Objective: Falls are a major cause of hospital-related costs in people aged ≥65 years. Despite this, falls are often seen as trivial and given low priority in an emergency department (ED), especially in the absence of overt major injury. ED systems that care for falls patients are often inefficient. The aims of this study were to: (1) design and implement a standardised and systematic approach to patients presenting to an ED after a fall; and (2) achieve hospital efficiency gains, such as reduced hospital length of stay, through implementation of this approach. Methods: A prospective study was conducted with pre- and postintervention measurement of outcomes. The key features of the intervention were direct admission to an ED short stay unit, standardised assessment of cognition, medications, mobility and discharge risk, and access in the ED to a geriatric consultation service for complex patients. Results: In the 12 months of the intervention, 1435 male and female patients aged ≥65 years were enrolled in the study. At the end of 12 months, these patients had significantly higher ED discharge (66% vs 46%; P < 0.001) and, if admitted, shorter median hospital stays (6 vs 2 days; P < 0.001) compared with the baseline pre-intervention phase. Analysis 1 year later revealed that these outcomes were sustained or further improved. Conclusion: A systematic approach to falls in older patients attending the ED is feasible and beneficial. Decreased hospital stay and improved rates of effective discharge from ED back to the community are achievable and sustainable. What is known about the topic?: Falls are common, serious and costly. Not identifying and managing falls risk factors is a common feature of ED practice. As a result, admission rates to hospital for patients who fall are high. What does this paper add?: In this large study we have shown that a systematic approach to falls assessment is feasible, sustainable and results in higher discharge rates from the ED. What are the implications for practitioners?: EDs are the gateway to a hospital bed. It is possible to redesign ED flow and bring front-loaded multidisciplinary geriatric care into an ED short stay environment, to the benefit of patients and health systems.