Table 2 Description of fall risk assessment tools used in SCI rehabilitation settings. Column three represents the maximum score (a high score infers a higher fall risk). The thresholds for assigning fall risk based on the scores are specified in column four
Scale Name | Domains Evaluated | Maximum Score | Interpretation |
|---|---|---|---|
STRATIFY [17] | recent falls, agitation, vision, toileting frequency, transfers and mobility | 6 | 0 = low fall risk 1 = medium fall risk 2 + = high fall risk |
Schmid Fall Risk Assessment Tool [18] | mobility, mentation, elimination, prior fall history and current medications, agitation, attempting to get out of bed unsafely, vision, orthostatic hypotension, balance and sensory issues, history of fractures or osteoporosis, alcohol/substance abuse and malnutrition | 5 | 0–2 = normal fall risk ≥3 = high fall risk |
Morse Fall Scale [19] | fall history, secondary diagnosis, ambulatory aid, IV, gait/transfers, and cognition | 125 | 0–24 = low fall risk 25–44 = moderate fall risk ≥45 = high fall risk |
Customized Scale Site D | history of falls, medication, dizziness, sensory impairments, toileting, cognitive impairments, balance/mobility issues, co-morbidities, bed transfers/mobility, mobility in patient room, bathroom and on the unit, and behavioural traits (e.g. judgement, self-control/impulsivity, anxiety) | Yes or No scale | Any yes answer requires development of a plan |
Customized Scale Site E | neuromuscular deficits, cognition, sensory deficits, bowel/bladder, postural hypotension, history of seizures | 17 | 0 = low fall risk ≥1 = high fall risk |
Customized Scale Site F *based on the Morse fall scale | number of diagnoses, vision, toileting, medication, mobility, and cognition | 100 | 0–64 = low fall risk ≥65 = high fall risk |