Falling Into Line: Standardising Falls Assessments In Emergency Departments Patients Aged ≥ 65 Years

Introduction

Falls in older adults are a common Emergency Department (ED) presentation associated with significant morbidity and an estimated prevalence of 26.5% within this population. ¹They may indicate reversible underlying medical, cardiac, neurological, or medication-related causes. National guidance recommends assessment including observations, electrocardiography (ECG), lying and standing blood pressure (LSBP), and delirium screening. ² Completeness of this assessment can be challenged by the ED setting.

This quality improvement project aimed to evaluate baseline practice and improve adherence to a structured falls assessment in patients aged ≥65 years presenting following a fall.

Method

A quality improvement project was conducted in a District General Hospital ED. Data was collected over seven weeks with fortnightly review of patients aged ≥65 years presenting following a fall. Documentation of observations, ECG, LSBP, and 4AT was assessed. Interventions included staff teaching and WhatsApp reminders (Week 3), posters, email prompts, and safety briefing reinforcement (Week 5), followed by a no-intervention sustainability phase (Week 7). A post-project staff survey identified barriers to implementation.

Results

Of 293 patients aged ≥65 years, 86 (29.4%) presented following a fall, consistent with local baseline rates (25.1%). Of these, 54 were discharged and 32 were admitted.

Baseline completion rates were: observations 83.3%, ECG 45.8%, LSBP 6.3%, and 4AT 20.8%. By Week 7, ECG improved to 63.1% and 4AT to 31.6%. Observations remained high (76.0–84.2%). LSBP remained low throughout (5.26–17.65%), with no sustained improvement.

Barriers included patient factors (mobility limitations and delirium), workload and capacity pressures, staffing constraints, prioritisation of injury-focused care in Minor Injuries areas, and access to equipment limitations.

Conclusion

Low-cost interventions improved ECG completion and delirium screening in older adults presenting with falls. LSBP remained persistently low, reflecting perceived patient-related and workflow barriers. Identified operational and educational factors will inform future PDSA cycles to improve standardisation and patient safety.

References: 

1. Salari N, Darvishi N, Ahmadipanah M, Shohaimi S, Mohammadi M. Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research [Internet]. 2022 Jun 28;17(1). Available from: https://josr-online.biomedcentral.com/articles/10.1186/s13018-022-03222…
2. National Institute for Health and Care Excellence (NICE).Overview | Falls: Assessment and Prevention in Older People and in People 50 and over at Higher Risk | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2025. Available from: https://www.nice.org.uk/guidance/ng249