A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an Emergency Department.

Background: The National Institute for Health and Care Excellence (NICE) 2004 Falls guideline was developed to

improve the assessment and management of falls and prevention of future falls. However, adherence to the

guideline can be poor. As emergency departments (EDs) are usually consulted by older adults (aged 65 and over)

who experience a fall, they provide a setting in which assessments can be conducted or referrals made to more

appropriate settings.

The objective of this study was to investigate how falls are managed in EDs, reasons why guideline

recommendations are not always followed, and what happens instead.

Methods: The study involved two EDs. We undertook 27 episodes of observation of healthcare professional

interactions with patients aged 65 or over presenting with a fall, supported by review of the clinical records

of these interactions, and subsequently, 30 interviews with healthcare professionals. The qualitative analysis

used the framework approach.

Results: Various barriers and enablers (i.e. determinants of practice) influenced adherence at both EDs, including the

following: support from senior staff; education; cross-boundary care; definition of falls; communication; organisational

factors; and staffing.

Conclusions: A variety of factors influence adherence to the Falls guideline within an ED, and it may be difficult to

address all of them simultaneously. Simple interventions such as education and pro-formas are unlikely to

have substantial effects alone. However, taking advantage of the influence of senior staff on juniors could

enhance adherence. In addition, collaborative care with other NHS services offers a potential approach for

emergency practitioners to play a part in managing and preventing falls.