Implementing a Humpty Dumpty

Pediatric Falls Assessment

in Pediatric Patients
Deborah Hill-Rodriguez, ARNP, MSN, CS-BC,
Maria Lina Bing Wood, ARNP, MSN,
Patricia R. Messmer, PhD, RN,BC, FAAN, Mary Ann Henry, MBA, RN,
Deborah Salani, ANRP, MSN, CPON, CPN, Dania Vasquez, ARNP, MSN,
Maria E Soto, ARNP, MSN, Cheryl Minick, BSN, RN, CPN

Miami Childrens Hospital

Largest free-standing 268 beds pediatric teaching

hospital in the SE U.S.; Only licensed specialty hospital in
South Florida exclusively for children.
One of first Five ANCC free-standing US childrens
hospitals; Florida 1st free standing childrens.
More than 40 pediatric specialties & subspecialties with a
650+ medical and 700+ nursing staff; Treat more than
185,000 patients/year; 2nd busiest Miami Dade County
ED (87,000 visits/yr).
1st US hospital to host Radio Lollipop, radio station
providing entertainment; 1st Florida hospital Big Apple
Circus Clown Care program.
1st Mobile Preventive Care program.

JCAHO National Patient Safety (NPSG)

Goal # 9 Falls Prevention!
Reduce the risk of patient harm resulting
from falls.
Assess and periodically reassess each
patients risk for falling, including the
potential risk associated with the patients
medication regimen, and take action to
address any identified risks (JC Resources).

THINK
SAFETY

National Safe Kids Campaign

Falls-An unintended event resulting in a person coming to rest on the
ground/floor or other lower level (witnessed) or reported to have landed
on the floor (unwitnessed) not due to any intentional movement or
extrinsic force such as a stroke, fainting, seizure. (FHA)
National Safe Kids Campaign http://www.safekids.org/tier3.
NCPS Fall Prevention and Management www.patientsafety.gov/FallPrev

According to the National Safe Kids Campaign falls are the leading cause
of unintentional injury for children
Half of these injuries occurred in children younger than five years old.

Children under 10 have the greatest risk of fall-related death and injury.
More than 2.3 million children < 14 were treated in the ED in 2002
Over half of all non-fatal injuries are associated to falls.
Curiosity and development of motor skills have been related to falls.

Children At-High Risk For Falls

Preschoolers
Children under ten are twice at risk for falls
compared with the total population
Children with disabilities and minimal
mobility may be at greater risk
Children in wheelchairs, regardless of
cognitive ability are at risk from wheelchair
tips and falls

Developing a Pediatric Falls Scale

Reviewed falls data on most common elements

Age- 19-24 months old

Gender- (Male 2:1 ratio)
Diagnosis Respiratory/Pulmonary/ENT #1, Neurological #2
Not within 24 hours post-op
Had not received any medications that affect LOC
Had not been NPO for more than 24 hours
Fell on a Monday, followed by Thursday
Highest in October
Related to equipment
- Tripped over piece of equipment or furniture
- Fell out of crib
- Fell in liquid

Humpty Dumpty Scale Parameters

Age
Gender
Diagnosis
Cognitive impairments
Environmental Factors
Response to Surgery / Sedation / Anesthesia
Medication usage
Falls Assessment Tool score- At risk for falls if above 12
Maximum Score 23
Minimum Score 7

Review of Literature
Grenier-Sennelier, C., et al (2002). Designing adverse event prevention
programs using quality management methods: case of hospital falls.
International Jn Quality in Health Care, 14, 419-426.
Hendrich, A.L., Bender, P.S., Nyhuis, A. (2003). Validation of the Hendrich II
Fall Risk Model: A large concurrent case/control study of hospitalized
patients. Applied Nursing Research, 16(1), 9-21.
Lord, S.R., et al (2005). The effect of an individualized fall prevention
program on fall risk and falls in older people: A randomized,
controlled trial. Jn American Geriatrics Society, 53 (8). 1296-1304.
Meyers, H.& Nikoletti, S. (2003). Fall risk assessment: A prospective
investigation of nurses clinical judgment and risk assessment tools in
predicting patient falls. International Jn Nursing Practice, 9, 158-165.
OConnell, B., Myers, H. (2002). Research in brief. The sensitivity and
specificity of the Morse Fall Scale in an acute care setting. Journal of
Clinical Nursing, 11(1), 134-135.

Review of Literature
Britton, J.W. (2005). Kids cant fly: preventing fall injuries in children.
State Medical Society of Wisconsin, 104(1), 33-36.
Graf, E. Pediatric hospital falls: Development of a predictor model to
guide pediatric clinical practice. STTI Convention, Nov. 2005.
Murray, J.A., et al. (2000). Pediatric falls: is height a predictor of injury
and outcome? The American Surgeon, 66(9), 863-865.
Park, S.H., Cho, B.M., Oh, S.M. (2004). Head injuries from falls in
preschool children. Yonsei Medical Journal, 45(2), 229-232.
Pillai, S.B., et al. (2000). Fall injuries in pediatric population: Safer
and most cost effective management. Jn Trauma, 48(6), 1050-51.
Tarantino, C.A., Dowd, M.D., Murdock, T.C. (1999). Short vertical falls in
infants. Pediatric Emergency Care, 15(1), 5-8.
Wirrell, E.C., et al. (1996). Accidental injury in a serious risk in children
with typical absence epilepsy. Archives Neurology, 53(9), 929-32.

Falls Assesssment Instruments

Adult Tools

Morse Fall Scale (2002)

Hendrich (2003)

Pediatric Tools

Elaine Graf (Graf-PIF Scale Childrens Memorial Medical Center)
-

LOS- for each additional 5 days- 2Xs the risk for falls
Children without an IV- 4Xs the risk
PT/OT ordered- 3Xs the risk
Seizure Medication- 5Xs the risk
Orthopedic diagnosis- 4Xs the risk

MCH The Humpty Dumpty Falls Assessment Tool

- Based on a retrospective review of pediatric falls
- Most common elements included in grading criteria of the tool

Falls Assessment Tool

(The Humpty Dumpty Scale )

Assessing/screening for risk factors for falls in children

Using identifiers to implement falls prevention protocol
Implementing protocol according to patient needs
Reassessing patient and modifying as appropriate
Reporting incidence of falls
Measuring/monitoring rates
Enhancing falls prevention program

Patient Falls Safety Protocol

Low Risk Standard (Score 7-11)

Assess elimination needs, assist as needed

Call light is with in reach, educate patient/family on its
functionally

Environment clear of unused equipment, furnitures in
place, clear of hazards

Orientation to room

Bed in low position, brakes on

Side rails X2 or 4 up, assess large gaps, such that a patient
could get extremity or other body part entrapped, use
additional safety precautions.

Patient Falls Safety Protocol

Low Risk Standard (Score 7-11)

Use of non-skid footwear for ambulating patients

Use of appropriate size clothing to prevent risk of
tripping

Assess for adequate lighting, leave nightlights on

Patient and family education available to parents
and patients

Document fall prevention teaching and include in
the plan of care

High Risk Standard (Score 12 or >)

Evaluate medication administration times
Remove all unused equipment out of room
Protective barriers to close off spaces, gaps in the bed
Keep door open at all times unless specified isolation
precaution are in use

Keep bed in the lowest position, unless patient is
directly attended

Educate Patient/Family regarding falls prevention

Document in the nursing narrative teaching and plan of
care

High Risk Standard (Score 12 or more)

Identify with Humpty Dumpty Sticker/Sign
on patients, in beds & charts

Check patient minimum every hour

Accompany patient with ambulation

Move patient closer to nurses station

Assess need for 1:1 supervision

Purpose/Methodology
Purpose
To validate Humpty Dumpty Scale

Methodology

Research design was a comparative study comparing actual 2005
falls data to a control group matching for age, gender and
diagnosis

Research Questions

What parameters should be included in a pediatric falls assessment
tool?

What score indicates at-risk for falls?

Methodology
Unit Variable Neurological
Oncology
Special Medical
Respiratory
Surgical
CICU
CV Unit
PICU
Playroom (Units)
Total

Actual Falls %
22 (31%)
10 (14%)
12 (17%)
9 (13%)
3 (4%)
3 (4%)
3 (4%)
2 (3%)
7 (10%)
71 (100%)

Comparative Falls %
31 (44%)
6 (8.5%)
19 (27%)
7 (10%)
2 (3%)
3 (4%)
1 (1%)
2 (3%)
7 (10%)
71 (100%)

Demographics
Diagnosis

Neurological
Gastrointestinal
Respiratory
Renal
Cardiac
Oncological
Surgical
Orthopedic
Other

Total

Actual Falls % Comparative Falls %

34 (48 %)
11 (16%)
9 (13%)
5 (7.0%)
3 (4.2%)
3 (4.2%)
1 (1.4%)
1 (1.4%)
4 (5.6%)

71 (100.0%)

33 (47%)
10 (14%)
9 (12%)
6 (8.5%)
3 (4.2%)
3 (4.2%)
1 (1.4%)
1 (1.4%)
4 (5.6%)

71 (100.0%)

Demographics

Age
2 Years or <
3 to 6 Years
7 to 12 Years
13 Years or Older
Total

Actual Falls %
31 (44%)
11 (16%)
8 (11%
21 (30%)
71 (100%)

Comparative Falls %
31 (44%)
11 (16%)
9 (13%)
20 (28%)
71 (100%)

Gender
Female
Male
Total

Actual Falls %
35 (49.3%)
36 (50.7%)
71 (100.0)

Comparative Falls %
35 (49.3%)
36 (50.7%)
71 (100.0)

Data Analysis

Humpty Dumpty Falls Scale

Mean

Std. Deviation

HDFS Actual

13.2154

2.26724

65

HDFS Control

12.9385

2.77194

65

Tests of Within-Subjects Contrasts: MEASURE_1

Type III Sum of
Squares

df

Mean Square

Sig.

Linear

2.492

2.492

.549

.461

Linear

290.508

64

4.539

Source

falls

falls
Error(falls)

Humpty Dumpty Falls Scale Comparison

Mean

Std. Deviation

FS Actual

14.9571

2.04610

70

FS Control

14.2143

2.68054

70

Tests of Within-Subjects MEASURE Type III

Type III Sum of
Squares

Source

falls

df

Mean Square

Sig.

falls

Linear

19.314

19.314

5.879

.018

Error(falls)

Linear

226.686

69

3.285

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Data Analysis
Mean Scores Actual & Comparison Groups Humpty Dumpty Falls Scale

15
12

13.21

12.93

actual
comparison

6
3
0
Group

Humpty Dumpty Patient Falls Program

Humpty Dumpty Falls Prevention Program trademarked by MCH
Interest from:

National Patient Safety Foundation for journal publication, webinar

JCAHO

Child Health Corporation of America

National Association of Childrens Hospitals and Related Institutions

American Pediatric Surgical Nurses Association, Society of Pediatric
Nursing

Other hospitals (over 100 hospitals have inquired with approx. 20
purchased)

NDNQI

Cerner Documentation Systems

AIG Insurance for MCHs claim prevention
Marketing materials for purchase and distribution

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Outcomes
Patient Outcomes
Increased knowledge about falls
Reduced severity of fall related injuries by 28%
reduction in falls since implementation (2005)

Program Outcomes
Interdisciplinary approach to fall prevention and
management
Increased staff awareness of fall prevention and
management support
Reliability/validity of tool

Thank you!
For more information, contact
Deborah Hill-Rodriguez, MSN, ARNP, CS,BC
deborah.hill@mch.com

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