The Journal — June 2017
Tex Med. 2017;113(6):e1.
By Emilie Y. Prot, DO, MPH; Jeffery P. Taylor, MPH; and Amanda Cernovich, MPH
Dr Prot, Department of Preventive Medicine; Mr. Taylor, Epidemiology and Disease Surveillance Unit; and Ms. Cernovich, Department of Preventive Medicine, Texas Department of State Health Services, Austin, Texas. Send correspondence to Emilie Y. Prot, DO, MPH, Department of Preventive Medicine, Texas Department of State Health Services, 1100 W 49th St, Mail Code 1864, PO Box 149347, Austin, TX 787149347; email: email@example.com.
Fall-related injuries are most common among persons aged 65 years and older. Worldwide, approximately 28% to 35% of people aged 65 years and older fall each year. Along with a rising elderly population, a better understanding from a public health perspective of the health care resources and the significance of falls in the elderly is essential.
This study analyzes falls occurring in persons aged 65 years and older using the Austin-Travis County Emergency Medical Services data on falls over a 5-year period. The aim of this epidemiologic study is to provide data to help decisionmakers create policies to prevent falls, morbidity, and mortality in our communities.
According to the World Health Organization, fall-related injuries are most common among persons aged 65 years and older. Worldwide, approximately 28% to 35% of people aged 65 years and older fall each year. This number increases to 32% to 42% for those older than 70 years.1 Not only do falls impact the person who is injured, causing a significant amount of pain, disability, loss of independence, and premature death, but they also have serious repercussions on the lives of caregivers and friends.1 The Centers for Disease Control and Prevention reported that 2.8 million elderly individuals are treated in emergency departments for fall injuries each year.2 Because our rising elderly population often requires more intensive health care resources, understanding falls from a public health perspective becomes essential.
A study by Lin et al showed how the analysis of Emergency Medical Services (EMS) data can be used to prevent injuries and help plan resource use for prehospital trauma rescue.2 Information on the prevalence and circumstances of falls among residents of the City of Austin and Travis County is limited. To better understand the significance and circumstances in falls occurring in persons aged 65 years and older, an epidemiologic investigation was initiated to analyze Austin-Travis County Emergency Medical Services (ATCEMS) data on falls over a 5-year period.
Public Health Implications
Falls are a leading cause of injury among older adults. Not only can these incidents cause significant injury and fear of subsequent falls in the elderly, but they are also costly in terms of quality of life and expenses. Falls can be prevented through education, awareness, and hazard-proofing homes by using community partnerships.
The EMS data were collected from July 1, 2010, to September 30, 2015, from the Austin Texas Metro Area Syndromic Surveillance System. Data were then filtered for Problem Description for "Fall" for analysis including contact date, patient age, problem description (priority of fall), primary impression, location type, and outcome. Additionally, for this investigation, the procedures related to receiving an emergency call were observed. After 911 was dialed, a call was transferred to an EMS communication dispatcher who determined the nature of the emergency and dispatched an ambulance to the location of the call. Following the National Academy EMD Protocol: Medical Priority Dispatch System (Table 1), the EMS dispatcher selected the primary chief complaint of the caller through a menu on the electronic medical system. After gathering additional information, an algorithm was used to attach a priority to the emergency.
The EMS algorithm determined the priority of the response for falls by a severity ranking, which ranged from 1 (imminent life threat) to 5 (non-life-threatening) (Table 2).3 After the paramedic arrived on site, the primary impression was determined, and this was recorded in the syndromic data.
Between July 1, 2010, and September 30, 2015, ATCEMS responded to 19,935 fall incidents in persons aged 65 years and older. Eighty-three incidents were not included in the analysis because of missing patient age information. The results were unable to exclude repeat EMS responses to the same patient.
Table 3 shows the number of responses by age group. A total of 19,935 emergency responses from July 1, 2010, through September 30, 2015, involved falls. The mean age for persons was 81 years with a range from 65 years to 124 years. Most (58.6%) responses related to falls involved persons aged 80 years and older.
Table 4 shows the priority for 19,915 dispatches for falls by age group. Most (76.5%) falls were classified as non-life-threatening with no significant signs, symptoms, or history (Fall Priority 4). A total of 3416 falls were considered as imminent life threats or involving significant signs and symptoms (Fall Priorities 1 and 2). These falls represented 17.2% of incidents. No relationship between fall priority and age group was evident.
Figure 1 shows that falls occurred at 29 different locations; the top five locations in ranked order were as follows: homes or residences (n=11,391, 61.3%), assisted living centers (n=3232 [17.39%]), nursing homes (n=2330 [12.54%]), places of business (n=930 [5%]), and parking lots (n=698 [3.76%]). Table 5 shows locations where falls occurred by priority of the response.
Most (83.6%) falls that occurred at home were considered non-life-threatening, classified as Fall Priority 5. However, 67.2% of falls that occurred at personal homes were considered an imminent life threat and classified as Fall Priorities 1 and 2.
Injuries represented 64.7% (n=12,951) of all falls in Travis County for those aged 65 years or older. Figure 2 shows the number of falls by primary impression. Injuries to the head, lower extremities, or upper extremities accounted for 5,595 incidents (28.6% of all incidents).
Of the 3730 falls resulting in a head injury, 1397 (50.7%) occurred in persons aged 65 to 79 years, and 2333 (59.9%) were older than 80 years (Table 6). A slightly greater proportion of head injuries from falls were seen in those older than 90 years compared with those aged 65-69 years. Most of the head injuries were sustained at the home residence (n=1,521), followed by assisted living centers (n=781) and nursing homes (n=682).
When analyzing for temporality, we found no significant differences in responses when analyzing the days of the week with corresponding number of falls. However, over the period from 2010 to 2015, a steady increase in the number of fall emergencies was observed (Figure 3). This increasing trend is consistent with the Travis County census data stating that the over-65 population has increased 29% since 2009.4
In 2013, a total of 91,108 persons aged 65 years or older lived in Travis County.4 The EMS data showed 3813 falls in this age group in 2013 or an estimated one EMS dispatch for a fall for every 24 persons in this age group. ATCEMS responded to a total of 19,935 fall incidents in persons aged 65 years and older between July 1, 2010, and September 30, 2015. The mean age of persons involved with fall responses was 81 years, with a range from ages 65 to 124 years. A total of 17.2% of fall incidents were considered imminent life threats involving significant signs and symptoms and classified as Fall Priorities 1 and 2. Not surprisingly, injuries were the primary impression for most (64.7%) of the fall incidents. Additionally, adults older than 90 years were more likely to sustain a head injury compared with those aged 65 to 69 years.
The EMS data have been studied to improve the response to EMS calls and prevent injuries through community programs. A study by Lin et al from 2009 to 2010 found a total of 68,927 trauma cases, 25.7% of which were due to falls. The most injured were in the adult group (aged 18-64 years), accounting for 74.2% of falls, followed by 20.9% in the elderly group (aged >65 years).2 Another study by Cantwell et al found that more than 77,891 falls cases involved older adults (6.5% of overall ambulance demand), and falls by older people were the second largest contributor to ambulance demand in Melbourne, Australia.5
Our data are consistent with prior literature and showed the number of falls had been steadily increasing over the period from 2010 to 2015, along with Travis County’s large and growing population of older adults.4 As of September 21, 2016, ATCEMS has launched a Fall Prevention Program offering free home safety assessments and fall prevention education and resources for aging adults.6 This epidemiologic investigation over a 5-year period will be useful to compare with future data after the implementation of the Fall Prevention Program. This 5-year investigation can serve as a useful baseline from which to evaluate the effectiveness of the Fall Prevention Program.
- World Health Organization. Falls prevention in older age. http://www.who.int.utsph.idm.oclc.org/ageing/projects/falls_prevention_older_age/en/. Accessed October 27, 2016.
- Lin LW, Lin HY, Hsu CY, Rau HH, Chen PL. Effect of weather and time on trauma events determined using emergency medical service registry data. Injury. 2015;46(9):1814-1820.
- Falls. National Academy EMD Protocol: Medical Priority Dispatch System, The EMS Dispatcher, 2015.
- CAN Community. Older adults. http://www.cancommunitydashboard.org/populations/older-adults.php. Accessed October 31, 2016.
- Cantwell K, Burgess S, Morgans A, Smith K, Livingston, Dietze P. Temporal trends in falls cases seen by EMS in Melbourne: the effect of residence on time of day and day of week patterns. Injury. 2016;47(1):266-271.
- ATCEMS launches new fall prevention program [press release]. Austin, TX: City of Austin ATCEMS Public Information Office. September 21, 2016. https://www.austintexas.gov/news/atcems-launches-new-fall-prevention-program. Accessed October 27, 2016.
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