Downloaded from http://ebm.bmj.com/ on July 31, 2017 - Published by group.bmj.com
CLINICAL PREDICTION GUIDE
A 6-point risk score predicted which elderly patients would fall
in hospital
Oliver D, Britton M, Seed P, Martin
FC, Hopper AH. Development and
evaluation of evidence based risk
assessment tool (STRATIFY) to
predict which elderly inpatients will
fall: case-control and cohort studies. BMJ. 1997 Oct25;315:I049-53.
Objective
To develop and evaluate a risk-assessment tool that uses data from risk factors easily collected by nurses in routine hospital care to predict which
elderly patients will fall while in the
hospital.
Design
A case-control study to develop the
tool, and 2 cohort studies to validate it.
Setting
A teaching hospital (development
and local validation) and a district
general hospital (remote validation)
In the United Kingdom.
Patients
For development of the tool, 116 patients (mean age 85 y) in a geriatric
unit who had fallen (involuntarily
coming to rest on the ground or surface lower than their original station)
were matched with the patient in the
next bed who had not fallen. Local
validation was done with 217 patients
(395 assessments and 71 fails) and remote validation was done with 331
patients (446 assessments and 79 falls).
Main outcome measures
Sensitivity and specificity of scores (j
to 5 for predicting falls in the local
and remote validation studies.
Description of prediction guide
For each case- and control-patient,
21 variables were collected on age,
sex, function (including the Barthel
Index), mental status, medication use,
medical history, and nursing assessment of current clinical characteristics. Assessors were not blinded to fall
status of the patients. 5 clinical factors (presented with fall or has fallen
since admission, agitation, visual impairment, frequent toileting needs,
and poor transfer ability and mobility) were associated with falling. For
validation, each patient was assessed
weekly (up to 8 weeks) using scores
from 0 to 5. Risk scores for those who
had fallen were compared with those
who had not fallen for a given week.
Main results
A score of > 2 had high sensitivity and
a score of > 3 had high specificity foii
predicting elderly persons who
at risk for falling (Table).
Conclusion
A risk score that predicted which eld|
erly patients were at risk for fallin|
was developed, validated, and founl
to be accurate.
Source of funding: No external funding.
For article reprint; Dr. D. Oliver, Depart!
ment of Elderly Care (Division ofMediant}!
United Medical and Dental Schools, Si,
Thomas's Hospital, London SB1 7EH, fitgland, UK. FAX 44-171-928-2339.
Abstract and Commentary also published in AQ
Journal Club. 1998;128:57. A modified abstrw
wiii Appear in Evidence-Based Nursing. 1998 Jd.
Validation of a 0- to 5-point risk-assessment score to predict which
elderly patients are at risk for falling in hospital
Validation
Local
Local
Remote
Remote
Score
Sensitivity (95% CI)
Specificity (CI)
+LR*
>2
>3
>2
>3
9 3 % (84% to 98%)
69% (57% to 80%)
92% (84% to 97%)
54% (43% to 66%)
88% (84% to 91%)
96% (94% to 98%)
68% (63% to 73%)
8 8 % (84% to 91 %)
7.6
18.6
2.9
4.4
0.08
&<
O.f;
0.5;;
*+LR = likelihood ratio for the presence of condition (falls) if the test is positive; -tK:
likelihood ratio if the test is negative. Both calculated from data in article.
. :.:.:
Commentary
Interventions targeted to decrease the incidence of falls in the elderly are important in any setting. The appeal of this study
by Oliver and colleagues is that it proposes
an instrument to identify patients in the
hospital who are at risk for falling, using
readily available clinical data that can be
rapidly summarized in a score by nursing
staff.
The instrument had the greatest predictive value in the population for which it
had been derived (teaching hospital), but
it aiso performed fairly well when tested
in a different setting (community hospital). Implementation of preventive measures, which are supported by observational studies cited by the authors, can be
accomplished simultaneously with calculation of a high-risk score.
96
A limitation of the study is that no randomized trials have convincingly shown the
effectiveness of preventive measures in hospitalized geriatric patients. An identification
bracelet designed to increase awareness in
high-risk patients of their potential for falling failed to produce positive results in 1
study (1), and use of a bed alarm system only
resulted in a trend toward a decrease in falls
out of bed in another (2). Also, no attempt
has been made to differentiate risk for injurious falls from that of noninjurious falls.
Even though noninjurious falls have substantial morbidity (e.g., fear of falling, immobility, anxiety, and depression), morbidity and mortality primarily result from hip
fractures. T h e same measures may not be
equally effective for the prevention of both.
Interventions that have proven to be effec-
tive in preventing fractures in nursui;
homes (3) should receive a high priori*}'?
future studies of risk reduction in eldfl?
hospitalized patients.
Because of the variability in patient p$
ulation 'and nursing practices (a
stressed by the authors), the scale .i*'
need to be validated locally.
.::;:.:
Claudia Begfa$.
University of South Fltx*
Tampa, Floridti^
•
••'-"s
References
-::fi
1. Mayo NE, Gloutney L, Levy A f e f
PhysMed Rehabil. I994;75:1302-8--w
2. Tideiksaar R, Feiner CF, MabyJ- W*>:
JMed. 1993;60:522-7.
3. Lauritzen JB, Petcrsen MM,
Lancet. I993;341:l 1-3.
Downloaded from http://ebm.bmj.com/ on July 31, 2017 - Published by group.bmj.com
A 6-point risk score predicted which elderly
patients would fall in hospital
Evid Based Med 1998 3: 96
doi: 10.1136/ebm.1998.3.96
Updated information and services can be found at:
http://ebm.bmj.com/content/3/3/96.citation
These include:
References
Email alerting
service
This article cites 1 articles, 1 of which you can access for free at:
http://ebm.bmj.com/content/3/3/96.citation#BIBL
Receive free email alerts when new articles cite this article. Sign up in the
box at the top right corner of the online article.
Notes
To request permissions go to:
http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to:
http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to:
http://group.bmj.com/subscribe/