic Regression was used to determine if age, gender, height, weight, and PROMIS scales predicted self-reported falls risk. Results: 94,761 orthopaedic patients comprising 315,273 visits (44% male, mean age 53.7+/-17 years) and 13,720 foot/ankle patients comprising 33,480 visits (37% male, mean age 52.7+/-16.1 years) had complete data for analysis. Table 1 provides the means/SD/p-values/effect sizes for patient self-identifying at risk to fall stratified by PROMIS PF/ PI/Dep t-scores. Although all PROMIS scores demonstrated significant impairment between patients at risk designation (yes/no), PROMIS PF had the largest effect size for ALL Ortho and FOOT AND ANKLE patients (0.8 and 0.7 respectively). Patients who are at risk to fall have PROMIS PF t-scores >1.5 lower than the United States normative population while the patients not at risk are less <1 SD. In the adjusted regression models gender and PROMIS PF had the largest coefficients. Conclusion: Falls are a major threat to quality of life and independence yet prevention/treatment strategies are difficult to implement across a health system. There is also a tremendous societal cost with orthopaedic surgeons often the recipient of these debilitated patients. PROMIS assessments are part of the AOFAS OFAR initiative to track patient recovery with treatment and can additional be used to fulfill a quality indicator requirement by CMS. This study demonstrates these assessments (PROMIS threshold values) can also be linked to self-report falls risk (yes/no) and may identify patients at risk with no face to face time required from the provider.

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