Article, Geriatrics

Are triage questions sufficient to assign fall risk precautions in the ED?

a b s t r a c t

Objectives: The American College of Emergency Physicians Geriatric EMergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assess- ment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a func- tional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls. Methods: Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered.

Results: The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n = 23) as at risk for falls, whereas the 4SBT identified 43% (n = 25). Combining triage ques- tions with the 4SBT identified 60.3% (n = 35) as at high risk for falls, as compared with 39.7% (n = 23) with triage questions alone (P b .01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were in- patients unaware that they were at risk for falls (new diagnoses).

Conclusions: Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and sig- nificantly increases the detection of older adults at risk for falls.

(C) 2016


Despite the high burden of injury from falls and an emphasis on fall prevention for patients in the hospital, the current emergency

? Funding sources/disclosures: All authors report support by a grant from the Cum- mings Endowment for Research in the School of Health and Rehabilitation Sciences at Ohio State University to perform this study. In addition, LTS is supported by a Falls Preven- tion Coalition Grant from the Ohio Department of Health, Office of Injury Prevention Part- nership. The use of Research Electronic Data Capture database technology is supported by the Ohio State University Center for Clinical and Translational Science grant support via a National Center for Advancing Translational Sciences Grant, UL1TR001070.

?? Meeting presentations: Accepted for poster presentation at 2016 American College of

Emergency Physicians Research Forum. Southerland, LT; Slattery, L; Rosenthal, JA; Kegelmeyer, D; and Kloos, A. “Are triage questions sufficient to assess fall risk in the ED?”

? Conflict of interests: None reported.

?? Author contributions: LTS, JAR, DK, and AK conceived the study, designed the trial, and

obtained research funding. LTS, LS, and DK supervised the conduct of the study, data col- lection, and quality control. LTS and AK analyzed the study data. LTS drafted the manu- script, and all authors contributed substantially to its revision.

* Corresponding author at: 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210. Tel.: +1 614 293 8305; fax: +1 614 293 3124.

E-mail address: [email protected] (L.T. Southerland).

department (ED) practices of falls screening and management are inadequate [1]. The ED setting is an ideal health care site to focus on fall prevention, as 2.6 million older adults present to the ED for a fall or fall related injury each year [2]. In addition, 31% will fall again within 6 months of their ED visit [3].

We wished to implement sustainable fall risk detection and fall pre- vention from the ED. The first step in this process, as recommended by the Agency for Healthcare Research and Quality, is to choose a fall risk assessment. The current fall risk assessment in most EDs is a quick ver- bal query by the triage nursing staff (Table 1). This consists of 2 ques- tions about previously validated risk factors for future falls–recent falls and use of a cane or walker–and a nursing assessment of altered mental status. However, it is unclear if this is sufficient to identify all, or even most, patients at risk for falls. Self-report or verbal query alone is likely insufficient to risk stratify patients. A meta-analysis of questionnaire tools to predict fall risk after the ED visit found that all were inadequate [3]. This may be because older adults often misrepre- sent or underestimate their own fall risk or may be due to the distrac- tions of acute illness and the ED setting. A functional, quantitative fall risk assessment is needed.

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Table 1

Wording of the triage assessment questions

Have you fallen in the past month?

Do you use a walker, cane, or other assistive device to help you walk? (Nurse assessment) Are there signs of altered mental status?

Triage nurses in the ED ask these questions to all patients as part of a stan- dard fall risk assessment, similar to most institutions in the United States.

Although there is no gold standard for fall risk stratification, the Cen- ter for Disease Control (CDC) Stop Elderly Accidents, Deaths, and Inju- ries (STEADI) Fall Prevention Guidelines recommend combining a verbal query with a functional assessment [4]. Most functional gait and balance tests were developed in non-ED settings without the time, space, and equipment limitations of the ED (see Table 2). Func- tional assessments of gait and balance are difficult to incorporate into routine care in the ED setting, as even simple equipment such as a chair without wheels or arms may be unavailable. gait assessments such as the Timed Up and Go Test (TUGT) necessitate removing patients from necessary cardiac monitors and are nursing intensive. Prior studies of administration of the TUGT in the ED have required a trained geriatric nurse liaison or Research staff. In a normal busy ED setting, the TUGT is overly burdensome.

The CDC STEADI guidelines recommend 2 alternatives to the TUGT–the Sit-to-Stand test and the 4-Stage Balance Test (4SBT) [4]. The 4SBT can be done at the bedside with monitors attached, and as an additional benefit, orthostatic vital signs can be obtained simulta- neously (Figure) [5]. The 4SBT is limited in that it evaluates static bal- ance only, not gait. However, prior research suggests that a simple static balance test has similar fall risk prediction validity as more com- plicated balance and gait tests, and in the ED setting, stance testing can identify recurrent fallers as well as the TUGT [6].

We hypothesized that following the CDC recommendations and in- corporating a validated balance assessment into the ED evaluation would detect a higher number of patients at risk for falls.


Study design and setting

Institutional review board-approved prospective cohort study of ambulatory older adult ED patients. Our ED is a 106-bed unit in a tertia- ry care hospital with over 76 000 ED visits a year, 13% of which are older adults.

Selection of participants

Nursing staff were approached to assist in identifying ED patients 65 years and older who were able to stand unassisted for greater than 1 minute and able to follow simple directions. Exclusion criteria included acute Lower extremity pain limiting weight bearing, orders for bed rest, non-English speaking, and unable to follow simple commands.

Figure. The 4SBT, reproduced from the CDC STEADI guidelines with permission [4]. The 4SBT requires a patient to stand in 4 progressively harder stances for 10 seconds each. The test is terminated early, and patient is considered at risk for falls if the patient cannot hold a stance for 10 seconds. The patient is at low fall risk if they can hold the tandem stance for 10 seconds.


Use of the 4SBT for fall risk stratification in older adults in the ED.

Methods and measurements

Of the adults 65 years and older in the ED during study recruitment hours, 43% did not meet criteria, and 30% were unavailable (out of the room for testing or discharged before contact for the study). Of those approached, 43% participated (n = 63). Basic demographic information was collected. The results of the nursing triage screen for falls risk were noted. A “yes” response to any of the questions meant that the person was a fall risk (Table 1). The patient’s ED nurse and the research staff ad- ministered the 4SBT together. Patients were also asked about their own self-perception and prior diagnosis of fall risk. Every patient received an educational handout on fall prevention. If the patient was at risk for falls based upon the results of the 4SBT (ie, unable to hold tandem stance for 10 seconds), the patient’s physician team was informed. All patients at risk were referred to our institution’s fall prevention clinic, an outpa- tient clinic run by physiatrists and physical therapists that performs multimodal evaluations for fall risk factors and arranges treatment.


Study data were collected and managed using Research Electronic Data Capture tools hosted at the authors’ institution. Research Electronic Data Capture is a secure, web-based application designed to support

Table 2

Possible standardized gait and balance tests evaluated for ED use, abstracted from a recent review [10].



time to perform


Chair without wheels and a 3-m straight path

5 min

Sit-to-Stand test

Chair without arms or wheels

30 s

10-m walking test

10-m path to walk

b1 min

Berg Balance Scale

Yardstick, 2 standard chairs (1 with arm rests, 1 without), footstool or step, stopwatch or wristwatch, 15 f. walkway

15-20 min

Step test

7.5-cm step, step up and down quickly

10 min



40 s

L.T. Southerland et al. / American Journal of Emergency Medicine 35 (2017) 329332 331

data capture for research studies [7]. Microsoft Excel 2013 (Microsoft Corp, Redmond, WA) was used to calculate means and proportions as indicated. Fisher exact test was used to compare the probabilities of identifying a person as being at fall risk using triage screening alone vs the triage screen with the addition of the 4SBT.


Characteristics of study participants

Sixty-three patients were recruited for the study. Two did not re- ceive triage fall screens and so were excluded from the final analysis. Three patients were excluded because of inability to attempt the 4SBT, 1 because of pain and 2 because of nursing availability. This resulted in 58 patients for the final analysis. Average age was 74.1 years (range, 65-94), 40.0% were women, and almost all were community dwelling (98.3%). Most of them lived with family, with only 27.6% (n = 16) living alone. Five (8.6%) were in the ED for a fall-related chief complaint. The other patients presented for a variety of com- plaints, most commonly shortness of breath or cough.

Main results

The nursing triage screen identified 39.7% (n = 23) of patients as at risk for falls, and more than half of these patients also were identified as high risk by the 4SBT (56.5%, n = 13). Of those who were screened as no fall risk, 34% (n = 12) failed their 4SBT. The 4SBT alone identified 43% (n = 25) as at high risk for falls. Combining triage questions with the 4SBT identified 60.3% (n = 35) of patients as at high risk for falls, as compared with 39.7% (n = 23) with triage questions alone, a significant increase in patients screening at risk for falls (P b .01, 1 degree of free- dom). Only 10 of the 35 patients at risk for falls had been told that they were at risk for falls in the past, leading to 25 new diagnoses of high risk (43.1% of total patients), 10 of which were made by the 4SBT alone.


The ED is an important setting for fall risk screening and prevention, but previously developed Screening tools have been inadequate. Fol- lowing the CDC STEADI guidelines by combining functional balance testing with triage screening questions identified a new population of older adults at risk for falls. Nursing administration of the 4SBT is feasi- ble in the ED setting, although our use of a convenience sample suggests that the true rate of compliance is likely lower. On the other hand, the previously ambulatory patients who refused testing because of inability to stand or were too sick to be approached likely required admission and could be assessed later in their hospitalization. Another 2 patients were not screened because nursing staff were too busy to perform the examination. Despite these difficulties, this pilot study does prove the feasibility of a 40-second fall risk Screening examination even in the context of a busy ED. Training materials for administering the 4SBT are available free from the CDC and readily available online (http:// If further research demonstrates im- proved outcomes with the addition of this screening measure, it could be easily implemented across the United States.

Combining a verbal query of recent falls and risk factors with func- tional testing is the recommended algorithm for risk assessment per the CDC guidelines. However, the guidelines were developed for an out- patient clinic setting and recommend not proceeding to functional test- ing if the verbal query is negative. We found that in the ED, the standard triage questions missed almost half of patients who were identified as high risk by the 4SBT. Deferring functional testing if the verbal query is negative may miss many high-risk patients. This could be because asking about historical risk factors is insufficient in the setting of the acute illness or injury that brought the patient to the ED or because ver- bal risk assessments in general are insufficient, which has been

suggested by others [8]. Our data suggest that all older adults in the ED should proceed to functional testing.

The discordance between the triage query and the 4SBT is not unex- pected. A verbal query identifies fall risk factors and historical falls. Similar to the TUGT, the 4SBT alone is not sufficient to identify all fallers, and the added information from the verbal query is still needed [9]. The 4SBT measures static balance and will identify patients who, whether from neurological insults, peripheral neuropathy, weakness, vision deficits, or other etiologies, have difficulty with static balance that will predispose them to falls. These patients may not have fallen yet but are at risk. Com- bining the 2 provides information about past and future fall risk.

The addition of a CDC-approved functional screening test for balance and falls risk also elevates ED falls risk screening, from a focus on preventing falls just in the hours the patient is in the department to long-term prevention. Most patients found to be at risk were unaware of their risk. The patient education provided and referral for outpatient follow-up were a new intervention for those patients. Multidisciplinary fall risk interventions have had equivocal results in the past, but prior studies suggest that by focusing these interventions on high-risk pa- tients only and by arranging for services (rather than just offering pa- tient referrals), these interventions have a much higher likelihood of preventing falls and increasing quality of life. Improving our initial de- tection sensitivity is, therefore, likely to improve the overall outcomes of any fall prevention intervention.

This is a small pilot study of a convenience sample of ambulatory older adult ED patients, and therefore, results may not be generalizable to the entire ED population or to other institutions. Patients who consented were willing to stand and undergo balance testing. General- izing this test to all ambulatory older ED patients may reveal high rates of patients who are unwilling or unable to attempt the 4SBT. In addition, this study does not link the detection of high risk for falls with ensuing fall rates, so this increased detection may not have clinical relevance.

As a result of this pilot study, all nurses in our ED are being trained to perform the 4SBT for those at risk for falls and before walking older adult patients. The assessment has been incorporated into ED care by means of an electronic medical record nursing rounding note. Addition- al research will evaluate which patients are receiving screening and whether positive falls risk assessments change patient management.


In summary, this is the first study to suggest that a standard verbal query may not be sufficient for the detection of older adults at risk for falls in the ED. The 4SBT is a feasible addition to risk stratification in the ED and identifies significantly more patients at high risk for falls. Further research is needed to evaluate the predictive capabilities of this test for post-ED visit fall prediction and Prevention strategies.


Thank you to the undergraduate students (William Hartman, Nia Caldwell, and Matthew Swigonski) who helped with recruitment, Kimberly Payne, PT who initially proposed the 4SBT as a feasible ED- based test, and all the ED nurses who identified possible trial partici- pants and assisted with the study.


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