Falls are seen internationally as a major health issue, with increasing research in recent decades attributed to falls prevention programmes (Close et al, 2002; Weiss et al, 2003; Snooks et al, 2010). These programmes often focus on the elderly and are community based, however, some have prehospital personnel involvement. Fleming et al (2008) suggests that many people fall more than once, further strengthening the current resolve towards preventative programmes.
Ambulance paramedic workload as the result of falls could be up to 2 days per month in the UK (Newton et al, 2006). Snooks et al (2006) reported that paramedics respond to 300 000—400 000 calls for elderly falls annually. This results in 8% of total paramedic workload in the UK, however, 40% of these patients were not conveyed to hospital post fall. Though Snooks et al (2006) believe this figure should be closer to 600 000 per year, equating to approximately 18% of paramedic workload. Of the calls made in the London geographical area, approximately 50% were made outside of standard business hours.
The UK is comparable to the US, with 7.5% of urban paramedic workload attributable to falls, particularly in the elderly (Snooks et al, 2010). The only Australian prehospital study that reported falls was conducted in Victoria and found 39% of patients fell from standing and had no prehospital defined major trauma, with 6% either falling from a height or something falling on them from a height and sustaining prehospital major trauma (Boyle et al. 2008). Fleming et al (2008) agrees that falls contribute to a significant portion of paramedic workload, particularly for those left at home.
Falls from around the house and buildings attribute to 70% of falls, with morbidity and mortality from more serious falls (Knight et al, 1999). Snooks et al (2006) continue 78.3% of patients in their study had no obvious injury, in addition to 7.4% with minor injuries post fall. Further, Fleming et al (2008) suggests that increased falls could be due to a decline in muscle function and age. Snooks et al (2010) indicate that patients could have a reduced quality of life post a fall due to functional deterioration, institutionalization, social isolation and secondary dependency. Whilst, Weiss et al (2009) highlighted that elderly patients are concerned with hasty admission to a nursing home facility post a fall.
Falls are significantly more frequent in females than in males, especially in the older age group. Newton et al (2006) has indicated 35% of person’s over 65 years fall at least once per year. In direct comparison, paediatrics are the second most common age group to fall and suffer fall related injuries. Knight et al (1999) has suggested that paediatrics account for 10% of paramedic workload, both from school and non-school locations. Razzak et al (2004) and Eckstein et al (2002) indicate that falls represent a major portion of paediatric injuries, second only to motor vehicle crashes.
Given the frequency of adult and paediatric falls, it is vital paramedics understand the difference between adult and paediatric falls and the implication for paramedic practice. The objective of this study was to identify the incidence of falls and the outcome from an ambulance perspective.
Methods
Study design
A literature search of selected medical electronic databases.
Definitions
There is no definition of fall in the prehospital literature, with the in-hospital literature using a similar definition to community-based prevention programmes. This article has defined a fall as:
‘inadvertently coming to rest on the ground or other lower level with or without loss of consciousness and not as a result of a major intrinsic or extrinsic event.’ (Whitehead et al. 2003)
Standing fall is defined as:
‘inadvertently coming to rest on the ground or other lower level with or without loss of consciousness from a standing position, i.e. same height fall’.
Procedure
The literature search was conducted using the medical electronic databases of Ovid MEDLINE (1950 to end of July 2010), CINHAL (1982 to end of July 2010, EMBASE (1970 to the end of July 2010), Meditext (1970 to end of July 2010), Cochrane Central Register of Controlled Trials (CENTRAL) (1950 to the end of July 2010), and Scopus (1996 to the end of July 2010).
The MeSH headings and keywords used include: emergency medical service, emergency medical technician, ambulance, air ambulance, military medicine, emergency treatment, emergency medicine, first aid, pre-hospital, prehospital, out-of-hospital, paramedic and fall. The MeSH headings and keywords were used both individually and combined to identify relevant articles.
Articles of any study type were included if their principal purpose was to identify and/or investigate the incidence of falls in the prehospital environment, including emergency departments (ED) presentations and patient outcomes from falls and their related injuries.
Articles were excluded if they did not report falls in the prehospital environment. Articles reporting post-mortem studies of fall victims were excluded due to a lack of relevance to the prehospital environment. Articles were also excluded if they were not written in English or focused on prevention or community-based interventions.
The reference lists of the retrieved articles were also examined to ascertain if any articles had been missed in the initial electronic search.
Results
There were 405 articles located in the search with 21 meeting the inclusion criteria. There were five studies excluded leaving 16 studies available for review There was one pragmatic cluster randomised trail (Snooks et al, 2010), seven retrospective studies (Eckstein et al, 2002; Razzak et al, 2004; Talving et al. 2005; Newton et al, 2006; Snooks et al, 2006; Cheung et al, 2007; Boyle et al. 2008) and two prospective studies (Knight et al, 1999; Fleming et al. 2008). One study was a combined prospective and retrospective study (Wiese et al, 2009).
Of the remaining five studies, one was an epidemiological study (Marks et al, 2002), one a literature review (Gray and Walker, 2008), one clinical observation study (Lapostolle et al, 2005), one pilot study (Close et al, 2002), and one case study (Braude and Shalit, 1999). There were four articles that combined prehospital and in-hospital data, which were excluded due to the inability to extract the prehospital data from the in-hospital data. There was also one study protocol that was excluded as it did not report any results (Mason et al. 2003).
This review has highlighted literature from numerous countries, with the UK, US and Australia being the key contributors to prehospital falls research and their management. Currently there are no Australian prehospital studies pertinent solely to falls; however, falls data is found within trauma based studies in the Australian environment. Table 1 displays the specific breakdown of the studies located in the search.
| Research type n | n | Author and country of study |
| Pragmatic cluster randomised trial | 1 | Snooks et al - UK (Snooks et al, 2010) |
| Prospective | 2 | Knight et al - US (Knight et al, 1999) |
| Fleming et al - UK (Fleming et al. 2008) | ||
| Retrospective | 7 | Boyle et al - Australia (Boyle et al. 2008) |
| Cheung et al - Hong Kong (Cheung et al, 2007) | ||
| Talving et al - Sweden (Talving et al. 2005) | ||
| Razzak et al - Pakistan (Razzak et al, 2004) | ||
| Eckstein et al - US (Eckstein et al, 2002) | ||
| Snooks et al - UK (Snooks et al, 2006) | ||
| Newton et al - UK (Newton et al, 2006) | ||
| Prospective and retrospective | 1 | Weiss et al - USA (Weiss et al, 2003) |
| Epidemiological | 1 | Marks et al - UK (Marks et al, 2002) |
| Clinical observational | 1 | Lapostolle et al - France (Lapostolle et al, 2005) |
| A pilot Study | 1 | Close et al - UK (Close et al, 2002) |
| Review | 1 | Gray and Walker - UK (Gray and Walker, 2008) |
| Case study/series | 1 | Braude et al - USA (Braude and Shalit,1999) |
| TOTAL | 16 |
Discussion
Falls and fall related injuries contribute to a significant portion of ambulance workload, between 8% in the UK (Snooks et al, 2006) and 39% in Australia (Boyle et al. 2008) for adults. People over 65 years of age fall frequently in the prehospital environment (35%), with varying degree of injuries in the UK (Newton et al, 2006).
Considering age and gender
Paediatric falls range from 5% in the UK (Razzak et al, 2004) to 36.2% for school-based trauma in South Dakota, USA (Knight et al, 1999). The majority of falls in the prehospital environment are females over the age of 65 years, with no injuries or minor injuries. (Marks et al, 2002). Marks et al (2002) has suggested that 59% of fallers were female, and the mean age of non-transported patients was 73 years of age. Snooks et al (2006) report similar results in their study, with 63.4% females and an average age of 83 years. Close et al (2002) present similar findings, with an average of 82 years, with 57% of fallers being female.
Cheung et al (2007) and Lapostolle et al ( 2005) are the only studies to refute these statistic’s by suggesting that 79% and 67% were male respectively, with an average of 37.2 and 37.7 years respectively. Yet, this could be due to the mechanism of fall types investigated, Cheung et al (2007) explored traumatic blunt injuries resulting in extradural haematoma, whilst Lapostolle et al (2005) focused on prognostic factors of falls from a significant height. Despite the strong support of falls incidence greater in females, there is no evidence to indicate whether this data is reflective of longer life span of females than males.
Marks et al (2002) has identified that 33% of all fallers lived alone. This is clearly an issue when the vast majority of falls are females over 65 years of age with at times decreasing functional mobility. Emergency service calls for those living alone who have fallen may require assistance only back to bed or a chair and not transported to hospital. To date, there are no studies that have been conducted to provide epidemiological statistics to identify the exact nature of calls made by persons’ who live alone. There is strong evidence indicating that with increasing age, the risk of falls and fall related injuries also increases, particularly for those 65 years and older (Marks et al, 2002).
The workload of ambulance practictioners
Falls contribute significantly to workload of ambulance paramedics, particularly in the adult population (Boyle et al. 2008). Boyle et al (2008) reported on a trauma study in Victoria that identified falls contributing to 39% of paramedic workload. The workload is considerably less in the UK and in the US, between 7.5% (Snooks et al, 2010)—8% (Snooks et al, 2006) respectively.
There is currently no explanation for this in the literature, although Australia’s ageing population could represent one key factor in the increased workload of falls in the Australian prehospital environment. Fleming et al (2008) also argues that falls is a major contributor to the operational functioning of ambulance paramedics.
Further, paediatrics are the second major age group to suffer falls in the prehospital environment. There was 36.2% of all school-based attendances by paramedics are due to falls and fall related injuries in the US each year, followed by other trauma and medical illnesses, 27.0% and 24.5% respectively (Knight et al, 1999). Newton et al (2006) suggests that current data on falls in emergency medicine significantly underestimates the impact on paramedic workload.
Snooks et al (2006) has indicated 49% of patients have re-accessed healthcare in two weeks post fall, particularly for those patients left at home. However, there is no information that identifies the exact nature of the re-presentation including whether they were related to the previous fall(s) or had emergency service involvement. Snooks et al (2010) agree that approximately 50% of calls have no clinical basis for the call, with falls contributing to 50%.
Falls and trauma injuries
Boyle et al (2008) in their Victorian state-wide trauma study identified falls presenting to major trauma centres as accounting for only 6% of the total trauma workload in Victoria. However, standing fall numbers were reported but outcomes were not analysed due to another study looking at these falls at the same time (Boyle et al. 2008). Boyle et al (2008) also highlight that falls > 5 metres is significantly associated with hospital defined major trauma and a high mortality rate. Braude et al (1999) has described the potential challenges of accessing a patient, post a traumatic fall.
Cheung et al (2007) continued the traumatic injuries investigation and identified falls as 30% of the cause of traumatic extradural haematoma. Talving et al (2005) agrees, explaining that falls can be caused by hypotension of various causes. However, this study is of limited value due to the focus on hypotension rather than the mechanism of fall.
Cheung et al (2007) explored traumatic blunt injuries resulting in extradural haematoma, while Lapostolle et al (Lapostolle et al, 2005) focused on prognostic factors of falls from a significant height. Lapostolle et al (Lapostolle et al, 2005) identifies the patient age, height of fall and nature of impact as all being determinants of the overall prognosis of the patient. It is nonetheless important to note that the abovementioned factors are not within paramedic control. This is particularly important for traumatic falls, as Lapostolle et al (2005) has shown that a mortality rate of 70% is possible.
Transportation to hospital
Falls in the prehospital environment are a major contributor to non-transport/services not required, accounting for over one-third of cases (34%). (Marks et al, 2002). Marks et al (2002) indicates falls represent 55% of non-injured patients, who did not require transportation, however only 30% refused transport. Marks et al (2002) acknowledges that this data does not determine if the opinion of the crew in attendance affected the decision of non-transportation. Falls in the study by Marks et al (2002) has been examined collectively, therefore this study provides no data that represents the potential or mechanism of injury for those left at home.
Gray and Walker (2008) reported that 73% of patients in their study were left at home and referred to more appropriate primary care, minor injury clinics or general practitioner clinics. The emergency department in South Yorkshire hospital avoided admission in 48% of its fall presentations, by referring the patients to or direct discharge.(Gray and Walker, 2008) One study showed that 78.3% of patients had ‘no injury or illness’, and 38% of people over 65 years who fall, do not require transport (Snooks et al, 2006). Conversely, Newton et al (2006), argues that only 11% of patients are ‘assist only’, i.e. assisted from the floor back to bed or a chair, cases in the UK.
Newton et al (2006) expands that approximately three-quarters of the patients who have fallen have not been admitted to hospital, further strengthening the need for multidisciplinary prevention programmes. Although there is strong evidence to show that many falls in the prehospital environment result in minor injuries, if any. There is a distinct lack of literature available that explores the events leading up to, and immediately post fall, in particular the effect of patient co-morbidities. In fact, the study by Snooks et al (2006) highlighted that in almost half of the patients left at home, contact with health services was made within two weeks of the fall, both in the UK and in the US.
‘Falls contribute significantly to the workload of ambulance paramedics, particularly in the adult population’
The role of extended care paramedics
Gray and Walker (2008) state that extended care paramedics (ECPs) play a pivotal role in fall management in the prehospital environment, particularly in referral to fall support services and emergency department avoidance. Given that up to 50% of ambulance transports are from private residents, paramedics are at the front-line in patient assessment and management of falls (Weiss et al, 2003). Close et al (2002) indicate that paramedics can provide vital information to high-risk groups in the community, who are unlikely to use the ambulance service, when they should, this also includes community-based referrals for falls assessment teams.
Fall prevention programmes
Snooks et al (2010) indicate maximum results from current fall prevention programmes in the UK and US are dependant on early identification of patients who are at risk of falling or have already fallen. Mason et al (2003) has indicted in the UK that falls is an area of healthcare that is receiving attention in the form of referring the patients to more appropriate level of care. However, this system is based on emergency personnel, or paramedic assessment. Marks et al (2002) reports that this could be a cost-effective means in the overall management of falls for the health service in the UK.
Newton et al (2006) expands, that approximately three-quarters of the patients who have fallen have not been admitted to hospital, further strengthening the need for multidisciplinary prevention programmes. Similarly, Snooks et al (2006) support multifactorial/ multidisciplinary programmes, while reducing the number of unnecessary hospital presentations. Snooks et al (2010) support the need for assessment of such programmes and the impact of patient’s quality of life and overall outcomes. To date, there is no longitudinal study assessing the effectiveness of these programmes in patient outcomes based entirely in the prehospital environment.
Newton et al (2006) has explored the monetary cost to the health services generally, with £2000– 3000 per faller, of which the hospital pays half in the UK and 80% in New Zealand. Although recognizing that the monetary cost to the ambulance services is not known. Currently there is no data exploring the monetary cost of falls outside of the UK, US and New Zealand. Newton et al (2006) extends that ambulance scene times are significantly longer for non-transported falls patients, with the ‘cost’ to the service often felt at operational level rather than monetary expense. Hence, reducing the number of falls will benefit the service operationally and financially.
Limitations
This review is potentially limited by the lack of hand searching of journal articles, as some articles may not be listed in the medical electronic databases. There is a potential that some journal articles may not have been included in this review if they were published in languages other than English. The findings presented in this review are to be interpreted with caution, due to the low-level methodologies and the small sample sizes used in various studies located.
Conclusion
This review has shown that falls and fall related injuries contribute a significant proportion of ambulance service workload. Adults over 65 years of age and paediatrics fall frequently with the majority of falls in the prehospital environment being females over the age of 65 years who sustain no injury or only minor injuries.
This review has shown significant gaps in the research concerning Australian prehospital falls and the outcome of the falls. There is still a need for further research into the appropriate and efficient assessment of the falls patient including co-morbidities, risk factors and likelihood of further falls, and the potential outcomes, in the Australian context.