Marianjoy Rehabilitation Hospital Marianjoy Rehabilitation Hospital Fall Risk Assessment Tool ProjectFall Risk Assessment Tool Project

Donna Pilkington, RN, MSML, CRRNDonna Pilkington, RN, MSML, CRRN

Kathleen Ruroede, PhD, MEd, RNKathleen Ruroede, PhD, MEd, RN

Nancy Cutler, RN, MS, CRRNNancy Cutler, RN, MS, CRRN

Fall Risk Assessment LiteratureFall Risk Assessment Literature

• Morse Fall Scale

• Marianjoy Fall Risk Assessment

Morse Fall ScaleMorse Fall Scale

• The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling.

• The MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings.

• It consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability.

• A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and

• 54% estimated that it took less than 3 minutes to rate a patient.

Morse Fall Scale IndicatorsMorse Fall Scale Indicators1. History of falling with in three

months No = 0 Yes = 25

2. Secondary Diagnosis No = 0 Yes = 15

3. Ambulatory Aid Bed rest/nurse assist = 0

Crutches/cane/walker =15

Furniture = 30

4. IV/Heparin Lock No = 0 Yes = 20

5. Gait/Transferring Normal/bedrest/immobile = 0

Weak = 10

Impaired = 20

6. Mental Status Oriented to own ability = 0

Forgets limitations = 15

Scoring the Morse Fall ScaleScoring the Morse Fall Scale

Risk Level MFS score Action

________________________________________

No Risk 0 – 24 Basic Care

Low Risk 25 – 50 Standard Fall

Precautions

High Risk > 51 High Risk

Precautions

Marianjoy Fall Risk AssessmentMarianjoy Fall Risk Assessment

• Altered elimination patterns 10

• Unilateral neglect

10

• Impaired cognition 20

• Sensory deficits (hearing,

sight, touch) 5

• Agitation 20

• Impaired mobility 5

• History of previous falls 20

• Impulsiveness 20

• Communication deficits 20

• Lower extremity hemiparesis 10

• Activity intolerance 10

• Episodes of dizziness/seizures 10

• Special medications (narcotics, psychotropic, hypnotic, antidepressants etc.) 5

• Diuretics, and drugs that

increase GI motility 5

• Upper extremity paresis 5

• Age greater that 65 or less

than 16 5

•High Risk: >60 points Place Patient in Caution Club

Guiding Question?Guiding Question?

Is the Marianjoy Fall Risk

Assessment a valid and reliable

method for predicting rehabilitation

patient fall events if it is properly

scored at admission?

Description of Research StudyDescription of Research Study

• Pilot study of 50 patients

– 25 patients who had fallen

– 25 matched patients who had not fallen

• Dependent variable fall status

• Independent variables

– Caution Club status

– Admission FIM total score

– Modified admission Berg Balance total score

– Admission fall risk assessment

Pilot Study ResultsPilot Study Results

• Patients significantly differed on Berg, FIM, and fall risk assessment scale

• Five items found to separate fall groups

– History of falls

– Unilateral neglect

– Episodes of dizziness / seizures

– Special medications

– Diuretics and drugs that increase GI motility

– Sensory deficits

Always be Always be alert for a alert for a new and new and creative creative idea... You idea... You never know never know what’s in what’s in your graspyour grasp

Replicated Study with a Larger SampleReplicated Study with a Larger Sample

• 2005 data used

• Total N = 450 patients included

• 125 patients with documented fall status

• 325 patients who had not fallen were randomly selected from dataset

• 232 patients were on caution club status

• 218 patients not on caution club status

Replicated Study with a Larger SampleReplicated Study with a Larger Sample

• Hypotheses tested

– Patients did not significantly differ on fall status for:

• Fall assessment

• Admission FIM Score

• Modified Berg Balance Score

• Age

Replicated Study with a Larger SampleReplicated Study with a Larger Sample

• Statistical Procedures– Descriptive statistics– Sensitivity and specificity on original scale– Sensitivity and specificity on converted

dichotomous scale– Item analysis on dichotomous scale that

separate fallers from non-fallers– Total of 9 items discriminate groups

Replicated Study with a Larger SampleReplicated Study with a Larger Sample

• Statistical Procedures

– Validity procedures using factor analysis (component analysis)

– Reliability analysis using Cronbach’s Alpha

– Logistic regression to develop predictive model of fall status

– Development of new “Caution Club” threshold value – New Threshold Cut Score = > 4

Always be ready for any Always be ready for any surprises while working on surprises while working on

the projectthe project

Results – Descriptive StatisticsResults – Descriptive StatisticsDescriptive Statistics

325 65.60 16.793

125 62.27 17.596

FallNo

Yes

AgeN Mean

Std.Deviation

Gender

179 55.1

52 41.6

146 44.9

73 58.4

FallNo

Yes

No

Yes

Female

Male

ValidFrequency Percent

Results – Inferential StatisticsResults – Inferential StatisticsRanks Original Fall Assessment by Fall Status

325 189.19 61488.00

125 319.90 39987.00

450

FallNo

Yes

Total

Initial Fall Risk AssmntN Mean Rank Sum of Ranks

Test Statisticsa

8513.000

61488.000

-9.561

.000

Mann-Whitney U

Wilcoxon W

Z

Asymp. Sig. (2-tailed)

Initial FallRisk Assmnt

Grouping Variable: Falla.

Results – Inferential StatisticsResults – Inferential Statistics

Ranks Original Fall Assessment by Caution Club Status

218 109.50 23871.00

232 334.50 77604.00

450

Caution ClubNo

Yes

Total

Initial Fall Risk AssmntN Mean Rank Sum of Ranks

Test Statisticsa

.000

23871.000

-18.365

.000

Mann-Whitney U

Wilcoxon W

Z

Asymp. Sig. (2-tailed)

Initial FallRisk Assmnt

Grouping Variable: Caution Cluba.

Results – Inferential StatisticsResults – Inferential StatisticsRanks

214 265.93

236 188.84

450

214 287.94

236 168.88

450

214 223.75

236 227.09

450

NewCautionClubWeightCutat3No

Yes

Total

No

Yes

Total

No

Yes

Total

Total Berg

FIM Total Admissionwithout tubshower

Age

N Mean Rank

Berg and FIM Significantly Differ, but Age does not significantly differ

Results from Item Analysis Results from Item Analysis • Nine items found to discriminate fall groups

– History of Falls (Weight 2)– Impulsiveness (Weight 2)– Communication Deficits – Altered Elimination Patterns– Unilateral Neglect– Lower Extremity Hemiparesis– Upper Extremity Hemiparesis– Special Medications– Diuretics and Drugs that Increase GI Mobility

Factor AnalysisFactor Analysis and Reliability and Reliability

• Three Components Extracted

• 55% Total Explained Variance in Model

Rotated Component Matrixa

.841 .045 -.014

.826 -.008 -.092

.710 .211 -.043

-.110 .739 -.069

.104 .722 .087

.477 .504 .061

.212 .354 .080

-.038 -.003 .813

-.048 .097 .768

UEExtremHemipDichot

LEHemiparDichot

UnilatNeglDichot

HxFalls2

Impuls2

CommunDeficDichot

AlterEliminDichot

SpecialMedsDichot

DiureticsDichot

1 2 3

Component

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.

Rotation converged in 5 iterations.a.

Reliability Statistics

.558 9

Cronbach'sAlpha N of Items

Logistic Regression ModelLogistic Regression Model

• R Square Value .253

Variables in the Equation

.015 .035 .188 .665 1.015

-.033 .009 13.646 .000 .968

-1.398 .280 25.024 .000 .247

-.011 .007 2.837 .092 .989

1.690 .520 10.555 .001 5.419

Total Berg

FIIM Total Adm

New Caution Club

Age

Constant

Step1

a

B S.E. Wald Sig. Exp(B)

Variable(s) entered on step 1: totberg, FIIMtotadm, NewCautionClubWeightCut3, Age.a.

Results from CrosstabulationsResults from CrosstabulationsOriginal Caution Club Status by Fall Crosstabulation

200 18 218

44.4% 4.0% 48.4%

125 107 232

27.8% 23.8% 51.6%

325 125 450

72.2% 27.8% 100.0%

Count

% of Total

Count

% of Total

Count

% of Total

No

Yes

CautionClub

Total

No Yes

Fall

Total

New Caution Club Status by Fall Crosstabulation

191 23 214

42.4% 5.1% 47.6%

134 102 236

29.8% 22.7% 52.4%

325 125 450

72.2% 27.8% 100.0%

Count

% of Total

Count

% of Total

Count

% of Total

No

Yes

NewCautionClubWeightCutat3

Total

No Yes

Fall

Total

Sensitivity and SpecificitySensitivity and Specificity

d

191

c

23

b

134

a

102

Fall

+ -

Caution

Club

+

-

236

(a+b )

214

(c+d )

125

(a+c )

325

( b+d )

d

191

c

23

b

134

a

102

d

191

c

23

b

134

a

102

Fall

+ -

Caution

Club

+

-

236

(a+b )

214

(c+d )

125

(a+c )

325

( b+d )

Sensitivity = a / (a + c) = 102 / 125 = .82 Specificity = d / (b + d) = 191 / 325= .59False Negative = c / (a + c) = 23 / 125 = .18

False Positive = b / (b + d) = 134 / 325 = .41 PPV = a / (a + b) = 102 / 236 = .43 NPV = d / (c + d) = 191 / 214 = .89

Odds and Odds RatioOdds and Odds Ratio

• True Odds Ratio = 6.25

• This can be interpreted to mean that a patient who is on caution club status was 6.2 times more likely to incur a fall than a patient who was not on caution club status.

Odds and Odds RatioOdds and Odds Ratio

• Relative Risk of a Fall = 3.9

• This can be interpreted to mean that the risk of patients on caution club status are 3.9 times more likely to occur than those patients who were not on caution club status.

Don't get off Don't get off strategy and strategy and stay focusedstay focused

Conclusions and Conclusions and RecommendationsRecommendations