Northeast Kansas Regional Trauma Council Executive ...Tracy McDonald – it would be nice to get Todd Maxon to come up and speak. Darlene – Maybe a Consortium Ransom – interested

Final Agenda 2/8/19 2019 Kansas Trauma Program | 1

Agenda Minutes Follow up In Attendance Conference Call:

866-620-7326 Conference Code: 958 411 6860

Call to Order Approve December 11, 2018 Minutes Don Fishman, MD

System Finance Treasurer’s Report See attached Spreadsheet. NE Mini-Grant is Open until April 1st. See attached application.

Tracy McDonald

Trauma Program Update

The Trauma Calendar is updated.

Lifeline – the new webinar for the Trauma Program Managers is available through KS-Train under course number 1082908. Topic: “To Designate or not to Designate? That is the Question.” 2018 Fourth Quarter Data is due to submission from the state by March 1st. Your Regional Quarter Submission Report is included. Stop the Bleed Statewide Initiative: Purchase is underway. Distribution Policy Designate a facility and a person of contact. Regional Designation Report: Lawrence Memorial Hospital – Passed their site survey and their final report is working through the ACT Designation Review Committee. Upcoming Site Surveys for NE Region in 2019: Providence Medical Center Ransom Memorial Hospital Nemaha Valley Community Hospital Community Memorial Healthcare - Marysville Miami County Medical Center Anderson County Hospital April Symposium – The ACT would like each region to claim a priority on the Bis Assessment to tackle for SFY 2020. The Bis Assessment will be discussed at the ACT meeting rescheduled for Feb 20th.

Ren Morton

Northeast Kansas Regional Trauma Council

Executive Committee Meeting Agenda

Conference Call

February 11, 2019, 1:00 p.m.

http://www.kstrauma.org/trauma_education_calendar.htmhttps://www.train.org/ks/welcome


Agenda Minutes Follow up Awareness dates:

March is Brain Injury Awareness Month March 1st is Self-Injury Awareness Day

Education 2019 Education Funding Requests: Ransom Memorial – TNCC - $1,155.00 ATLS-Holton-Reinecke - $575 ATLS-Holton-Warner - $975 Approval of TNCC Funding Request in the amount of [ ] Approval of ATLS funding Requests in the amount of [ ] 1st Motion: 2nd Motion: Motion Passes: Your finalized April Symposium is attached.

Executive Committee

Injury Prevention KDHE Prevention Program Update – Daina Zolck

Severe Weather Awareness Week is March 3-9 in

Kansas. Encourage families to be weather-ready for

emergencies.

Also, consider signing up to be a Weather-Ready Ambassador.

Poison Prevention Week is March 17-23.

If you would like free materials to distribute (ie. Poison Hotline

magnets, postcards, flyers, etc.), contact the Poison Control

Center at 800-222-1222 and select 4, or email Stefanie Baines

at [email protected].

Tracy McDonald Darlene Whitlock Daina Zolck

Special Populations

Pediatrics: Geriatrics: The Older Driver Meeting with KDOT was held on January 22nd. Presentations included the YMCA and KDOT Public Transportation. YMCA is partnering with KDHE’s Arthritis Program to offer Enhance Fitness – an evidence-based exercise program helping older residents maintain mobility and combat the social isolation exacerbating their health conditions. If you are interested in having a local provider trained to provide the Enhance Fitness program, please contact Jennifer Bruning, executive director of the Kansas State Alliance of YMCAS, at [email protected]. KDOT Public Transportation is encouraging rural communities to support public transportation systems to assist these residents in attending their medical appointments and reduce isolation. See

Tracy Cleary Ren Morton

https://www.biausa.org/public-affairs/public-awareness/brain-injury-awarenesshttp://www.selfinjuryfoundation.org/self-injury-awareness-day.htmlhttp://www.kdheks.gov/cphp/families.htmhttp://www.kdheks.gov/cphp/families.htmhttps://www.weather.gov/wrn/ambassadorsmailto:[email protected]://ksymca.org/http://www.kdheks.gov/arthritis/http://www.ymca.net/enhancefitness/mailto:[email protected]://www.ksdot.org/burtransplan/pubtrans/index.asp


Agenda Minutes Follow up their video Kansas Rural Transit: Connecting Everyone to Everywhere. KDOT offered the resource: www.roadwiserx.com to check if a patient’s medications are interacting in a way that may inhibit their driving capabilities. The Kansas Trauma Program is researching the CDC STEADI program for its effectiveness in fall prevention. Please see the attached documents for an Info Sheet on the Enhance Fitness Program, a Risk Factor Checklist for the STEADI Program, and an Outcome Evaluation of STEADI in primary care.

Prehospital Dan Hudson Darren Hall

Healthcare Coalitions

Steve Hoeger Danielle Marten

Old Business

Don Fishman, MD

New Business Don Fishman, MD

Announcements / Each Facility / Agency

All Regional Partners

Adjournment .

Don Fishman, MD

NEXT UP

Meeting Date Time Location Form 2019 ACT Meeting Feb 20 10:00 am – 3:00pm Kansas Medical

Society, Topeka In-person

2019 Executive Committee Meeting Apr 8 Symposium

All-Day Stormont Vail In-person

2019 ACT Meeting May 1 10:00am – 3:00pm Kansas Medical Society, Topeka

In-person

2019 Executive Committee Meeting Jun 10 1:00pm Conference Call

2019 Executive Committee Meeting Aug 12 1:00pm Children’s Mercy In-person

2019 ACT Meeting Aug 21 10:00am – 3:00pm Kansas Medical Society, Topeka

In-Person

Kansas Statewide Symposium Oct 9 All-Day Ascension – Via Christi Hospitals Wichita

In-Person

2019 Executive Committee Meeting Oct 14 1:00pm Conference Call

2019 ACT Meeting Nov 6 10:00am – 3:00pm Kansas Medical Society, Topeka

In-Person

2019 Executive Committee Meeting Dec 9 1:00pm TBD In - person

https://www.youtube.com/watch?v=K4whYW0QIxo&feature=em-share_video_userhttps://www.youtube.com/watch?v=K4whYW0QIxo&feature=em-share_video_userhttp://www.roadwiserx.com/https://www.cdc.gov/steadi/index.htmlhttps://www.cdc.gov/steadi/index.html

Final Minutes to be approved 2/11/19 2018 Kansas Trauma Program | 1

Agenda Minutes Follow up In Attendance Tracy McDonald, Darlene Whitlock, Teresa Taylor, Dr. Sachs,

Dr. Berry, Darren Hall, Courtney S., Tammy Newberry, Kenna Young, Ashley Barkley, Tracy Cleary, Mary Lynn From Marysville, Dr. Colberg, Brint Baker, Krista Eyler, Dan Hudson, Dorothy Rice

Conference Call: 866-620-7326 Conference Code: 958 411 6860

Call to Order Meeting called to order at: 1:10pm Approve October 8, 2018 Minutes Minutes approved with attendance adjustments: 1st Motion: Darren Hall 2nd Motion: Dr. Colberg Motion Passes: Minutes approved with changes

Don Fishman, MD

System Finance Treasurer’s Report Carry over Balance: $11,164.20 2019 Funds: $18,000 Available Funds: $29,164.20 October Expenses included statewide symposium expenses totaling $736.49. Just under budget. Acute Hospital education funding totaling $1,923.50 Ending balance: $26,504.21 Discussion of system development line-item. Excess of $2,800 to re-allocate to other funding areas. Re-allocation of undesignated funds ideas: Fall prevention trainer training or grants PI collaborative with TQIP Stop the Bleed Kits Updating Trauma Systems Video Increase Acute Hospital Education Funding See attached Spreadsheet. Motion to: Allocate $1,400 undesignated funds to Injury Prevention and Acute Hospital each. 1st Motion: Dan Hudson 2nd Motion: Tracy McDonald Motion Passes: $1,400 allocated to Injury Prevention and Acute Hospital.

Tracy McDonald

Trauma Program Update

KDHE is beginning their strategic planning process. User Group Meeting – Dec 12

Ren Morton, RTC

Northeast Kansas Regional Trauma Council

Executive Committee Meeting Agenda

Holton Community Hospital

December 10, 2018, 1:00 p.m.


Agenda Minutes Follow up Webinar – contact Melinda Marlar ([email protected]) to register. Stop the Bleed Statewide Initiative: Presentation of Stop the Bleed Application Vote on Distribution Company for Stop the Bleed Kits, see attached brochures for North American Rescue Company and Bound Tree Medical. Approval of purchasing stop the Bleed Kits from BoundTree 1st Motion: Darren Hall 2nd Motion: Tracy MacDonald Motion Passes: Stop the Bleed Kits purchased from Bound Tree Approval of Bleeding Control Funding Application 1st Motion: Tracy McDonald 2nd Motion: Dan Hudson Motion Passes: Motion Passes implement Application with changes discussed.

Education 2018-2019 Education Funding Requests: Coffey County Hospital – RTTD - $1,697.79 *Reimbursement policy for RTTD caps at $1,500.00 Approval of RTTD Funding Request in the amount of 1,697.79 and the two ATLS Education Request (ATLS-Goff and ATLS-Colberg) 1st Motion: Tracy McDonald 2nd Motion: Darren Hall Motion Passes: Education requests approved

Ren Morton, RTC

Injury Prevention KDHE Prevention Program Update – Ashley Barkley

DDPI mini-grants to communities and opioid overdose crisis

response grants to local health departments have been

awarded.

The Kansas Violent Death Reporting System has received its

second year of data. 2015 and 2016 data will be combined in

one report which is hoped to be available spring 2019.

There is hope for a Stepping on Leader training in spring…more

information to follow.

Injury Prevention Mini-grants will be reviewed this week.

Safe Kids Day will be at the Topeka Zoo on Saturday, May 4th. If

anyone is interested in having a booth, please contact

me. (Registration form attached.)

Tracy McDonald Darlene Whitlock Ashley Barkley

mailto:[email protected]://www.kdheks.gov/idp/KsVDRS.htm


Agenda Minutes Follow up Safe Kids Kansas just adopted their 2019 Public Policy Platform

and Priorities. We will send a Policy Brief to Legislators in

January at the beginning of the session.

Safe Kids Kansas has adopted a strategic plan for 2019-2022.

If anyone is interested in serving on an injury-focus committee

around the areas of Safe Sleep, Child Passenger Safety, Poison

Prevention or Fire/Burn Prevention, please email Cherie Sage

at [email protected]. CPS meets monthly while the other

groups meet bi-monthly.

Upcoming events:

National Burn Awareness Week is February 3-9

National TV Safety Day is February 2, 2019 - more information

on TV and furniture tip-over prevention is available at

www.safekids.org

Severe Weather Awareness Week is March 3-9

National Poison Prevention Week is March 17-23 – materials

are available through Stefanie Baines at the Poison Control

Center at KU – email [email protected], or call 800-222-1222

and select education outreach. Or visit

https://www.kansashealthsystem.com/medical-

services/poison-control/materials-for-educators

Darlene: Would the NEKRTC be willing to draft a letter to KDOT about the HWY-75 Death Toll. Krista Eyler volunteers to research the statistics and draft a letter. Dr. Colberg supports this action.

Pediatrics ACT approved a workgroup for pediatric language to be worked into possible regulation changes. Regulations takes 2-3 years to change, and we are beginning on working on the language. Carry over funds discussion. Short one-day pediatric symposium to use funds for a pediatric-specific speaker. $3,300 can be used toward speakers and symposiums and will need to be spent by March 31, 2019. Tracy McDonald – it would be nice to get Todd Maxon to come up and speak. Darlene – Maybe a Consortium Ransom – interested in hosting a symposium if it could be worked out to have speakers come out.

Tracy Cleary

http://www.safekidskansas.org/http://www.safekidskansas.org/mailto:[email protected]://www.safekids.org/mailto:[email protected]://www.kansashealthsystem.com/medical-services/poison-control/materials-for-educatorshttps://www.kansashealthsystem.com/medical-services/poison-control/materials-for-educators


Agenda Minutes Follow up Teresa Taylor – we have a 4-hour symposium on February 15th on trauma topics that we could fit pediatric speakers into. Please contact Wendy between December 13th – 27th for EMSC needs.

Prehospital No Updates EMS survey to EMS Directors about Pediatric education care and PECC. It closes this Thursday at 5:00. 9 questions and takes less than 5 minutes.

Dan Hudson Darren Hall

Healthcare Coalitions

No Updates Steve Hoeger Danielle Marten

Old Business None.

Don Fishman, MD

New Business Regional Symposium Discussion:

Ren Morton, RTC

Announcements / Each Facility / Agency

Darlene- Draft a letter to the ACT and interested parties about getting creative with the funding and/or restoring funding. Also the ability to have unique identifiers for patient to track linear in the registry.More information will be forth coming.

All Regional Partners

Adjournment Meeting Adjourned at 2:24pm.

Don Fishman, MD

NEXT UP Meeting Date Time Location Form 2019 Executive Committee Meeting Feb 11 1:00pm TBD Conference

Call

2019 Executive Committee Meeting Apr 8* Symposium

All-Day Topeka – Stormont Vail

In-person

2019 Executive Committee Meeting Jun 10 1:00pm TBD Conference Call

2019 Executive Committee Meeting Aug 12 1:00pm TBD In-person

2019 Executive Committee Meeting Oct 14 1:00pm TBD Conference Call

2019 Executive Committee Meeting Dec 9 1:00pm TBD In - person

2018 Carryover Balance $12,159.20

2019 RTC funds $18,000.00

2019 Beginning Balance $30,159.20

Date Expense/Description Check Payable To Budget Actuals Remaining Invoiced

10/24/2018 Hotel Statewide Symposium Dr. Fishman $96.79 $903.21 X

10/24/2018 Hotel Statewide Symposium Lois Towster $96.79 $806.42 X

10/24/2018 Hotel Statewide Symposium David Seastrom $162.91 $643.51 X

10/24/2018

Registration Fees Statewide

Symposium (Fishman, Hall, Seastrom,

Towster @ 95.00ea) KDHE Training Fee Fund $380.00 $263.51 X

$1,000.00 $736.49 $263.51

$2,500.00

$2,500.00 $0.00 $2,500.00

$0.00

$0.00 $0.00 $0.00

$1,358.00

$1,358.00 $0.00 $1,358.00

SFY 2019 NEKRTC Expenditure Spreadsheet July 1, 2018-June 30, 2019

I. Administrative Components

System Leadership

System Development

Public Information and Education

System Finance

$7,900.60

$7,900.60 $0.00 $7,900.60

$3,000.00

$3,000.00 $0.00 $3,000.00

10/8/2018 RTTDC Holton Community Hospital $773.50 $13,627.10 X

10/8/2018 ATLS_Raisdana Randsom Memorial Hospital $575.00 $13,052.10 X

10/8/2018 ATLS_Boyack Randsom Memorial Hospital $575.00 $12,477.10 X

12/5/2018 ATLS_Goff Holton Community Hospital $850.00 $11,627.10 X

12/5/2018 ATLS_Colberg Holton Community Hospital $575.00 $11,052.10 X

12/10/2018 RTTDC Coffey County Hospital $1,697.79 $9,354.31

$14,400.60 $5,046.29 $9,354.31

II.Clinical ComponentsInjury Prevention & Control

Prehospital

Acute Hospital

$0.00

$0.00 $0.00 $0.00

Emergency Preparedness

$0.00

$0.00 $0.00 $0.00

$0.00

$0.00 $0.00 $0.00

$0.00

$0.00 $0.00 $0.00

$0.00

$0.00 $0.00 $0.00

TOTALS $30,159.20 $5,782.78 $24,376.42

Starting Balance $30,159.20 Ending Balance $24,376.42

Note-red text is awarded-encumbered funds

System Evaluation

Undesignated Funds (Other)

Special Populations

Rehab Availability

Kansas Department of Health and Environment (KDHE)

Fiscal Year 2019 Mini-Grant Application

Application due date: Monday, April 1, 2019, 5 pm

Trauma Region:

Organization Name:

Project/Program Coordinator:

Mailing Address:

City: Zip:

Telephone: Fax:

E-mail:

Award amount will not exceed $4,000, Regions reserve the right to partially fund request(s).

Grant Amount Requested:

Targeted Injury Prevention Area (check all that apply):

Child Passenger Safety Home Safety

Fire/Burn Prevention Falls Prevention

Wheeled Sports Safety Drowning Prevention Pedestrian Safety Other__________________________ Poison Prevention __________________________

Please list community partners collaborating on this project:

Describe the target population of the proposed project:




Describe the proposed project (who, when, what, where, and how):

Describe how the project will be evaluated (i.e. number of participants impacted by project, amount of

educational information distributed, number of individuals trained, etc):

Identify desired outcomes:




Project Materials Item Type Item Quantity Unit Cost of

Item

Total Cost of

Item(s)

Safety Device

Safety Device

Educational Materials

Promotional Materials

Meeting/Training

Expense

Instructor/Technician

Expense

Other Expenses

Total Grant Request:____________

Budget justification (please provide expense details):

Timeline for Project:

North East 2018 Q3

170035 /*Anderson County Hospital*/, 100%

170022 /*Atchison Hospital*/, 0%

170094 /*Coffey County Hospital*/,

170045 /*Community HealthCare Systems,Inc.*/, 100%

179045 /*Community HealthCare Systems,Inc. , St Mary*/, 100%

170113 /*Community Memorial Healthcare*/, 100%

170133 /*Saint Luke's Cushing Hospital */,

170131 /*F.W. Huston Medical Center*/,

170074 /*Geary Community Hospital*/, 100%

170099 /*Hanover Hospital*/,

170004 /*Hiawatha Community Hospital*/, 100%

170160 /*Holton Community Hospital*/, 100%

170067 /*Horton Community Hospital*/,

179002 /*Irwin Army Community Hosp*/,

170137 /*Lawrence Memorial Hospital*/, 100%

170182 /*Menorah Medical Center*/, 100%

170142 /*Mercy Regional Health Center*/,

170109 /*Miami County Medical Center*/, 100%

170070 /*Morris County Hospital*/, 0%

170057 /*Nemaha Valley Community Center*/, 100%

170001 /*Newman Regional Health*/, 100%

170049 /*Olathe Medical Center*/, 100%

170176 /*Overland Park RMC*/, 100%

170146 /*Providence Medical Center*/, 100%

170014 /*Ransom Memorial Hospital*/, 100%

170164 /*Sabetha Community Hospital*/, 100%

170016 /*Saint Francis Hosp & Medical Center*/, 100%

170009 /*Saint John Hospital*/, 100%

170025 /*Saint Luke's South Hospital*/, 100%

170104 /*Shawnee Mission Medical Center*/, 99%

170086 /*Stormont-Vail HealthCare Inc*/, 98%

170040 /*University of Kansas Hospital*/, 100%

170128 /*Wamego City Hospital*/, 100%

170076 /*Washington County Hospital*/, 0%

178001 /*Dwight D. Eisenhower VA Med Center*/

Percentage of submitted quarter cases that were received by the deadline

Start Time End Time Timeframe Type Category Topic - Working Title Speaker Accountable Party Done?

8:30 AM 9:00 AM 30 min Registration Opens

8:50 AM 9:00 AM 10 min Opening Remarks Don Fishman, Chairperson

9:00 AM 9:30 AM 30 min Lecture Update Kansas Trauma Program Update Danielle Sass

9:30 AM 10:00 AM 30 min Lecture Other TQIP Imaging Best Practices Tracy McDonald Tracy McDonald Confirmed

10:00 AM 10:15 AM 15 min BREAK

10:15 AM 11:00 AM 45 min Lecture Geriatric

Geriatric Fractures pre/post surgery

for best outcomes. Focus: AAOS

Clinical Practice and Blocks Dr. Dalenberg, Ransom Dorothy Rice Confirmed

11:00 AM 11:45 AM 45 min Case Study Peds From EMS to Tertiary Care Dave Seastrom Dave Seastrom Confirmed

11:45 AM 12:30 PM 45 min Lecture Peds Transfers and Documentation Angie Cunningham

Tracy McDonald

Dan Hudson Confirmed

12:30 PM 1:00 PM 30 min Networking LUNCH

1:00 PM 2:00 PM 60 min Lecture Other

Human Trafficking and Intimate

Partner Violence Mortality Rate

Sarah Evans-Simpson

Clinical Nurse, KUMC Tracy McDonald Confirmed

2:00 PM 3:00 PM 60 min Skill Station Other Advanced Airways: Cricothyrotomy Dr. Berry Dan Hudson Confirmed

3:00 PM 3:15 PM 15 min BREAK

3:15 PM 3:30 PM 15 min RTC Business General Membership Elections

3:30 PM 3:45 PM 15 min Closing Remarks Don Fishman, Chairperson

3:45 PM 4:30 PM 45 min RTC Business Executive Committee Meeting

Help Your Patients Take Charge

EnhanceFitness (EF)Originally known as Lifetime Fitness, EF is an award-winning, community-based exercise program that combines cardiovascular, stretching, and balance exercises and strength training. It was developed by researchers at the University of Washington. EF participants enjoy the dynamic and interactive sessions, and health benefits have been documented across diverse communities. Encourage your patients to sign up for the program at a location nearby.

Who is it for? EF was developed to encourage older adults to exercise regularly and prevent functional decline. The program is now used by adults of all ages who want to improve or maintain physical function. EF is appropriate for a range of fitness levels, and can be tailored to people with arthritis and other

conditions that limit their mobility.

How is it conducted? EF is conducted in hour-long sessions three times a week on an ongoing basis. Instructors lead small groups of 10–25 people through a series of stretches, low-impact aerobics, and

strength training activities (using soft ankle and wrist weights). Sessions usually consist of warm-up and cool-down periods, a cardiovascular workout, strength training,

and stretching. Balance exercises are included throughout. All activities can be adapted to participants’ fitness levels and tailored to specific health conditions. Fitness checks are provided at the beginning of the program and every 4 months thereafter.

What are the qualifications of the instructors? EF instructors are required to hold a nationally recognized fitness instructor certification and have

a current CPR certification. They also receive 12 hours of specialized training by an EF master trainer. Experience working with older adults is recommended.

What are the benefits? EF has been rigorously studied and evaluated across ethnically and socioeconomically diverse

communities. Proven benefits include improvements in overall fitness, social function, physical function, and depressive symptoms.1, 3-4

No safety concerns have been reported in the literature.1-4

Participants report high levels of satisfaction and continued participation. Cost-benefit analyses show that older adults who participate in EF cost their insurers less, due primarily

to fewer inpatient hospital stays.2 EF has won several awards including the 2005 Annual Innovation in Prevention Award from the

U. S. Department of Health and Human Services.

Evidence-Based Community Programs

Fees and LocationEnhanceFitness is a low-cost program. Fees per session may vary by location. Check www.apta.org/Arthritis to find current locations.

For More InformationProject Enhance www.projectenhance.org

Centers for Disease Control and Prevention www.cdc.gov/arthritis/interventions.htm

EnhanceFitness (EF)

Summary of the Evidence

Author, Year Design Participants Outcomes

Wallace JI, Buchner DM, Grothaus L, et al. (1998)

6-month RCT* 100 older adults Improved physical functioning depression85% program completion rate at 6 months

Ackermann RT, Cheadle A, Sandhu N, et al. (2003)

Retrospective matched cohort study Compared estimated healthcare costs and utilization rates of Lifetime Fitness program participants vs. controls

1,114 program participants aged 65 or older 3 randomly selected matched controls per participant

Adjusted total healthcare costs for participants were 94.1% of control costsFor participants attending > 1 class per week, total adjusted follow-up costs were 79.3% of controls

Belza B, Shumway-Cook A, Phelan EA, et al. (2006)

Outcomes testing of program participants at 4 and 8 months

2,889 older adults enrolled in program

Outcomes sustained at 8 months: strength, functional mobility self-rated health

Ackermann RT, Williams B, Nguyen HQ, et al. (2008)

Retrospective cohort study Compared estimated healthcare costs and utilization rates of EF participants vs. controlsOutcomes assessed at 1 and 2 years

1,188 older adult participants Matched group of controls

No difference in healthcare costs in Year 1Year 2 outcomes: adjusted total healthcare costs for participants inpatient costs for participants

Selected References 1 Wallace JI, Buchner DM, Grothaus L, et al. Implementation and effectiveness of a community-based health promotion program for older adults. Journal of Gerontology: Medical Sciences. 1998;53(4):M301–M306.

2 Ackermann RT, Cheadle A, Sandhu N, et al. Community exercise program use and changes in healthcare costs for older adults. American Journal of Preventive Medicine. 2003;25(3):232–237.

3 Belza B, Shumway-Cook A, Phelan EA, et al. The effects of a community-based exercise program on function and health in older adults: the EnhanceFitness program. Journal of Applied Gerontology. 2006;25(4):291–306.

4 Ackermann RT, Williams B, Nguyen HQ,, et al. Healthcare cost differences with participation in a community-based group physical activity benefit for Medicare managed care health plan members. Journal of the American Geriatrics Society. 2008;56(8):1459–1465.

Learn more about evidence-based physical activity programs at www.apta.org/Arthritis.

*RCT = randomized controlled trial

http://www.ncbi.nlm.nih.gov/pubmed/18314570http://www.ncbi.nlm.nih.gov/pubmed/18314570http://www.ncbi.nlm.nih.gov/pubmed/14507530http://www.ncbi.nlm.nih.gov/pubmed/14507530http://jag.sagepub.com/content/25/4/291.abstracthttp://jag.sagepub.com/content/25/4/291.abstracthttp://www.ncbi.nlm.nih.gov/pubmed/18637982http://www.ncbi.nlm.nih.gov/pubmed/18637982

CHECKLIST Patient

Fall Risk Factors Date

Time AM PM

Fall Risk Factor Identified Present? Notes

2017

Stopping Elderly Accidents, Deaths & Injuries2017

Centers for Disease Control and Prevention National Center for Injury Prevention and Control

FALLS HISTORY

Any falls in past year? Yes No

Worries about falling or feels unsteady when standing or walking? Yes No

MEDICAL CONDITIONS

Problems with heart rate and/or arrhythmia Yes No

Cognitive impairment Yes No

Incontinence Yes No

Depression Yes No

Foot problems Yes No

Other medical problems Yes No

MEDICATIONS (PRESCRIPTIONS, OTCs, SUPPLEMENTS)

Psychoactive medications Yes No

Opioids Yes No

Medications that can cause sedation or confusion Yes No

Medications that can cause hypotension Yes No

GAIT, STRENGTH & BALANCE

Timed Up and Go (TUG) Test ≥12 seconds Yes No

30-Second Chair Stand Test:Below average score based on age and gender Yes No

4-Stage Balance Test:Full tandem stance

Implementation of the Stopping Elderly Accidents,

Deaths, and Injuries Initiative in Primary Care: An

Outcome Evaluation

Yvonne A Johnston, DrPH, MPH, MS, Gwen Bergen, MS, MPH, PhD, Michael

Bauer, MS, Erin M Parker, PhD, Leah Wentworth, PhD, MPH, Mary McFadden,

BS, CPH, Chelsea Reome, MPA, Matthew Garnett, MPH

Dow

nloaded from https://academ

ic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny101/5103473 by guest on 23 January 2019

https://physicians.dukehealth.org/articles/diagnose-%E2%80%93-geriatrics-issue-91-what-finding-shown-here-common-among-elderly-patients?

Published by Oxford University Press on behalf of The Gerontological Society of America 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

1

Intervention Research

Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome EvaluationYvonne A. Johnston, DrPH, MPH, MS,1,* Gwen Bergen, MS, MPH, PhD,2 Michael Bauer, MS,3 Erin M. Parker, PhD,4 Leah Wentworth, PhD, MPH,5 Mary McFadden, BS, CPH,6 Chelsea Reome, MPA,6 and Matthew Garnett, MPH3

1Master of Public Health Program, Binghamton University, New York. 2National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia. 3Bureau of Occupational Health and Injury Prevention, New York State Department of Health, Albany, New York. 4US Public Health Service, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, Georgia. 5System Administration, State University of New York (SUNY), Albany, New York. 6Broome County Health Department, Binghamton, New York.

*Address correspondence to: Yvonne Johnston, DrPH, MPH, MS, Master of Public Health Program, Binghamton University, PO Box 6000, Binghamton, NY 13902-6000. E-mail: [email protected]

Received: May 8, 2018; Editorial Decision Date: July 29, 2018

Decision Editor: Suzanne Meeks, PhD

AbstractBackground and Objectives: Older adult falls pose a growing burden on the U.S. health care system. The Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative was developed as a multifactorial approach to fall prevention that includes screening for fall risk, assessing for modifiable risk factors, and prescribing evidence-based interventions to reduce fall risk. The purpose of this study was to determine the impact of a STEADI initiative on medically treated falls within a large health care system in Upstate New York. Research Design and Methods: This cohort study classified older adults who were screened for fall risk into 3 groups: (a) At-risk and no Fall Plan of Care (FPOC), (b) At-risk with a FPOC, and (c) Not-at-risk. Poisson regression examined the group’s effect on medically treated falls when controlling for other variables. The sample consisted of 12,346 adults age 65 or older who had a primary care visit at one of 14 outpatient clinics between September 11, 2012, and October 30, 2015. A medically treated fall was defined as a fall-related treat-and-release emergency department visit or hospitalization. Results: Older adults at risk for fall with a FPOC were 0.6 times less likely to have a fall-related hospitalization than those without a FPOC (p = .041), and their postintervention odds were similar to those who were not at risk. Discussion and Implications: This study demonstrated that implementation of STEADI fall risk screening and prevention strategies among older adults in the primary care setting can reduce fall-related hospitalizations and may lower associated health care expenditures.

Keywords: Falls, Intervention, Screening

Falls among community-dwelling older adults pose a sig-nificant and growing public health concern globally (Peel, 2011; Williams et al., 2015) as well as in the United States

(Verma et al., 2016). Older adults reported 29 million falls in 2014 with 7 million of these resulting in injury (Bergen, Stevens, & Burns, 2016). In 2016, older adult falls

The Gerontologistcite as: Gerontologist, 2018, Vol. XX, No. XX, 1–10

doi:10.1093/geront/gny101Advance Access publication September 20, 2018

Copyedited by: KO

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mailto:[email protected]?subject=

resulted in over 29,000 deaths, and 3.2 million emergency department (ED) visits, of which 963,000 were hospital-ized (Centers for Disease Control and Prevention [CDC], National Center for Injury Prevention and Control, 2017). Between 2007 and 2016, there was a 31% increase in the age-adjusted death rate due to falls among older adults (Burns & Kakara, 2018). These falls impose an economic burden on the U.S. health care system, resulting in approxi-mately $50 billion in medical costs for 2015 (Florence et al., 2018). With the older adult population in the United States projected to increase 55% by 2030, an estimated 49 million falls and 12 million fall injuries are expected to occur in that year alone unless the rate of older adult falls is reduced (Bergen et al., 2016; Burns, Stevens, & Lee, 2016).

In an analysis of the 2005 U.S. Medicare Current Beneficiary Survey, less than half of older adults who fell talked to their health care provider about it (Stevens et al., 2012). The American Geriatric Society and British Geriatrics Society’s (AGS/BGS) Clinical Practice Guideline recommends a multifactorial approach to fall prevention including having the health care provider ask older adult patients about falls; assess for modifiable risk factors such as gait, balance, and medications; and prescribe interven-tions such as strength and balance exercises or medication adjustments (Kenny et al., 2011). Despite the availability of these clinical guidelines, primary care providers (PCPs) often fail to use them; thus, the development of educational materials and referral resources has been recommended to improve provider fall prevention practices (Jones, Ghosh, Horn, Smith, & Vogt, 2011). The CDC National Center for Injury Prevention and Control developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initia-tive (www.cdc.gov/STEADI) based on AGS/BGS guidelines, health behavior theory, and input from health care provid-ers; and offers health care providers a conceptual frame-work for older adult falls prevention (Stevens & Phelan, 2013).

The STEADI Initiative

The STEADI initiative includes a suite of materials (e.g., clinical algorithm, fact sheets, training videos) to help health care providers discuss fall risks with older adults and incorporate effective fall prevention into their practices. STEADI includes these core elements:

1. Screening to identify older adults with an increased falls risk.

2. Assessing to identify modifiable risk factors (e.g., medi-cation review, functional ability test, measuring visual acuity, orthostatic blood pressure, podiatry review, and home hazard evaluation).

3. Intervening to reduce fall risk using evidence-based strategies (e.g., strength and balance program, medica-tion management, occupational therapy, and corrective eyewear).

In 2011, the CDC funded the New York State Department of Health (NYSDOH) to implement the STEADI initiative in New York State (Stevens, Smith, Parker, Jiang, & Floyd, 2017). NYSDOH partnered with the Broome County Health Department and United Health Services (UHS)—the largest health care provider in the county—to implement the STEADI initiative into UHS’s outpatient practices by:

1. Integrating the core elements of STEADI into the UHS workflow.

2. Modifying the outpatient electronic health record (EHR) to prompt health care providers to apply STEADI and record associated data.

3. Training health care providers in the use of STEADI.

STEADI was implemented in the first UHS primary care practice in September 2012 with rollout to 18 other pri-mary care practices in 2013 and 2014 (Stevens et al., 2017).

Multifactorial fall prevention interventions, which first identify an individual’s fall risk factors and subsequently intervene to address those factors, have been associated with a 24% reduction in falls (Gillespie et al., 2012). The CDC’s STEADI initiative was developed as a multifactorial intervention, though to date its effects have not been sys-tematically examined.

The UHS implementation offered a unique opportu-nity for outcome evaluation of the STEADI initiative. UHS had organizational capacity to retrieve data related to fall screening, assessment, and intervention from the outpatient EHR as well as medically treated falls from ED and hos-pital EHRs both pre- and postimplementation. The pur-pose of this study was to evaluate the impact of the UHS Broome County implementation of STEADI on medically treated falls with the hypothesis that the implementation of STEADI would result in fewer medically treated falls.

Design and Methods

The RE-AIM FrameworkThe RE-AIM Framework is a comprehensive model for planning and evaluation of health interventions that can inform both research and practice (Glasgow, Klesges, Dzewaltowski, Bull, & Estabrooks, 2004; Kessler et al., 2013; Klesges, Estabrooks, Dzewaltowski, Bull, & Glasgow, 2005). This framework conceptualizes the impact of these health interventions as a function of five key dimensions: Reach, Effectiveness, Adoption, Implementation, and Maintenance (Glasgow, Vogt, & Boles, 1999). The RE-AIM Framework was used for both process and outcome evalu-ation of the UHS STEADI initiative. This article reports on the outcome evaluation with a focus on effectiveness.

Effectiveness of the UHS STEADI InitiativeFor this study, effectiveness was evaluated based on patient utilization of hospital services (Schwenk et al., 2012), for fall-related events both before and after implementation of the STEADI intervention. The two measures of patient

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http://www.cdc.gov/STEADI

utilization, available from the inpatient EHR, were fall-related treated-and-released ED visits and fall-related hospitalizations (hereafter referred to as medically treated falls). To provide context for our findings, an analysis of population trends for the county was conducted.

The UHS STEADI Initiative

The EHR was modified to prompt nurses to annually screen patients aged 65 and older (“older adult patients”) by asking whether the patient had: (1) two or more falls in the past 12 months, (2) one fall in the past 12 months with an injury, (3) one fall in the past 12 months and gait and balance prob-lems, (4) any gait or balance problems, and/or (5) presented with an acute fall (Stevens et al., 2017). Answers to these five questions were recorded in the outpatient EHR and a patient with an affirmative response to any question was considered to have an increased falls risk. For these patients, the nurse was to: (a) conduct a medication review, (b) provide educa-tional materials, (c) administer the Timed Up and Go (TUG) test to identify gait and balance issues, (d) record TUG results in the EHR, and (e) place the Fall Prevention Referral Form (a triplicate form available in online Supplemental Materials), on the computer keyboard for the PCP to complete during the patient examination. The Fall Prevention Referral Form listed evidence-based fall prevention interventions available in Broome County that the PCP might prescribe including outpatient physical therapy and fall prevention programs available in the community (e.g., Tai Chi).

On the basis of the patient’s screening results, the PCP would then perform a medical assessment and develop a Fall Plan of Care (FPOC) to address any identified issues. The PCP checked the recommended interventions on the Fall Prevention Referral Form and checked the box labeled “Fall prevention referral completed” in the EHR along with documenting the plan of care in the EHR. After the visit, the wellness coordinator or an office staff member scanned the Fall Prevention Referral Form and added it to the patient’s EHR.

In practice, health care providers did not follow every step for all patients. For many patients, the TUG test was not administered, in part due to challenges with fitting the TUG into the clinic workflow and/or provider resistance (Stevens et al., 2017). Not all at-risk patients received a FPOC. In this article, we take advantage of this variation in implementa-tion to compare at-risk patients who received a FPOC—that is, fall prevention interventions—with those who did not.

UHS STEADI Outcome Evaluation

The outcome evaluation has two analyses. First, we con-duct bivariate and regression analyses on the UHS EHR data to examine the relationship between receiving a FPOC and subsequent health outcomes (i.e., ED visits or hospi-talizations). Second, we examine the overall trends in fall-related ED visits and hospitalizations for older adults in

Broome County between 2007 and 2015, including time periods both before and after implementation of STEADI.

UHS Medically Treated Falls Outcome AnalysisThe sample consisted of 12,346 adults aged 65 or older in 2015 who had a primary care visit at one of 14 Broome County outpatient UHS clinics between September 11, 2012 (first implementation of STEADI) and October 30, 2015 (end of the study). The criterion of age 65 or older in 2015 was used to capture the universe of older adults who would be eligible for screening during the study period. Primary care visit data for the sample were obtained from the UHS outpatient EHR, which included demographic information and STEADI fall risk assessment variables. For those patients identified as being at risk for falls, medical charts were reviewed for any documentation related to pre-scribed fall risk intervention and these data were abstracted manually. Fall-related ED visits and hospitalizations for the sample at either of the two Broome County UHS hospitals were obtained from the inpatient EHR for visits between January 1, 2009, and October 30, 2015—both pre- and post-STEADI implementation. This project received expe-dited review and approval by the UHS Institutional Review Board and the Human Subjects Research Review Committee at Binghamton University deferred to this decision.

VariablesOlder adults who were asked any of the screening ques-tions were considered screened (Figure 1). If a patient was screened more than once during the study period, the first screening was used to determine screening status and the date of this visit was used as the screening date for analysis. Those who did not have any fall risk screening information recorded were considered unscreened and were excluded from the outcomes analysis as it was not possible to deter-mine fall risk for these patients.

Among those who were screened, subjects were consid-ered at risk if they answered yes to any of the five screening questions. Older adults who answered no to all five screen-ing questions were considered to be not at risk. Older adults who did not have any “yes” responses and who answered “no” to some but not all screening questions were consid-ered to have an incomplete screen (undetermined risk) and were excluded from the outcome analyses.

The FPOC variable was used to measure the implemen-tation of strategies to prevent falls. Among those who were identified as at risk, they were considered to have a FPOC if any of the following items were documented in their EHR: (a) physical therapy/fall prevention program referral, (b) assistive device prescription, (c) fall risk brochure or a home safety checklist provided, or (d) fall risk addressed in a narrative note by a nurse or a PCP. Older adults who were identified as being at risk for a fall were categorized as not having a fall plan of care (no FPOC) if there was no documentation of any of the earlier mentioned fall risk pre-vention strategies in the medical record.

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http://academic.oup.com/gerontologist/article-lookup/doi/10.1093/geront/gny101#supplementary-data

All outcome analyses were conducted on these three groups—Group 1: At-risk and no FPOC, Group 2: At-risk with FPOC, and Group 3: Not-at-risk.

The outcome variables were medically treated falls defined as a treat-and-release ED visit or hospitalization for a fall. Both ED visits and hospitalizations were identified from the inpatient EHRs of the two UHS hospitals in Broome County based on the criteria that (a) the principal diagno-sis field in the record was for injury, and (b) the first valid external cause of injury was coded E880-E888 (excluding E887) (Centers for Disease Control and Prevention, 2017). Fall-related events were categorized as occurring either before (pre-) or after (post-) the initial screening. Person-months were calculated as the number of months between the patient’s first screening date and the end of the study, and used in multivariate analyses to control for the varying postscreening exposures among patients.

The number of ED visits and the number of hospitali-zations were determined for each patient pre- and post-STEADI screening.

Analytic MethodsUnivariate and multivariate analyses were conducted using SPSS for Windows, version 24 (2016, IBM Corporation). Descriptive statistics for demographic variables as well as prescreening ED visits and hospitalizations were generated including percentages and 95% confidence intervals (CI) by group. Bivariate analyses examined relationships between demographic and grouping variables. Baseline rates of fall-related events among groups were compared using one-way analysis of variance and post hoc analysis was conducted using Dunnett’s T3 as the Levene’s test revealed unequal variances. Poisson regression was conducted to examine the group’s effect on the number of postscreening fall-related ED visits and hospitalizations. Regression analyses controlled for sex, age, and exposure in person-months. An alpha level of .05 was used for tests of statistical significance.

Broome County Trend AnalysisED visit and hospitalization data for Broome County older adult falls were extracted from the NYSDOH’s Statewide

Figure 1. Flow of older adult* patients through the United Health Services Modified Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention initiative, 2012–2015. Note: *Older adult defined as patients aged 65 years and older. 1Screening determined by whether or not older adult was asked 5 questions about falls history in the past year. 2Older adults who answered yes to one of the 5 questions. 3Older adults who answered no to all 5 questions. 4Older adults who did not answer yes to any question but did not answer no to all 5 questions. 5Older adults were considered to have a Fall Plan of Care if there was documentation in the electronic health record for: (a) referral to physical therapy or a fall prevention program, (b) prescription for an assistive device, (c) fall risk addressed in a narrative note by nurse or primary care provider, or (d) fall risk brochure or home safety checklist provided.


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Planning and Research Cooperative System (New York State Department of Health, 2016) and analyzed for 35 full quarters from January 1, 2007, through September 30, 2015. Falls were determined based on the CDC State Injury Indicators Report: Instructions for Preparing 2015 Data (Thomas & Johnson, 2017).

Rates of ED visits and hospitalizations for falls were cal-culated for the total older adult population and by gender using quarterly treatment data. As quarterly census data were not available for the denominator, the yearly popu-lation of Broome County for the relevant year was used. The rate was multiplied by 100,000 to obtain a rate of ED visits and hospitalizations for falls per 100,000 popula-tion. These rates were regressed by quarter to determine the trend. Data were extracted and analyzed using SAS 9.4 software (SAS Institute Inc., Cary, NC).

Results

UHS Medically Treated Falls Outcomes.Among the 12,346 older adults with a primary care visit during the study period, 89.7% (n = 11,080) were screened (Figure 1). Of those screened, 601 older adults had incom-plete screening data and were excluded from the analyses. The excluded adults compared with the screened were more often men (47% vs 42%, p < .001), in the young-est age group (71% vs 57%, p < .001), and of a minority race (11% vs 6%, p < .001). The final sample consisted of 10,479 adults aged 65 or older at the time of screening. Within this cohort, 18.3% (n = 2,032) were identified as being at risk for a fall and 76.2% (n = 8,447) were not at risk. Among older adults with a fall risk, 60.9% (n = 1,237) had documentation in the EHR for at least one element of a FPOC and 39.1% (n = 1,237) did not have any docu-mented evidence of a FPOC. The percent of at-risk patients who received a FPOC varied by clinic location from 32% to 85% (data not shown).

The sample was composed of 4,406 men (42.0%) and 6,073 women (58.0%) (Table 1). A higher proportion of older adults at risk for fall were women (66.7%) compared with those not at risk (55.8%). The mean age in 2012 was 72.7 years (SD = 7.8 years), with 39.1% of the sample aged 62–69 years, 38.5% aged 70–79 years, and 22.4% aged 80 or older. When compared to those not at risk for a fall, a lower proportion were aged 62–69 years (25.1% vs 42.5%, p < .001) and a higher percentage were aged 80 or older (38.2% vs 18.6%, p < .001). The sample was predominantly white (94.3%) and there was no significant association between race and risk group (Table 1).

Those at risk who received a FPOC and those who did not had similar rates of prescreening fall-related ED vis-its (34.3 [95% CI: 29.0, 39.6] and 34.7 [95% CI: 27.5, 41.9], respectively) and hospitalizations (51.7 [95% CI: 38.6, 64.9] and 46.5 [95% CI: 31.1, 62.0], respectively) (Table 1). Those not at risk had significantly lower rates of

prescreening fall-related ED visits (9.5, 95% CI: 8.4, 10.5) and hospitalizations (11.4, 95% CI: 9.1, 13.9).

Women were 1.4 times more likely to have a fall-related ED visit postscreening compared with men when control-ling for age in 2012, postscreening months of exposure, and risk-treatment group (Table 2). The likelihood of an ED visit increased 1.1 times with age for each additional year. Older adults who were not at risk for a fall were 0.6 times as likely to have a fall-related ED visit when com-pared to those who were at risk for a fall but did not receive a FPOC (odds ratio [OR]= 0.6, 95% CI 0.4, 0.7). Those at risk for a fall who received a FPOC were not significantly more or less likely to have a fall-related ED visit when com-pared to those at risk for a fall who did not receive a FPOC (OR = 1.3, 95% CI: 1.0, 1.7).

Women were 1.5 times more likely to have a fall-related hospitalization postscreening compared with men when controlling for other variables (Table 2). Age was signifi-cantly associated with the likelihood of hospitalization, increasing 1.1 times for each additional year. Older adults not at risk for a fall were half as likely to have a fall-related hospitalization when compared to those who were at risk and did not receive a FPOC (OR = 0.5, 95% CI: 0.4, 0.8). Those at risk for a fall who received a FPOC were 0.6 times (95% CI: 0.3, 1.0) as likely to have a fall-related hospital-ization when compared to those at risk for a fall who did not receive a FPOC (p = .041).

Broome County Trends

Hospitalizations for falls among older adults trended downward at a statistically significant rate reduction of 2.5 admissions per 100,000 residents per quarter (Figure 2). When stratified by gender, much of this reduction was due to declines in the female fall hospitalization rate, which was statistically significant. Although the rate among men also trended downward, it was not significant. For ED visits, there was a nonsignificant upward trend over time of 1.1 cases per 100,000 residents per quarter (Figure 2). However, when stratified by gender, men appeared to have a statistically significant increase, whereas women did not.

Discussion and Implications

Effectiveness of the UHS STEADI InitiativeImplementation of the STEADI initiative into the out-patient clinic workflow at UHS was associated with a reduced number of fall-related hospitalizations for older adults prescribed a FPOC. For this group, the odds of a fall-related hospitalization postintervention were similar to older adults who were not at risk for a fall and were 40% lower than those at risk without a FPOC. Relatively few other studies have examined the effects of multifactorial falls interventions on fall injuries.

A meta-analysis of multifactorial fall risk interventions found that such interventions significantly reduced the rate


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Tab

le 1

. D

emo

gra

ph

ic C

har

acte

rist

ics

of

Old

er A

du

ltsa

Scr

een

ed f

or

Fall

Ris

k b

y Fa

ll R

isk

and

Tre

atm

ent

Gro

up

; Un

ited

Hea

lth

Ser

vice

s O

utp

atie

nt

Clin

ics;

Bro

om

e C

ou

nty

, N

ew Y

ork

, 200

9–20

15

Gro

up 1

: At-

risk

and

no

Fa

ll Pl

an o

f C

are

(ref

eren

ce

grou

p) (

n =

795)

Gro

up 2

: At-

risk

and

wit

h Fa

ll Pl

an o

f C

are

(n =

1,2

37)

Gro

ups

1 an

d 2:

To

tal A

t-ri

sk (

n =

2,03

2)G

roup

3: N

ot-a

t-ri

sk

(n =

8,4

47)

Gro

ups

1, 2

, and

3:

Tota

l (n

= 10

,479

)

Cha

ract

eris

tic

% (

N)

95%

CI

% (

N)

95%

CI

% (

N)

95%

CI

% (

N)

95%

CI

% (

N)

95%

CI

Sex

M

ale

36.7

(29

2)(3

3.5%

, 40.

2%)

31.0

(38

4)(2

8.4%

, 33.

6%)

33.3

(67

6)(3

1.2%

, 35.

3%)

44.2

(3,

730)

(43.

1%, 4

5.3%

)42

.0 (

4,40

6)(4

1.1%

, 42.

9%)

Fe

mal

e63

.3 (

503)

(59.

9%, 6

6.7%

)69

.0 (

853)

(66.

4%, 7

1.6%

)66

.7 (

1,35

6)(6

4.7%

, 68.

8%)

55.8

(4,

717)

(54.

7%, 5

6.9%

)58

.0 (

6,07

3)(5

7.1%

, 58.

9%)

Age

gro

up (

age

in 2

012)

62

–69

24.9

(19

8)(2

1.9%

, 27.

9%)

25.3

(31

3)(2

2.9%

, 27.

7%)

25.1

(51

1)(2

3.3%

, 27.

0%)

42.5

(3,

588)

(41.

4%, 4

3.6%

)39

.1 (

4,09

9)(3

8.2%

, 40.

0%)

70

–79

37.4

(29

7)(3

4.0%

, 40.

8%)

36.2

(44

8)(3

3.5%

, 38.

9%)

36.7

(74

5)(3

4.6%

, 38.

8%)

38.9

(3,

290)

(37.

9%, 3

9.9%

)38

.5 (

4,03

5)(3

7.7%

, 39.

4%)

≥8

037

.7 (

300)

(34.

3%, 4

1.1%

)38

.5 (

476)

(35.

8%, 4

1.2%

)38

.2 (

776)

(36.

1%, 4

0.3%

)18

.6 (

1,56

9)(1

7.8%

, 19.

4%)

22.4

(2,

345)

(21.

6%, 2

3.2%

)R

ace

W

hite

95.3

(75

8)(9

3.8%

, 96.

8%)

95.4

(1,

180)

(94.

2%, 9

6.6%

)95

.4 (

1,93

8)(9

4.5%

, 96.

3%)

94.1

(7,

946)

(93.

6%, 9

4.6%

)94

.3 (

9,88

4)(9

3.9%

, 94.

7%)

O

ther

2.9

(23)

(1.7

%, 4

.1%

)1.

9 (2

4)(1

.1%

, 2.7

%)

2.3

(47)

(1.7

%, 3

.0%

)3.

7 (3

10)

(3.3

%, 4

.1%

)3.

4 (3

57)

(3.1

%, 3

.7%

)

Unk

now

n1.

8 (1

4)(0

.9%

, 2.7

%)

2.7

(33)

(1.8

%, 3

.6%

)2.

3 (4

7)(1

.7%

, 3.0

%)

2.3

(191

)(2

.0%

, 2.6

%)

2.3

(238

)(2

.0%

, 2.6

%)

Pres

cree

ning

fal

l-re

late

d E

D v

isit

rat

ed34

.7(2

7.5,

41.

9)34

.3(2

9.0,

39.

6)34

.5(3

0.2,

38.

8)9.

5(8

.4, 1

0.5)

14.3

(13.

2, 1

5.5)

Pres

cree

ning

fal

l-re

late

d ho

spit

aliz

atio

n ra

ted

46.5

(31.

1, 6

2.0)

51.7

(38.

6, 6

4.9)

49.7

(39.

7, 5

9.7)

11.4

(9.1

, 13.

9)18

.9(1

6.1,

21.

7)

a Old

er a

dult

s de

fined

as

pati

ents

who

wer

e ag

e 65

yea

rs o

r ol

der

in 2

015.

bA

t-ri

sk d

enot

es t

hat

the

pati

ent

was

scr

eene

d as

bei

ng a

t ri

sk f

or a

fal

l. c F

all P

lan

of C

are

incl

udes

any

one

or

mor

e of

the

fol

low

ing:

(a)

ref

erra

l to

phys

ical

the

rapy

or

a fa

ll pr

even

tion

pro

gram

, (b)

pre

scri

ptio

n fo

r an

ass

isti

ve d

evic

e, (

c) f

all r

isk

addr

esse

d in

a n

arra

tive

not

e by

nur

se o

r pr

imar

y ca

re p

rovi

der,

or (

d) f

all r

isk

broc

hure

or

hom

e sa

fety

che

cklis

t pr

ovid

ed.

d Eve

nt r

ate

(rat

e pe

r 1,

000

pers

on-m

onth

s).


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Table 2. Occurrence of Medically Treated Falls (Treat-and-Release Emergency Department Visits or Hospitalizations) Among Older Adults by Fall Risk and Treatment Group; United Health Services; Broome County, New York, 2012–2015

Variable

Treat-and-release ED visits Hospitalizations

OR 95% CI p Value OR 95% CI p Value

Intercept 0.0 (0.0–0.0) .000** 0.0 (0.0–0.0) .000**Gender Male (ref) (ref) Female 1.4 (1.2, 1.7) .000** 1.5 (1.1, 2.2) .020**Age as of 2015 (years)a 1.1 (1.0, 1.1) .000** 1.1 (1.1, 1.1) .000**Exposure (months)a 1.0 (1.0, 1.1) .000** 1.0 (1.0, 1.1) .000**Risk-treatment group comparisons Group 1: At-risk—no Fall Plan of Careb (ref) (ref) Group 3: Not-at-riskb vs Group 1: At-risk—no Fall Plan of Careb 0.6 (0.4, 0.7) .000** 0.5 (0.4, 0.8) .003** Group 2: At-risk–with Fall Plan of Careb vs Group 1: At-risk—no Fall Plan

of Care1.3 (1.0, 1.7) .085 0.6 (0.3, 1.0) .041*

Note: ED = emergency department; (ref) = reference group.aAge and exposure are continuous variables. bFall Plan of Care includes: (a) referral to physical therapy or a fall prevention program, (b) prescription for an assistive device, (c) fall risk addressed in a narrative note by nurse or primary care provider, or (d) fall risk brochure or home safety checklist provided.*p < .05. **p < .01.

Figure 2. Linear rate regression by gender for United Health Services Hospitalizations and treat-and-release emergency department visits for adults age 65+; Broome County, New York, Quarter 1, 2007–Quarter 3, 2015. Note: *p < .05. **p < .01. 1. Rates are made using the yearly population for each quarter within that year, Rate = (Quarterly # cases)/(Broome County Yearly Population)*100,000. 2. Data are regressed by quarterly Interval (1 = Quarter 1 2007, 35 = Quarter 3 2015).


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of falls (rate ratio = 0.76 [95% CI: 0.67, 0.86]) but not the risk of falling (risk ratio = 0.93 [95% CI: 0.86, 1.02]) (Gillespie et al., 2012). A collaborative effort promoting fall prevention interventions in Connecticut saw an increase in the use of fall prevention visits and a reduction in serious fall-related injuries and fall-related use of medical services in intervention regions compared to regions with usual care (Tinetti et al., 2008). More recently, older adults who participated in a multifactorial falls intervention in Finland were 26% less likely to experience a fall-induced injury compared with the control group (Palvanen et al., 2014).

However, other studies of multifactorial fall prevention programs found some beneficial effects in the first year but did not find a decrease in the incidence of falls requiring medical treatment in the long term (Salminen, Vahlberg, & Kivela, 2009). In a study with a 9-month follow-up, there was no decrease in the incidence or overall costs of falls requiring visits to the ED or admissions to the hospital (Landis & Galvin, 2014). These authors, however, noted a nonsignificant trend toward fewer hospitalizations for falls if the patient was fully assessed, had a plan of care, and adhered to it.

In a systematic review and analysis, Sherrington, Tiedemann, Fairhall, Close, and Lord (2011) found that exercise programs as a single intervention reduced the rate of falls among community-dwelling older adults by 21%. The recent U.S. Preventive Services Task Force evidence review found that multifactorial interventions reduced the incidence of falls whereas exercise interventions were associated with broader range of fall outcomes including fewer older adults experiencing a fall and fewer injurious falls(Guirguis-Blake, Michael, Perdue, Coppola, & Bell, 2018). None of these studies examined the effects of a multifactorial intervention based on STEADI.

The UHS implementation of the STEADI initiative was the first and largest to date, demonstrating the feasibility of implementing a multifactorial intervention across a large health care system. The 14 UHS clinics in this study screened nearly 90% of older adults or over 11,000 patients at least once over a 3-year period, of which about 18% were deter-mined to be at risk. About 61% of those at risk received docu-mentation of a FPOC in their medical record. In comparison, a pilot of the STEADI initiative in Oregon screened 360 older adults or 19% of eligible patients over a 3-month period (Casey et al., 2016). Stevens and coworkers (2017) suggest factors that contributed to the success of the UHS program included a strong clinical champion who led the integration of STEADI into the clinical workflow and trained clinical and administrative staff to ensure everyone understood how to appropriately assess and record STEADI activities.

The 90% screening rate found in this study is high, but gaps remain in implementation. About 40% of those identified as at risk did not have a FPOC documented in their medical record. These results suggest that increasing the proportion of at-risk older adults with a FPOC has the potential to further reduce falls. However, time constraints

and competing demands are a recurring challenge in imple-menting clinical fall prevention efforts (Baker et al., 2005).

The trend regression results suggest that fall prevention activities, such as STEADI, Tai Chi, and Stepping On, may be associated with a decline in hospitalizations at UHS hos-pitals in Broome County and that gender may moderate the effects of fall programs over time. Significant rate decreases are seen in female hospitalizations but not in female ED visits whereas no changes are seen in male hospitalization rates, and male ED visit rates increased. Men are less likely than women to report falling, seek medical care for a fall, and discuss falls and fall prevention with a health care pro-vider (Bergen et al., 2016; Stevens & Sogolow, 2005) so health care providers may be less likely to consider fall risk in older men. This study found that the unscreened/par-tially screened group had a higher proportion of men com-pared with the screened group. In disseminating STEADI and other fall prevention activities, special efforts may be needed to educate health care providers on the threat of falls to older men and to tailor initiatives to include and address both genders.

This study has other implications for future dissem-ination. The STEADI initiative (https://www.cdc.gov/STEADI/) recommends a screening protocol of 12 ques-tions to identify older adults at risk of a fall. In this imple-mentation, five screening questions were integrated into the UHS workflow to accommodate the time available in a visit for screening (Stevens et al., 2017). This approach effect-ively identified those most at risk for a fall as evidenced by the prescreening rates of medically treated falls for those screened at risk compared with those not at risk. In add-ition, screening alone was not sufficient to prevent a fall. Our findings suggest that establishing a FPOC—that is, actually implementing strategies to address fall risk fac-tors—is required to reduce adverse fall outcomes. Notably, the STEADI core elements of screening, assessment, and intervention were tailored to the UHS outpatient and Broome County community settings. Adhering to the three core elements while customizing them to the clinical envir-onment made implementation feasible, while still resulting in reduced fall hospitalizations.

Limitations of the Study

This study is subject to several limitations. First, receipt of a FPOC was not randomized. If prescribing a FPOC is related to other unmeasured fall risk factors, this would result in selection bias. However, the demographic characteristics and the rate of medically treated injuries that occurred prior to screening were similar for those who received a FPOC and those who did not—suggesting that the two groups had simi-lar risks. Furthermore, the percent of at-risk patients who received a FPOC varied by clinic (data not shown), suggest-ing clinic factors may play a bigger part than patient fac-tors. Second, the FPOC elements were identified based on manual review of the medical record and it is possible that


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https://www.cdc.gov/STEADI/https://www.cdc.gov/STEADI/

fall prevention activities were missed, or that FPOC elements were recommended but not documented. Third, it was not possible to determine whether those who received a FPOC followed the recommendations or which elements they fol-lowed. Fourth, FPOC elements ranged from handing the patient a brochure to a physical therapy recommendation and ranged widely in their potential impact on falls. Fifth, outcome data only included fall-related events within the UHS system. If a UHS patient sought medical care for a fall outside the UHS system, those medically treated falls would not be captured. To mitigate this issue, data were restricted to the 14 primary care practices where patients were likely to use one of the Broome County UHS hospitals. These 14 practices represent 76.9% of the UHS older adult patient population. Sixth, the Broome County data included older adults outside of the UHS study intervention sites and the population size is calculated yearly rather than quarterly. Finally, the current multifactorial intervention at UHS was based on STEADI and included the core elements of screen-ing, assessing, and prescribing (www.cdc.gov/STEADI); however, these elements were tailored to the UHS and Broome County setting. There may be setting-specific char-acteristics that affected the success of this initiative. Health care organizations wishing to adopt STEADI will need to consider the unique context of this implementation as well as the barriers, facilitators, and feasibility of implementing the core elements in their settings. This study has demon-strated, however, that health systems can adapt the core ele-ments and still achieve measurable improvements in health outcomes by screening for fall risk among older adults and intervening with older adults who are at risk by prescribing a plan of care that addresses underlying risk factors.

ConclusionsOlder adult falls pose a large and growing burden on the U.S. health care system. This study shows that the STEADI conceptual framework for fall prevention can be used to identify and address modifiable risk factors in primary care settings to reduce the number of older adult fall-related hospitalizations. This study included a limited number of interventions such as providing fall prevention educational materials, prescribing an assistive device, and/or referring at-risk older adults to physical therapy or a community falls prevention program. Implementing additional evidence-based falls prevention interventions such as vision checks, podiatrist referrals, and medication review and manage-ment would address additional modifiable risk factors and have the potential to reduce fall injuries even further (Stevens & Burns, 2015). The UHS STEADI initiative dem-onstrated that fall risk screening and prevention strategies among older adults in the primary care setting can result in reduced fall injuries among their patients. Given the aging U.S. population, these findings are particularly noteworthy. With an average cost of over $30,000 for a fall-related hos-pitalization (Burns et al., 2016) and the increased burden on

informal caregivers (Wilkinson et al., 2018), wider imple-mentation of STEADI in primary care across the United States may be able to reduce expensive health care expendi-tures for fall injuries among older adults.

Supplementary MaterialSupplementary data are available at The Gerontologist online.

FundingThis work was supported by the Centers for Disease Control and Prevention Cooperative Agreement 3U17CE001997. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

AcknowledgmentsThe authors wish to thank Dr. Frank Floyd, Bridget Talbut, Leah Miller, Amy Booth, Srikanth Poranki, and Chris Alderman of United Health Services Hospitals, Inc., as well as Meaghan Tartaglia and Harrison Moss of the New York State Department of Health, Amy Roma of Mercy House of the Southern Tier, and Kara Burke of Albany Medical Center.

ReferencesBaker, D. I., King, M. B., Fortinsky, R. H., Graff, L. G. 4th,

Gottschalk, M., Acampora, D.,…Tinetti, M. E. (2005). Dissemination of an evidence-based multicomponent fall risk-assessment and -management strategy throughout a geographic area. Journal of the American Geriatrics Society, 53, 675–680. doi:10.1111/j.1532-5415.2005.53218.x

Bergen, G., Stevens, M. R., & Burns, E. R. (2016). Falls and fall injuries among adults aged ≥65 years—United States, 2014. Morbidity and Mortality Weekly Report, 65, 993–998. doi:10.15585/mmwr.mm6537a2

Burns, E., & Kakara, R. (2018). Deaths from falls among persons aged ≥65 years—United States, 2007-2016. Morbidity and Mortality Weekly Report, 67, 509–514. doi:10.15585/mmwr.mm6718a1

Burns, E. R., Stevens, J. A., & Lee, R. (2016). The direct costs of fatal and non-fatal falls among older adults - United States. Journal of Safety Research, 58, 99–103. doi:10.1016/j.jsr.2016.05.001

Casey, C. M., Parker, E. M., Winkler, G., Liu, X., Lambert, G. H., & Eckstrom, E. (2016). Lessons learned from implementing CDC’s STEADI falls prevention algorithm in primary care. The Gerontologist, 57, 787–796. doi:10.1093/geront/gnw074

Centers for Disease Control and Prevention. (2017). Tools and framworks: Tools for catgorizing injuries using ICD codes. Retrieved from https://www.cdc.gov/nchs/injury/injury_tools.htm. Accessed April 3, 2017.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2017). Web-based Injury Statistics Query and Reporting System (WISQARS) [online].


Copyedited by: KO

Dow



http://www.cdc.gov/STEADI);https://www.cdc.gov/nchs/injury/injury_tools.htmhttps://www.cdc.gov/nchs/injury/injury_tools.htm

Retrieved from https://www.cdc.gov/injury/wisqars/index.html. Accessed July 12, 2018.

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66, 693–698. doi:10.1111/jgs.15304

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. The Cochrane Database of Systematic Reviews, CD007146. doi:10.1002/14651858.CD007146.pub3

Glasgow, R. E., Klesges, L. M., Dzewaltowski, D. A., Bull, S. S., & Estabrooks, P. (2004). The future of health behavior change research: What is needed to improve translation of research into health promotion practice? Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine, 27, 3–12. doi:10.1207/s15324796abm2701_2

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89, 1322–1327. doi:10.2105/AJPH.89.9.1322

Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018). Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. The Journal of the American Medical Association, 319, 1705–1716. doi:10.1001/jama.2017.21962

Jones, T. S., Ghosh, T. S., Horn, K., Smith, J., & Vogt, R. L. (2011). Primary care physicians perceptions and practices regarding fall prevention in adult’s 65 years and over. Accident; Analysis and Prevention, 43, 1605–1609. doi:10.1016/j.aap.2011.03.013

Kenny, R., Rubenstein, L. Z., Tinetti, M. E., Brewer, K., Cameron, K. A., Capezuti, L., … Rockey, P. H. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older per-sons. Journal of the American Geriatrics Society, 59, 148–157. doi:10.1111/j.1532-5415.2010.03234.x

Kessler, R. S., Purcell, E. P., Glasgow, R. E., Klesges, L. M., Benkeser, R. M., & Peek, C. J. (2013). What does it mean to “employ” the RE-AIM model? Evaluation & the Health Professions, 36, 44–66. doi:10.1177/0163278712446066

Klesges, L. M., Estabrooks, P. A., Dzewaltowski, D. A., Bull, S. S., & Glasgow, R. E. (2005). Beginning with the application in mind: Designing and planning health behavior change interventions to enhance dissemination. Annals of Behavioral Medicine, 29(Suppl), 66–75. doi:10.1207/s15324796abm2902s_10

Landis, S. E., & Galvin, S. L. (2014). Implementation and assessment of a fall screening program in primary care practices. Journal of the American Geriatrics Society, 62, 2408–2414. doi:10.1111/jgs.13137

New York State Department of Health. (2016). Statewide Planning and Research Cooperative System (SPARCS). Retrieved from https://www.health.ny.gov/statistics/sparcs/. Accessed August 1, 2017.

Palvanen, M., Kannus, P., Piirtola, M., Niemi, S., Parkkari, J., & Järvinen, M. (2014). Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomised controlled trial. Injury, 45, 265–271. doi:10.1016/j.injury.2013.03.010

Peel, N. M. (2011). Epidemiology of falls in older age. Canadian Journal on Aging, 30, 7–19. doi: 10.1017/S071498081000070X

Salminen, M., Vahlberg, T., & Kivelä, S. L. (2009). The long-term effect of a multifactorial fall prevention programme on the inci-dence of falls requiring medical treatment. Public Health, 123, 809–813. doi:10.1016/j.puhe.2009.10.018

Schwenk, M., Lauenroth, A., Stock, C., Moreno, R. R., Oster, P., McHugh, G.,…Hauer, K. (2012). Definitions and methods of measuring and reporting on injurious falls in randomised con-trolled fall prevention trials: A systematic review. BMC Medical Research Methodology, 12, 50. doi:10.1186/1471-2288-12-50

Sherrington, C., Tiedemann, A., Fairhall, N., Close, J. C., & Lord, S. R. (2011). Exercise to prevent falls in older adults: An updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin, 22, 78–83. doi:10.1071/NB10056

Stevens, J. A., Ballesteros, M. F., Mack, K. A., Rudd, R. A., DeCaro, E., & Adler, G. (2012). Gender differences in seeking care for falls in the aged Medicare population. American Journal of Preventive Medicine, 43, 59–62. doi:10.1016/j.amepre.2012.03.008

Stevens, J. A., & Burns, E. R. (2015). A CDC compendium of effec-tive fall interventions: What works for community-dwelling older adults (3rd ed.). Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Stevens, J. A., & Phelan, E. A. (2013). Development of STEADI: A fall prevention resource for health care providers. Health Promotion Practice, 14, 706–714. doi:10.1177/1524839912463576

Stevens, J. A., Smith, M. L., Parker, E. M., Jiang, L., & Floyd, F. D. (2017). Implementing a clinically based fall preven-tion program. American Journal of Lifestyle Medicine, doi:10.1177/1559827617716085

Stevens, J. A., & Sogolow, E. D. (2005). Gender differences for non-fatal unintentional fall related injuries among older adults. Injury Prevention, 11, 115–119. doi:10.1177/1559827617716085

Stewart Williams, J., Kowal, P., Hestekin, H., O’Driscoll, T., Peltzer, K., Yawson, A.,…Chatterji, S.; SAGE collaborators. (2015). Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecoun-tries: Results from the WHO Study on global AGEing and adult health (SAGE). BMC Medicine, 13, 147. doi:10.1186/s12916-015-0390-8

Thomas, K. E., & Johnson, R. L. (2017). State injury indicators report: Instructions for preparing the 2015 data. Retrieved from https://www.cdc.gov/injury/pdfs/2015_state_injury_indicator_instructions-a.pdf. Accessed April 3, 2017.

Tinetti, M. E., Baker, D. I., King, M., Gottschalk, M., Murphy, T. E., Acampora, D.,…Allore, H. G. (2008). Effect of dissemination of evidence in reducing injuries from falls. The New England Journal of Medicine, 359, 252–261. doi:10.1056/NEJMoa0801748

Verma, S. K., Willetts, J. L., Corns, H. L., Marucci-Wellman, H. R., Lombardi, D. A., & Courtney, T. K. (2016). Falls and fall-related injuries among community-dwelling adults in the United States. PLoS One, 11, e0150939. doi:10.1371/journal.pone.0150939

Wilkinson, A., Meikle, N., Law, P., Yong, H. J., Butler, P., Kim, J.,…Hale, L. (2018). How older adults and their informal carers pre-vent falls: An integrative review of the literature. International Journal of Nursing Studies, 82, 13–19. doi:10.1016/j.ijnurstu.2018.03.002


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NE Agenda 2019.0211NE Minutes 2018.1210NE Budget Expenditures 2019.0211KDHE RTC Mini-grant FY19 Application Final (1)NE Quarter submission report 2019.02TNCC_Ransom_App_Rosters_2018.1219ATLS_Reinecke_Applicaton_2019.0109ATLS_Warner_Application_2019.0109NE Symposium Final AgendaEnhanceFitness Info Sheet4_STEADI-Form-RiskFactorsCk-508CHECKLIST Fall Risk FactorsFALLS HISTORYMEDICAL CONDITIONSMEDICATIONS (PRESCRIPTIONS, Otcs, SUPPLEMENTS)GAIT, STRENGTH & BALANCEVISIONPOSTURAL HYPOTENSIONOTHER RISK FACTORS

7_Outcome Evaluation of STEADI in primary care.pdf

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Northeast Kansas Regional Trauma Council Executive ...Tracy McDonald – it would be nice to get Todd Maxon to come up and speak. Darlene – Maybe a Consortium Ransom – interested