There are numerous fall risk tools used to assess adult patients in various settings.
Pediatric fall risk assessment tools
DiGerolamo et al. (2017) found generally adult fall risk assessment tools do not adequately assess risk in children. The reliability and validity of pediatric assessment tools is not consistent in different types of institutions and in diverse populations. Pediatric tools thus, should describe testing that fits your population. The Ryan-Wenger et al. (2012) article describes in detail issues of reliability and validity of pediatric assessment tools.
Obstetric fall assessment tools
Numerous articles report the inability of fall risk assessment tools used with elderly or medical surgical patients to predict falls of obstetrical patients. Obstetrical patients have short-term risk for falls which varies at different stages of the hospital stay. The few OB specific tools lack sufficient testing for reliability and validity. 221592685
Much more research is needed in this area (Ryan-Wenger et al., 2012
)
Descriptions of fall scales
Here are some sample descriptions of commonly used fall scales. Each organization should assess which scale is most relevant for their organization, especially information about the tool's ability to predict falls.
The Morse Fall Scale (MFS) is focused on six risk factors. Each risk factor is scored, and those scores are totaled. A total score of 125 is possible. The MFS is divided into ranges: a low fall risk score is below 25, a medium risk is between 25 and 50 and high risk for falling is 51 or higher.
The MFS has shown sensitivity scores between 72% and 88% and specificity scores between 29% and 83%. A recent test of specificity (Kim et al., 2007) reported a specificity score of only 48.3%. According to Morse the inter-rater reliability was found to be 96%.
The MFS determines the following risk factors for a total risk score:
• History of falls
• Secondary diagnosis
• Ambulatory aides
• IV/Heparin lock
• Gait/Transferring ability
• Mental status
The Hendrich II Fall Risk Model screens of eight fall risk factors plus gate and balance. A total score of 5 or greater indicates high risk for falls. Sensitivity in the 2003 report by Hendrich was 74.9% and specificity 73.9%. In a 2007 study by Kim et al, the sensitivity score was 70% with the specificity score of 61.5%.
The Hendrich II assess for the following risk factors:
Get Up and Go Test
This is part of the Hendrich Fall Risk Model but can be administered separately. It takes five minutes to administer and tests balance, gait, speed and mobility.
Patient instructions
- Sit comfortably in a straight-backed chair.
- Rise from the chair.
- Stand still momentarily.
- Walk 10 feet.
- Turn around.
- Return to chair and sit down.
Primarily used to measure gate and balance
Timed Up and Go (TUG)
This is a simple test often used in non-acute settings. The patient is asked to stand up without using arm assistance from a straight-backed chair. Then the patient is asked to walk 10 feet, turn around and come back to the chair. These activities should be performed under 10 seconds.
Dynamic Gait Index
Used to assess the eight facets of gait. Score each of 8 stages as: (3) Normal, (2) Mild Impairment, (1) Moderate Impairment, (0) Severe Impairment
Tinetti Performance Oriented Mobility Assessment (POMA)
Designed to measure balance and lower and upper body extremity strength. Administration time is 10 to 15 minutes (Canbek, et al, 2013).
St. Thomas Risk Assessment Tool (STRATIFY)
Used mostly to predict fall risk factors in the elderly. According to a report by Castellini, the True Positive Rate was 35.6%. The False Negative Rate was 64.4% of fallers. The researchers found the STRATIFY tool to not be not adequate to screen their inpatients population. They were concerned about having erroneous allocation of resources using this tool (Castellini, et al., 2017).
Mini Mental State Examination (MMSE)
Most popular screening tool for cognitive impairment. Measures orientation, immediate recall, short-term verbal memory, calculation, language, and construct ability https://en.wikipedia.org/wiki/Mini–mental_state_examination
Besides fall risk assessment on admission
While a fall risk assessment on admission for every patient is recognized as the standard of care, when to reassess the patient's risk for fall injury is less consistent. There is support in the literature for reassessment after the following events.
In addition, very high-risk patients should be assessed each day or even at every change of shift.
Instant Feedback:
The Hendrich II assesses for which of the following risk factors:
References
Canbek, J., Fulk, G., Nof, L., & Echternach, J. (2013). Test-retest reliability and construct validity of the Tinetti performance-oriented mobility assessment in people with stroke. Journal of Neurologic Physical Therapy, 37(1), 14-19.
Castellini, G., Demarchi, A., Lanzoni, M., & Castaldi, S. (2017). Fall prevention: is the STRATIFY tool the right instrument in Italian Hospital inpatient? A retrospective observational study. BMC health services research, 17(1), 656.
DiGerolamo, K. & Davis, K. F. (2017). An Integrative Review of Pediatric Fall Risk Assessment Tools. Journal of Pediatric Nursing. 34, 23-28.
Frank, B. J., Lane, C. & Hokanson, H. (2009). Designing a Postepidural Fall Risk Assessment Score for the Obstetric Patient. Journal of Nursing Care Quality. 24(1) ,50 – 54.
Hendrich, A. (2007). Predicting patient falls: using the Hendrich II Fall Risk Model in clinical practice. Am J NURS, 107(11), 50-4.
Hill-Rodriguez, D., Messmer, P.R., Williams, P.D., Zeller, R. A., Williams, A.R., Wood, M. & Marianne Henry, M. (2009). The Humpty Dumpty Falls Scale: A Case–Control Study. J Spec Pediatr Nurs. 14(1),22-32.
Kim, N., Siti, Wong, H Devi, K & Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. J Adv Nurs, 60 (4), 427-435
Ryan-Wenger, N. A., Kimchi-Woods, J., Erbaugh, M. A., LaFollette, L. & Lathrop, J. (2012). Challenges and conundrums in the validation of pediatric fall risk assessment tools. Pediatric Nursing. 38(3), 159-167.