https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Assessment and Clinical Outcomes of Fall Related Injuries at Emergency ABSTRACT INTRODUCTION Falls are a common cause of mortality in both sex and all age groups [1]. It is one of the common reasons for trauma care at emergency department (ED) visits among all age groups [2]. Fall-related injuries in- crease the cost on the health care system [3]. About half of falls result in injuries, and about 10% of those injuries are serious in- juries such as head injuries and fractures or injuries to the joint [4]. Falls and resulting injuries are frequently need medical care [5].Globally, falls are a major public health problem. Each year about 646,000 fatal falls occur. It is the second leading cause of accidental injury death after road traffic injuries. In low- and middle-income coun- tries, fatal falls occur over 80% [6]. It is one reason that leads to death and the Background and objectives: Falls are significant cause of mortality and morbidity with a considerable burden on societies, families and victims. The study aims to determine the interventions and outcomes of fall-related injuries, and the association between injury se- verity and fall height. Methods: A descriptive cross-sectional study was conducted among 322 fall-related in- jured persons in West and East emergency hospitals in Erbil City from September 2020 to February 2021. Study sample demography, location of injury, place of affected body re- gions, outcome, and hospital stay were analyzed. Results: Of the 322 patients studied, 68.9% were males, and 31.1% were female. Less than half of the samples (48.8%) were between the ages 18 to 36 years old. The most common location for fall-related injuries was residential facilities (44.1%) followed by the place of work (35.1%). According to the type of fall, fall from ground was 38.4%, and fall from a fall height of 1-3 meters was 48.8%. Finally, according to the injury classification, more than half (56.5%) of the study sample had a significant degree of severity. The discharged status of disposition at the emergency room had the highest percentage (64.9%) of the study sample. There was a significant difference between the scores of the items of fall conse- quences and outcomes regarding to type of ground (soft or hard). There was a significant relationship between injury severity and fall height (p-value = 0.00). Conclusion: Fall-related injuries are the most common cases at emergency departments in Erbil city. Among ages 18 to 36, men are more frequently exposed to falls than women. The highest risk of fall is occupation with construction laborers at the greatest risk. Fall- related injury is a burden on the health care system, particularly on emergency services in developing countries like Iraq in relations cost of care and resources. Key words: Fall, Unintentional fall, Injury severity, Fall height, Outcome. Shawbo Muhammad Osman; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: shawbo.othman@hmu.edu.krd) Vian Afan Naqshbandi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 50 Erbil Journal of Nursing & Midwifery Received: 17/03/2021 Accepted: 10/05/2021 Published: 30/05/2021 https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Third. leading cause of non-fatal injuries [7]. Although fall-related injuries are usual- ly reported in older age groups, other stud- ies have shown that younger people (15-49 years) have been recognized as the most vulnerable group affected by fall-related injuries. In addition, men are twice as likely to as women to be affected by falls [8]. Two of the three significant causes of injury deaths – fall and road traffic injuries– are expected to increase in rank compared to other causes of death, with falls increasing to become the 17th leading cause of death. [9].In Kurdistan, Iraq, there is no current study about falls in all circumstances, in- cluding settings and injury-prone environ- ments. The environmental, personal, and equipment risk factors for falls change in different communities. It is essential to know the severity of injuries and outcome of patients who sustain injuries by falls to be better prepared to manage these emer- gencies and to provide appropriate recom- mendations for prevention. This study will have a fundamental role in refining knowledge and will be recognized as a source of nurses and emergency staff. The finding of this study may help nurses and other healthcare professionals expand their knowledge and improve their practice related to fall-related injuries. This study aimed to explore the socio demographic characteristics, severity, interventions, and health outcomes associated with fall- related injuries and determine the associa- tion between injury severity and fall height. A descriptive cross-sectional study of 322 fall-related injured persons in West and East emergency hospitals in Erbil City was conducted from September 2020 to Febru- ary 2021. The sample size was determined by Z2 p q/d2, z = confident interval 95% (1.96), p= prevalence= (0.30), q = (1-p) = (0.70), d = sampling error (0.05) [10]. Patients who died upon injury or those who died in the emergency rooms (9) were omitted because there was no complete data regarding the circumstances of death and to avoid potential bias due to outcome measurement. The researcher obtained an approval letter from the Ethics Committee at Hawler Medical University/College of Nursing on September 2020 (number 833). The official approval was taken as well. The researcher prepared a questionnaire for collecting data based on the review litera- ture. The questionnaire was reliable and accessible to the public. The questionnaire was checked by a panel of experts who have extensive experience from different specialties. Based on their comments, the questionnaire was corrected and modified for appropriate data collection. A pilot study was conducted on 30 fall-related in- jured persons selected purposively from East and West emergency hospitals in Sep- tember 2020. The pilot study was benefi- cial to determine the reliability, clarity, ac- ceptability and time estimation for each participant to give full data which was 20- 30 minutes. Reliability was determined us- ing the Spearman-Brown formula. The fol- lowing procedures were used in data anal- ysis: descriptive statistical data analysis (frequency and percentage) and inferential statistical data analysis (independent sam- ple t-test and Chi-square test). Data were analyzed using SPSS version 21. Table 1 shows the socio demographic char- acteristics of the sample. Nearly half of the sample (48.8%) were aged 18 – 36 years old, and a majority were male was (68.9%). 31.7% graduated from primary school, and 49.1% lived in urban areas. The majority of the sample (86% ) were Iraqi, more than a third (37.9%) . 51 Erbil Journal of Nursing & Midwifery METHODS RESULTS https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article reported a social income status of Sufficient daily needs. identified their occupation as a worker, and more than half (57.1%) 52 Erbil Journal of Nursing & Midwifery Table 1: Distribution of socio demographic data of the study sample (n=322) The Characteristics Subgroups F. % Age groups 1 – 18 Years 91 (28.3) 18 -36 Years 157 (48.7) 36-54 Years 44 (13.7) > 54 Years 30 (9.3) Gender Male 222 (68.9) Female 100 (31.1) Education level Illiterate 57 (17.7) Able to read and write 70 (21.7) Primary school 85 (26.4) Secondary school 33 (10.3) College or institute 22 (6.8) Post graduate 11 (3.4) Child (N. A.) 44 (13.7) Residence Urban 158 (49.1) Rural 95 (29.5) Suburban 69 (21.4) Nationality Iraqi 277 (86) Others 45 (14) Occupation Manual employee 9 (2.8) Office (Government) employee 14 (4.3) Unemployed (house wife) 75 (23.3) Retired 10 (3.1) Worker 122 (37.9) Student 48 (14.9) Child (N. A.) 44 (13.7) Income Exceeds daily needs 3 (0.9) Sufficient for daily needs 184 (57.1) Insufficient for daily needs 135 (42) https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Table 2 shows information regarding fall- related injuries. The primary mode of arri- val was by none-ambulance mode (87%). Nearly half of the samples (44.1%) were injured at a residential facility, followed by the workplace (35.1%). Almost all falls (92.5%) were unintentional, and 89.1% of falls were falls to a hard ground. The most common mechanism of fall was fall from ground 38.4%, and the most com- mon fall height was fall from 1-3 meters (48.8%). On the pain scale, 54.3% of the sample reported, and on the Glasgow Co- ma Scale, 91.3% reported no head injury, and 79.2% received radiological investiga- tion. 53 Erbil Journal of Nursing & Midwifery Table 2: Distribution of information regarding fall of the study sample (n= 322) The characteristics Subgroups F. % Mode of Arrival Ambulance 41 (12.7) None-ambulance mode 281 (87.3) Location of fall Occurrence Residential facility 142 (44.1) Sports facility 26 (8.1) Work place 113 (35.1) Public / Commercial area 14 (12.7( Intentionality of fall Unintentional 298 (92.5) Intentional 24 (7.5) Ground of fall Soft 35 (10.9) Hard 287 (89.1) Fall Height < 1 Meter 109 (33.8) 1 – 3 Meters 157 (48.8) 3 – 6 Meters 51 (15.8) > 6 Meters 5 (1.6) Level of Consciousness Conscious 299 (92.9) Unconscious and or altered mental status 23 (7.1) Pain Scale Mild pain 7 (2.2) Moderate pain 132 (41) Severe pain 175 (54.3) Unconscious 8 (2.5) Total of Glasgow Coma Scale (GCS) No head injury GCS 15/15 294 (91.3) Severe head injury GCS 3-8 8 (2.5) Moderate head injury GCS 9--12 18 (5.6) Miner head injury GCS 13 -15 2 (0.6) Radiology investigation No 32 (9.9) X-Ray 255 (79.2) X-Ray with other radiology test 35 (10.9) Mechanism of fall F % Fall from ground 124 (38.4) Fall from stairs and scaffold 111 (34.5) Fall from building or structure 45 (14) Sport activity 27 (8.4) Others 15 (4.7) Total 322 (100) https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article was received back slab or cast for the affected area, 24.8% was received advice and giving medication, 22.4% was received open reduction and internal fixation, 15.6% was received wound dressing and suturing, 3.4% was received traction, oth- ers, craniotomy 2.8%, surgical debride- ment and external fixation2.5%, laparoto- my 1.2%. 54 Erbil Journal of Nursing & Midwifery Table 3 shows the characteristics of inju- ries. Of the sample, 53.1% has no soft tis- sue injury, 41.3% had no fracture, 99.1% had no spinal cord injury, and 97.3% had no visceral injury. More than half (56.5%) of study sample had major degree of se- verity. Table 4 shows the frequencies and percentages of the treatment type and in terventions of the study sample, 27.3% Table 3: Distribution of the injury charac- teristics among study sample (n= 322) The Characteristics Subgroups F. % Soft tissue injury None 171 (53.1) Yes 151 (46.9) Site of fracture None 133 (41.3) Skull and neck frac- ture 20 (6.2) Upper limb fracture 57 (17.7) Lower limb fracture 68 (21.1) Back frac- ture 11 (3.4) Chest frac- ture 5 (1.6) Pelvis frac- ture 15 (4.7) Multiple fracture 13 (4) Spinal cord injury SCI None 319 (99.1) Yes 3 (0.9) Visceral Injury No 313 (97.3) Yes 9 (2.7) Injury Severity Classification None 0 (0.0) Minor 104 (32.3) Moderate 29 (9) Major 183 (56.8) Death 6 (1.9) Table 4: Distribution of interventions of fall among the study sample (n= 322) The Outcomes Sub- groups F. % Open Reduction and Internal Fixation No 250 (77.6) Yes 72 (22.4) Laparotomy No 318 (98.8) Yes 4 (1.2) Surgical debride- ment and external fixation No 314 (97.5) Yes 8 (2.5) Craniotomy No 313 (97.2) Yes 9 (2.8) Wound dressing and suturing No 285 (88.5) Yes 50 (15.6) Back slab or cast for affected area No 234 (72.7) Yes 88 (27.3) Traction No 311 (96.6) Yes 11 (3.4) Advice and giving Medication No 242 (75.2) Yes 80 (24.8) https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Table 5 shows the differences between the fall consequences and outcomes regarding the ground of fall (soft or hard). There was a significant difference between the scores of the fall consequences and outcomes re- garding ground of fall. A high significance was reported for open reduction and inter- nal fixation (p=0.00), advice and giving medication (p=0.00), and disposition at emergency hospitals (p=0.00) with back slab or cast for the affected area (p=0.01), traction (p=0.01) and significant associa- tion for open reduction and external fixa- tion (p=0.04). There was no significance at the p ≤ 0.05 with craniotomy, laparotomy, wound dressing, and suturing. A significant relationship between injury severity and fall height was observed (p= 0.00). 55 Erbil Journal of Nursing & Midwifery Table 5: Distribution of the fall consequences and outcomes based on (Ground of fall) of the study sample (n=322) Fall outcomes Ground of fall (f.) Sig. p value Sig. Level at p. value ≤ 0.05 1- Open reduction and internal fixation Soft (35) 0.000 H.S. Hard (287) 2- Laparotomy Soft (35) 0.156 N.S. Hard (287) 3- Surgical debridement and external fixation Soft (35) 0.041 S. Hard (287) 4- Craniotomy Soft (35) 0.963 N.S. Hard (287) 5- Wound dressing and suturing Soft (35) 0.289 N.S. Hard (287) 6- Back slab or cast for affected area Soft (35) 0.019 S. Hard (287) 7- Traction Soft (35) 0.015 S. Hard (287) 8- Advice and giving medication Soft (35) .0000 H.S. Hard (287) 9- Disposition at emergency room Soft (35) 0.000 H.S. Hard (287) https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article results [15]. Residential facility was the most common place of fall followed by the workplace as reported in the same study [16]. A higher proportion of falls were unintentional, and majority of fall ground was hard. Injuries from fall height of 1-3 meters were the highest which is similar to the results by İçer et al [17]. Falls from the ground were highest among the sample which agrees with the study done by Alfreds- son [18]. The present study disagrees with the study by Grivna et al., which showed more patients had fallen from higher heights compared to ground lev- el [19].Most of the sample population were conscious and had a Glasgow co- ma score of 15. Most of the patients were stabilized and after primary care discharged directly from the emergency department, similar to study results This study shows that majority of the sample as between 18 – 36 years old, which aligns with the Lohanathan et al. retrospective study in South India [11]. The sample had a larger proportion of males than females, which aligns with the Ahmad et al. study results of fatal falls [12]. Usually, men are exposed to falls more frequently than women because boys are more active at early ages than girls, and men are more physical workers than women. Based on the occupation, workers were more than a third of the study sample and aligns with Dong et al., Meena, and Punia, which reported that the highest risk of fall was occupation with construction laborers as the largest occupation at risk [13] [14]. The primary mode of arrival was by none-ambulance mode, consistent with earlier studies by Fayyaz et al. that demonstrated similar 56 Erbil Journal of Nursing & Midwifery Table 6: Association between injury severity and fall height among the study sample (n=322). Sig. value at p. value 0.05 χ² value Total Fall height Injury severity classification >6 m F. % >3-6 m F. % >1-3 m F. % Less than one meter f. % 0.000 74.213 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 None 0 0.0 0 0.0 9 2.8 38 11.8 57 17.7 Minor 0 0.0 0 0.0 0 0.0 11 3.4 18 5.6 Moderate 3 0.9 0 0.0 38 11.8 60 18.6 82 25.5 Major 2 0.6 4 1.2 0 0.0 0 0.0 0 0.0 Death 5 1.6 4 1.2 47 14.6 109 33.8 157 48.8 Total DISCUSSIONS https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article observational data-based study by Dickin- son et al. which showed the same result [25]. Fall-related injuries are the most common cases at emergency departments in Erbil city. Men are exposed to falls more fre- quently than women among ages 18 to 36 years old. The highest risk of fall is occupa- tion with laborers of construction at the highest risk. Fall-related injuries have seri- ous implications on the burden of the health care system, particularly on emer- gency services in developing countries like Iraq in relation to cost of care and re- sources. Falls at work can be prevented by safety instruction to different groups, and proper regulation and legislation. Environmental variation based on architectural design may prevent falls among susceptible risk groups. The author reports no conflict of interests. [1] Turgut K, Sarihan ME, Colak C, Güven T, Gür A, Gürbüz S. Falls from height: a retrospec- tive analysis. World journal of emergency medicine. 2018;9(1):46. [2] Murray et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2197- 223. [3] Tuma et al. Epidemiology of workplace- related fall from height and cost of trauma care in Qatar. International journal of critical illness and injury science. 2013 Jan;3(1):3. done in South India done by Lohanathan et al [11]. X-Ray investigation was done for majority of the cases like the study by Dong et al [13]. Nearly half of sample population had soft tissue injuries similar to the retrospective study by Turgut et al. at the Emergency Department of Inonu University which reported the most common traumatic lesion of fall was soft tissue injury [1].Limbs were the commonly injured body part, similar to the study in India done by Kumar and Srivastava [20]. Nearly one percent of the study sample had spinal cord injuries, agreeing with the Oxley et al. study [21]. However, it disagrees with the Kennedy et al. study reporting nearly a quarter percent of falls had spinal cord injury which may be attributed to the long du- ration of the study and differences in the heights of fall [22]. More than half of the sample has a major degree of severity which disagreed with Luzia et al., which reported that most injuries were classi- fied as mild. Fall-related injuries involved specific medical and nursing interven- tions such as sutures, dressings, casting, orthopedic and neurologic surgical pro- cedures. The percentage of injuries re- sulting in death was 1.9% of cases similar to that reported by Luzia et al. [23]. In this study, nearly a quarter of the cases needed orthopedic surgery, which disa- grees with the study by Alizo et al., which showed that more than half of the sam- ple population needed orthopedic sur- gery [24]. Alizo et al. reported these find- ings among falls from height only and not all types of falls. The outcomes of pa- tients falling on soft grounds compared to those falling on solid grounds were statistically significant, similar to a Turk- ish study done by İçer et al. [17]. The pre- sent study showed a significant relation- ship between injury severity and fall height, similar to a retrospective 57 Erbil Journal of Nursing & Midwifery Conclusion Recommendation Conflict of interest References https://doi.org/10.15218/ejnm.2021.06 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article CPWR quarterly data report; 3rd quarter. July 2019. [14] Meena PC, Punia RK. Socio-demographic profile of fatal cases of fall from height-SMS Hospital, Jaipur during the year 2015-16. Indian Journal of Forensic Medicine & Toxi- cology. 2018 Apr; 2:93-8. [15] Fayyaz et al. Pattern of fall injuries in Paki- stan: the Pakistan national emergency de- partment surveillance (Pak-NEDS) study. BMC emergency medicine. 2015 Dec;15(2):1- 7. [16] Haggag OG, Zamzam IS, Sharaf Eldin AA, Madboly AG, Morad MM. Pattern of fatal injuries of fall from height at great Cairo: a retrospective analytical study (2009–2013). 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Org. au/Assets/Files/Fall-related- injuries-While-Walking. Report. pdf [22] Kennedy P, Cox A, Mariani A. Spinal cord injuries as a consequence of falls: are there differential rehabilitation outcomes?. Spinal Cord. 2013 Mar;51(3):209-13. [23] Luzia MD, Prates CG, Bombardelli CF, Adorna JB, Moura GM. Characteristics of falls with damage to hospitalized patients. Revista gaúcha de enfermagem. 2019;40(SPE). [24] Alizo et al. Fall from heights: does height really matter?. European journal of trauma and emergency surgery. 2018 Jun; 44(3):411 -6. [25] Dickinson A, Roberts M, Kumar A, Weaver A, [4] Hill et al. fall rates in hospital rehabilita- tion units after individualized patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised con- trolled trial. The Lancet. 2015 Jun 27;385 (9987):2592-9. [5] Ersoye et al. Analysis and injury patterns of walnut tree falls in central Anatolia of turkey. World journal of emergency sur- gery. 2014 Dec; 9(1):1-5. 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