Page 24 nursing.elitecme.com Complete Your CE Test Online - Click Here individualized patient needs. The following information is a summary of the initiative’s descriptions of various fall risk factor assessment tools (Minnesota Falls Prevention Initiative, no date given). Gait and balance assessment. For patients with gait and balance issues, the following tools may be helpful: ○ ○ Timed Up and Go (TUG): This test is easily used in both inpatient and outpatient settings. It involves asking patients to perform various balance- and gate-related tasks, such as rising from a chair without using their arms and walking and turning. ○ ○ Get Up and Go Test: Training is required to administer this test. It measures dynamic balance, gait speed, and functional capacity. ○ ○ Berg Balance Scale (BBS): This tool is a 14-item scale used to measure adult’s balance in a clinical setting. ○ ○ Dynamic Gait Index: This tool is used to rate the ability of a person to modify gait when responding to various task demands. ○ ○ Tinetti Performance Oriented Mobility Assessment (POMA): This is a task-oriented test that rates the ability of a person to maintain balance while performing activities of daily living tasks. Fear of falling. As noted earlier, fear of falling can seriously inhibit a person’s willingness to participate in his/her usual activities. The following scales are used to assess fear of falling: ○ ○ Activities-Specific Balance Confidence (ABC) Scale: The ABC scale is a 16-item scale used to ask adults to rate their confidence that will lose their balance or become unsteady during daily activities. This scale has the advantage of being able to be self-administered or administered by healthcare personnel via a personal or telephone interview. ○ ○ Fall efficacy scale (FES): FES is a 10-itme rating scale. It is used to assess confidence of people in performing their daily activities without falling. Cognitive assessment. Cognition is critically linked to falls. The following tools may be used as part of cognitive assessment: ○ ○ Mini-mental state examination (MMSE): This is a widely screening tool for cognitive impairment and has been well- validated. It measures orientation to time and place, immediate recall, short-term verbal memory, calculation, language, and construct ability. ○ ○ Montreal Cognitive Assessment (MoCA): This is a brief cognitive screening for persons with mild cognitive impairment. ○ ○ St. Louis University Mental Status (SLUMS): This tool and other screening tools can be accessed at http://aging.slu.edu/ index.php?page=screening-tools Depression assessment. There are a wide variety of tools available for the assessment of depression. Here are two examples of such tools: ○ ○ Geriatric Depression Scale: This is a basic screening tool for use in older adults. ○ ○ PHQ-9: The PHQ (Patient Health Questionnaire) is a self- administered screening and diagnostic tool for mental health disorders. The tool has been field tested in office settings. Environmental assessment checklists. It is imperative to thoroughly assess the patient’s environment for safety. Here are some examples of assessment tools for that purpose: ○ ○ Morse Fall Scale (MFS): The MFS is widely used in acute care and long-term care inpatient settings. This tool requires assessment of fall risk upon admission, after a fall, with a change in status, and at discharge or transfer to a new setting. This assessment tool has been deemed both valid and reliable. ○ ○ Hendrich Fall Risk Assessment: This tool is used for inpatient assessment and in some long-term care settings. However, it has not been researched as extensively as the Morse Fall Risk Assessment. ○ ○ St. Thomas Risk Assessment Tool (STRATIFY): This tool is used to identify risk factors and to create a risk profile score. Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (no date given) has developed an algorithm for fall risk assessments and intervention, which can be found on their website (https://www.cdc.gov/steadi/pdf/ Algorithm_2015-04-a.pdf). It is part of the Center’s National Center for Injury Prevention and Control and part of the STEADI (Stopping Elderly Accidents, Deaths, & Injuries) initiative. The algorithm begins by having the patient answer key questions, such as: “Have you fallen in the past year?” If yes, “How many times?” “ Were you injured?” “Do you feel unsteady when standing or walking?” “Do you worry about falling?” If the answer is “no” to all of the preceding key questions, they are deemed to be at low risk for falling and individualized interventions are recommended. If any of the questions were answered with a “yes,” then further evaluation is performed, fall risk is determined, and interventions based on risk are performed. EBP alert! The Centers for Disease Control algorithm and tools described by the Minnesota Falls Prevention Initiative should be used not only for assessment and to determine interventions, but also to gather data for research purposes. As nurses assume more prominent roles in the research process, they should consider how to participate in research in order to add to the nursing body of knowledge and to provide evidence that can be used to improve patient care. High reliability organizations When planning to develop or revise a fall prevention program, healthcare organizations could learn from the Aviation Safety Network. “High reliability organizations (HRO) are organizations with system in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors” (Gamble, 2013). The nuclear and airline industries, some of the most dangerous industries, have long been recognized for their work toward defect-free or error- free operations for extensive lengths of time. Many healthcare experts advocate that healthcare organizations adopt the HRO model to improve safety and reduce errors (Quigley & White, 2013).