FIRST-FALL: Falls Identification, Risk Stratification and Timely Intervention for Older Adults in the Emergency Department

Introduction
Falls are a leading cause of Emergency Department (ED) attendance among older adults and are associated with recurrent visits and high healthcare costs. From January 2023 to December 2024, our ED at Tan Tock Seng Hospital received 3,632 patients aged ≥65 years with falls or falls-related injuries, with an estimated annual cost of SGD 20 million. Despite guideline recommendations for early identification and multifactorial intervention, ED implementation remains inconsistent with frequent re-attendance.

Methods
FIRST-FALL, implemented in July 2024, is a quality improvement initiative in an 1,800-bed tertiary hospital ED. Patients aged ≥65 years with Clinical Frailty Scale 4–6 under the head injury pathway were screened by Geriatric Emergency Medicine nurses using comprehensive geriatric assessment. Eligible patients were referred to an EDIFY Advanced Practice Nurse for timely multifactorial falls risk assessment and interventions, including physiotherapy-led exercise prescription, medication optimisation, bone health screening, falls education, and community rehabilitation. All patients were reviewed by a geriatrician before discharge. Outcomes were compared with standard-care referrals to the geriatric falls clinic.

Results
Between July 2024 and August 2025, 96 patients (63.5% female; mean age 80.9 years; median CFS 4) were enrolled. Recurrent falls accounted for 85% of referrals; 22 patients required admission (54.5% acute ward, 40.9% community hospital, 4.5% Hospital@Home). FIRST-FALL reduced geriatric falls clinic default rates by 48% (18.8% vs 36.3%) and lowered ED re-attendance at 30 days (4.5% vs 11.7%) and 3 months (16.2% vs 21.7%). Among follow-up defaulters (N = 14), ED re-attendance remained lower than standard-care defaulters at 3 and 6 months (7.7% vs 26.7% and 7.7% vs 39.6%).

Conclusion
ED-based early falls risk identification with timely multidisciplinary intervention improves follow-up adherence and reduces repeat ED visits among high-risk older adults. FIRST-FALL provides a feasible, scalable approach to guideline-recommended falls care while mitigating substantial healthcare costs.