What is the scale used for fall assessment?: Key Scales & Factors

According to the Agency for Healthcare Research and Quality (AHRQ), up to one million hospitalized patients experience a fall each year. To proactively identify and mitigate this risk, healthcare professionals rely on standardized tools to answer the question, "What is the scale used for fall assessment?" The most prominent of these scales are the Morse Fall Scale (MFS) and the Hendrich II Fall Risk Model, which help clinicians evaluate patient factors and implement targeted prevention strategies.

Quick Summary

Several standardized tools exist for fall risk assessment, including the Morse Fall Scale and the Hendrich II Fall Risk Model. These scales evaluate various patient-specific and environmental factors to determine a patient's risk level and guide appropriate interventions.

Key Points

• Primary Scales: The most widely used scales for fall risk assessment are the Morse Fall Scale (MFS) and the Hendrich II Fall Risk Model.

• MFS Assessment Factors: The MFS evaluates six factors: history of falling, secondary diagnosis, use of ambulatory aid, presence of an IV, gait, and mental status.

• Hendrich II Assessment Factors: The Hendrich II model assesses eight risk factors, including confusion, depression, medication use, and performance on the "Get Up and Go" test.

• Targeted Interventions: The Hendrich II model is particularly useful for identifying specific, modifiable risk factors that can be addressed with targeted interventions.

• Other Tools: Specialized scales like the Timed Up and Go (TUG) Test and the Humpty Dumpty Fall Scale (HDFS) are used for specific populations and settings, such as outpatient clinics or pediatric units.

• Integrated Approach: The most effective fall prevention programs use a multifactorial strategy that combines validated assessment tools with ongoing patient monitoring, education, and tailored interventions.

Understanding Fall Risk Assessment in Healthcare

Fall risk assessment is a critical component of patient care, especially for older adults and those with mobility issues. The goal is to identify patients at a high risk of falling so that preventive measures can be put in place. By using validated scales, healthcare providers can systematically evaluate a patient's risk factors and create a targeted care plan to promote patient safety and prevent serious injury.

The Morse Fall Scale (MFS)

The Morse Fall Scale is one of the most widely used and well-known fall risk assessment tools, especially in acute care settings like hospitals. It is a quick and straightforward assessment based on six key variables. Each variable is assigned a specific point value, and the total score determines the patient's risk level.

• History of Falling: A history of a recent fall (within the last 3 months) is a significant predictor of future falls. A "yes" answer adds 25 points to the score.
• Secondary Diagnosis: The presence of multiple medical conditions increases a patient's overall risk. If a patient has more than one medical diagnosis, 15 points are added.
• Ambulatory Aid: The type of assistance a patient needs to walk indicates their level of stability. This can range from needing no aid (0 points) to using a cane or walker (15 points), or relying on furniture for support (30 points).
• IV or IV Access: Patients with an intravenous line or heparin lock have an increased risk of entanglement and impaired mobility. If an IV is present, 20 points are added.
• Gait: The patient's walking pattern is a key indicator of balance and mobility. An assessment classifies gait as normal (0 points), weak (10 points), or impaired (20 points).
• Mental Status: A patient's cognitive awareness of their own physical limitations is assessed. A patient who recognizes their limits and moves carefully scores 0, while one who overestimates their ability or is forgetful scores 15 points.

The Hendrich II Fall Risk Model

The Hendrich II Fall Risk Model is another evidence-based tool, commonly used in acute and long-term care settings. It is recognized for its brevity and ability to link specific risk factors to targeted interventions. The model includes eight independent risk factors and is often integrated into electronic health records for seamless use.

• Confusion/Disorientation/Impulsivity: This psychological factor adds 4 points.
• Symptomatic Depression: Patients with symptomatic depression are assigned 2 points.
• Altered Elimination: Alterations in urinary elimination, such as incontinence or frequency, are associated with fall risk, adding 1 point.
• Dizziness/Vertigo: Patients experiencing dizziness or vertigo are at higher risk and are given 1 point.
• Gender: Male patients are assigned 1 point, based on research indicating a gender-specific risk factor.
• Antiepileptic Medication: Prescribed antiepileptic medications increase risk and add 2 points.
• Benzodiazepine Medication: The use of benzodiazepines is linked to increased fall risk, adding 1 point.
• Performance on the "Get Up and Go" Test: This physical test measures a patient's mobility, balance, and gait. It is scored from 0 to 4 points based on their performance.

Comparison of MFS and Hendrich II

While both scales aim to prevent patient falls, they differ in their focus and application. The right choice depends on the clinical setting and patient population. The following table provides a clear comparison.

Feature	Morse Fall Scale (MFS)	Hendrich II Fall Risk Model
Primary Setting	Acute care hospitals	Acute care, long-term care
Number of Factors	6	8, plus Get Up and Go Test
Emphasis	Provides a quick, overall risk score	Identifies specific, modifiable risk factors
Key Strengths	Widely validated, easy to use, quick administration	Includes medication risk factors, focuses on root cause
Interventions	Triggers general fall prevention interventions based on risk level	Facilitates targeted, evidence-based care plans linked to specific risk factors
Scoring Range	0-125	0-16
Risk Threshold	Varies by facility but often: 0-24 (low), 25-45 (moderate), >45 (high)	A score of $\geq$ 5 indicates high risk

Other Assessment Tools

While the MFS and Hendrich II are prevalent, other tools are used for specific populations or settings:

• Timed Up and Go (TUG) Test: A simple, quick test often used in outpatient or home care settings. It measures the time it takes a patient to stand from a chair, walk 10 feet, turn around, and return to a seated position.
• St. Thomas Risk Assessment Tool (STRATIFY): Primarily used for elderly inpatients, this tool considers factors like a history of falls, agitation, and visual impairment.
• Berg Balance Scale: Assesses balance and functional mobility, often used for older adults to evaluate their risk of falling.
• Humpty Dumpty Fall Scale (HDFS): Specifically designed for pediatric patients, as adult scales are not applicable to this population.

Integrating a Multifactorial Approach

A robust fall prevention program involves more than just a single scale. A comprehensive, multifactorial approach is essential. The assessment tools help identify specific risk factors, but a true prevention strategy requires ongoing monitoring, targeted interventions, and patient and family education. For example, a patient scoring high due to gait issues would benefit from physical therapy, while a patient on high-risk medication might require a pharmacist consultation.

Conclusion

Determining what is the scale used for fall assessment is fundamental to patient safety protocols in healthcare. The Morse Fall Scale and the Hendrich II Fall Risk Model are two leading instruments, offering distinct benefits depending on the clinical environment. The MFS provides a rapid, general risk score, whereas the Hendrich II model pinpoints specific, modifiable risk factors. By utilizing these evidence-based tools, healthcare teams can move beyond simple assessment to develop personalized, proactive, and effective strategies that significantly reduce the incidence of patient falls and improve overall care outcomes.

Frequently Asked Questions

What is the primary scale used for fall assessment?

The most common scale used for fall assessment, especially in acute care settings, is the Morse Fall Scale (MFS). It is a six-item scoring system that quickly identifies a patient's risk for falling.

What factors are included in the Morse Fall Scale?

The Morse Fall Scale includes six factors: history of falls, secondary diagnoses, use of ambulatory aids, presence of an IV line, gait, and mental status.

What does a high score on the Morse Fall Scale indicate?

A high score on the Morse Fall Scale, typically above 45 points, indicates that a patient has a high risk of falling and requires increased attention and interventions to prevent falls.

What is the Hendrich II Fall Risk Model used for?

The Hendrich II Fall Risk Model is used to identify specific, modifiable risk factors for falls in adult inpatients in acute and long-term care settings, such as certain medications and mental status changes.

How is the Timed Up and Go (TUG) test used for fall assessment?

The TUG test is a simple test used to assess mobility and balance. It involves timing how long it takes a patient to stand up from a chair, walk 10 feet, turn, walk back, and sit down again.

Are there different fall scales for different patient populations?

Yes, scales are often tailored to different populations. For example, the Humpty Dumpty Fall Scale is designed specifically for pediatric patients, as adult scales are not applicable to children.

How do healthcare providers use the assessment scale scores?

Healthcare providers use the scores from fall assessment scales to categorize a patient's risk level (e.g., low, moderate, high). This information then guides the creation of a personalized care plan with targeted interventions to mitigate the identified risks.