St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients

Abstract

The St. Thomas’s Risk Assessment Tool in falling elderly inpatients, commonly known by its acronym STRATIFY, is a concise and highly practical instrument designed for the early identification and assessment of fall risk among patients admitted to inpatient setting. Developed specifically for rapid administration by nursing staff, the scale consists of five key risk factors that have been empirically demonstrated to be significantly and independently associated with falls during hospitalization. The ease of administration and reliance on simple, observable clinical factors make STRATIFY an essential component of preventative care protocols in geriatrics.

The implementation of STRATIFY allows healthcare professionals to quickly stratify patients into low- or high-risk categories, thereby facilitating the timely application of targeted fall prevention interventions. This instrument is intended to be used shortly after patient admission, integrating seamlessly into routine daily observation and clinical examination procedures conducted by nursing personnel.

Keywords

STRATIFY, Fall risk assessment, Geriatric care, Elderly inpatients, Mobility impairment, Agitation, Hospital safety, Nursing assessment, Fall prevention.

Authors

Oliver D, Britton M, Seed, P, Martin FC, Hopper AH (1997), CBO Richtlijn Preventie van valincidenten bij ouderen (2004) (Dutch Version).

Purpose

The primary purpose of the STRATIFY scale is to provide a rapid, reliable, and evidence-based method for identifying older adults at high risk of falling during their hospital stay. Recognizing that falls are a major source of morbidity, mortality, and extended hospitalization among the elderly, the scale serves as a critical screening tool to initiate proactive preventative measures. The tool is specifically structured to rely on clinical observations and patient history that are readily available to nursing staff, ensuring minimal disruption to the workflow.

The instrument’s design focuses on predicting falls that occur subsequent to the assessment, allowing clinicians to allocate resources efficiently towards those patients who require the most intensive supervision and environmental modification. By quantifying the risk based on the presence of specific, well-defined factors, STRATIFY supports standardized decision-making regarding patient care plans and safety protocols.

Construct

The core construct measured by the STRATIFY scale is the multifactorial risk of falling in the acute care setting. Unlike scales that rely on complex cognitive testing or detailed physical performance metrics, STRATIFY defines risk through five independent, clinically relevant factors. These factors represent common intrinsic and extrinsic vulnerabilities experienced by the frail and elderly population when adjusting to a hospital environment.

The five factors—including prior history of falls, cognitive status (as indicated by agitation), sensory deficits, physiological needs (urinary frequency), and functional mobility—collectively capture the most common predictors of accidental falls among inpatients. The construct assumes that the cumulative presence of these factors linearly increases the probability of a fall event during the admission period.

Validity

The STRATIFY scale has demonstrated robust validity across numerous geriatric and acute care settings internationally. Initial studies established predictive validity by showing that patients scoring high on the STRATIFY scale were significantly more likely to experience a fall during their hospitalization compared to those scoring low. Research consistently reports that a score of 2 or higher is generally indicative of high risk.

The scale typically exhibits high sensitivity, meaning it is effective at correctly identifying patients who will fall (minimizing false negatives). While its specificity (correctly identifying patients who will not fall) can vary depending on the patient population and setting, its strength lies in its ability to quickly screen and prioritize patients for intervention. Its criterion validity is supported by its strong correlation with actual fall incidence rates recorded in hospital settings.

Reliability

The STRATIFY scale benefits from high levels of inter-rater reliability. This high reliability stems from the objective and readily observable nature of the five risk factors. For instance, determining whether a patient has had a fall since admission or exhibits obvious transfer difficulties is generally unambiguous and requires minimal subjective interpretation by the nursing staff.

The clear definitions provided for each item ensure that different nurses, observing the same patient at the same time, are highly likely to generate the same score. This consistency is crucial for a clinical screening tool, ensuring that risk status does not fluctuate based on the specific healthcare provider completing the assessment. Test-retest reliability is also generally strong, particularly when assessing chronic factors like visual impairment or long-standing mobility issues, although factors like agitation or recent falls can change rapidly during the acute phase of illness.

Factor Analysis

As the STRATIFY scale is a brief, additive checklist rather than a complex inventory, formal factor analysis is generally employed to confirm the independence of the five components rather than to establish underlying latent psychological constructs. Studies supporting the scale’s development confirmed that the five listed factors—fall history, agitation, visual impairment, toilet needs, and mobility issues—are indeed independent predictors of fall risk.

The results of such analyses support the scale’s scoring method, where each factor contributes equally (one point) to the overall risk score. This structure reinforces the understanding that fall risk is truly multifactorial, and the presence of any combination of these independent risk factors significantly elevates the overall probability of an adverse event.

Instrument

Test Type: Clinical Checklist/Risk Assessment Tool

Format: Brief, five-item dichotomous checklist (Yes/No scoring)

Language Available: English (Original), Dutch, and various other translations due to widespread international use.

Population Group: Inpatients (Hospitalized patients)

Age Group: Older adults (Typically 65 years and older)

Population Details: Primarily used in acute medical, surgical, and geriatric wards where patients are often frail, acutely ill, or undergoing post-operative recovery, increasing their baseline fall risk assessment.

Test Methodology: The scale is administered through direct observation, review of the patient’s medical chart, and brief interviews with the patient or family. A score of 1 is assigned for each positive risk factor, resulting in a total score ranging from 0 to 5. A score of 2 or more typically mandates the implementation of high-risk fall prevention protocols.

Keywords

Inpatient fall, STRATIFY score, Clinical observation, Elderly hospitalization, Preventative protocol, Nursing checklist, Risk stratification, Mobility assessment.

Authors

Author ORCID Identifier: Not publicly standardized for all authors; professional profiles should be consulted.

Affiliation Email addresses: Contact details typically associated with St. Thomas’ Hospital, London, UK (initial development).

Correspondence Address: Correspondence is generally directed to the Geriatric Medicine Department affiliated with the authors at the time of publication (1997).

Permissions & Fee and Test Year

The STRATIFY scale was originally published in 1997. Due to its status as a widely recognized clinical screening tool, the instrument is generally considered to be in the public domain for clinical use within healthcare institutions, and no specific fee is typically required for its implementation in clinical settings. Permission is required for commercial reproduction or modification. The original PDF for the Dutch adaptation can be downloaded here: Toelichtingsformulier (Explanation Form).

Reference’s

Oliver D, Britton M, Seed, P, Martin FC, Hopper AH. (1997). Development and evaluation of evidence based risk assessment tool (STRATIFY) for predicting falls in hospital in-patients. Age and Ageing, 26(3), 159–165.

CBO Richtlijn Preventie van valincidenten bij ouderen. (2004). [CBO Guideline Prevention of fall incidents in the elderly]. Utrecht: College voor Zorgverzekeringen.

Items of the St. Thomas s Risk Assessment Tool in falling elderly inpatients

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

• een val sinds opname (A fall since admission/A history of falling)
• agitatie (Agitation)
• verminderde visus (Reduced vision/Visual impairment)
• frequent toiletbezoek (Frequent toilet visits/Need for frequent toileting or incontinence)
• transferproblemen/mobiliteitsproblemen (Transfer difficulties/Impaired mobility)