Understanding barriers and enablers to adherence to NICE falls guidelines when treating older adults who attend an emergency department (ED)

Background: Approximately one in three older adults (aged 65 and over) fall each year. Such falls commonly present at EDs (Help the Aged, 2005; Close, Ellis, Hooper, Glucksman, Jackson and Swift, 1999). The National Institute for Health and Care Excellence (NICE) 'Falls' guidelines (2004) were developed to improve management of falls, including their assessment and ways to prevent future falls. However, there is evidence of poor adherence to the guidelines (Sheldon et al., 2004). This research explores how falls are managed in EDs and the reasons why guidelines are not always followed. Methods: I undertook a detailed review of relevant research on the management of falls in EDs. Research also took place at two sites. Two particular research methods were employed; 1) observation research of healthcare professional and patient interaction, and 2) interviews with healthcare professionals. I observed the care of 27 patients and interviewed 30 health professionals. These methods were chosen in order to investigate factors influencing adherence. Results: Adherence to the guidelines was poor at both EDs. Various barriers and enablers (determinants of practice) influenced adherence, including: communication, complexity of patient care, services offered outside the ED, ED care processes (including education and busyness), variation in staff and cross-boundary care. Conclusions: A variety of factors influence adherence to the Falls guidelines within an ED, but it may be difficult to address all of them simultaneously and in the context of busy EDs. Simple interventions such as education and pro-formas are unlikely to have substantial effect on their own, although taking advantage of the influence of senior staff could enhance their effectiveness. In addition to such interventions, collaborative care with other NHS services offers a potential approach.