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Background: This tool can be used to identify risk factors for falls in hospitalized patients. The total score may be used to predict future falls, but it is more important to identify risk factors using the scale and then plan care to address those risk factors.
Reference: Adapted from Oliver D, Britton M, Seed P, et al. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ 1997;315(7115):1049-53. Reprinted with permission from BMJ Group.
How to use this tool: Please fill out the scale as instructed below. This tool can be used by staff nurses.
Use this tool in conjunction with clinical assessment and a review of medications (go to Tool 3I) to determine if a patient is at risk for falls and plan care accordingly. Note that this scale may not capture the risk factors that are most important on your hospital ward, so consider your local circumstances.
If your hospital uses an electronic health record, consult your hospital's information systems staff about integrating this tool into the electronic health record.
STRATIFY Risk Assessment Tool
Answer all five questions below and count the number of "Yes" answers.
|#||Question||Yes / No|
|1||Did the patient present to hospital with a fall or has he or she fallen on the ward since admission (recent history of fall)?||Yes = 1||No = 0|
|2||Is the patient agitated?||Yes = 1||No = 0|
|3||Is the patient visually impaired to the extent that everyday function is affected?||Yes = 1||No = 0|
|4||Is the patient in need of especially frequent toileting?||Yes = 1||No = 0|
|5||Does the patient have a combined transfer and mobility score of 3 or 4? (calculate below)||Yes = 1||No = 0|
Transfer score: Choose one of the following options which best describes the patient's level of capability when transferring from a bed to a chair:
0 = Unable
Mobility score: Choose one of the following options which best describes the patient's level of mobility:
0 = Immobile
|Combined score (transfer + mobility): ____________|
Total score from questions 1-5: ___________
0 = Low risk