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
PurposeTo 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

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

Total

71 (100.0%)

71 (100.0%)

Demographics
Age 2 Years or < 3 to 6 Years 7 to 12 Years 13 Years or Older Total Gender Female Male Total Actual Falls % 31 (44%) 11 (16%) 8 (11% 21 (30%) 71 (100%) Actual Falls % 35 (49.3%) 36 (50.7%) 71 (100.0) Comparative Falls % 31 (44%) 11 (16%) 9 (13%) 20 (28%) 71 (100%) Comparative Falls % 35 (49.3%) 36 (50.7%) 71 (100.0)

Humpty Dumpty Falls Scale

Mean HDFS Actual HDFS Control 13.2154 12.9385

Data Analysis
Std. Deviation 2.26724 2.77194 N 65 65

Tests of Within-Subjects Contrasts: MEASURE_1

Source falls Error(falls) falls Linear Linear Type III Sum of Squares 2.492 290.508 df 1 64 Mean Square 2.492 4.539 F .549 Sig. .461

Humpty Dumpty Falls Scale Comparison

Mean FS Actual FS Control 14.9571 14.2143 Std. Deviation 2.04610 2.68054 N 70 70

Tests of Within-Subjects MEASURE Type III

Source falls Error(falls) falls Linear Linear Type III Sum of Squares 19.314 226.686 df 1 69 Mean Square 19.314 3.285 F 5.879 Sig. .018

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

15 12 9 6 3 0 Group 13.21 12.93

actual comparison

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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