Embed Size (px)
Citation preview
PEDIATRIC FALLS RISK ASSESSMENT IN THE HOSPITALIZED CHILD
Ellen Kissinger RN B.A., California State University, Sacramento 1984
Angie Marin RN
B.S.N., California State University, Sacramento 1980
THESIS
Submitted in partial satisfaction of the requirements for the degrees of
MASTER OF SCIENCE
in
NURSING
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
FALL 2010
ii
© 2010
Ellen Kissinger RN Angie Marin RN
ALL RIGHTS RESERVED
iii
PEDIATRIC FALLS RISK ASSESSMENT IN THE HOSPITALIZED CHILD
A Thesis
by
Ellen Kissinger RN
Angie Marin RN
Approved by: ______________________________, Committee Chair Kelly Tobar RN, MS, EdD ______________________________, Second Reader Mary E Summers, RN, PhD ___________________________ Date
iv
Ellen Kissinger RN Students:
Angie Marin RN
I certify that these students have met the requirements for format contained in the University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis.
________________________________, Graduate Coordinator __________________ Alexa Curtis RN, FNP, PhD Date Department of Nursing
v
Abstract
of
PEDIATRIC FALLS RISK ASSESSMENT IN THE HOSPITALIZED CHILD
by
Ellen Kissinger RN
Angie Marin RN
Statement of Collaboration
This project was a collaborative effort in which the work and decision making was
equally shared by both researchers.
Statement of the Problem
In 2005, a Joint Commission initiated a national safety goal to reduce patient harm
from falls. The Morse Fall Scale, a validated and the most rigorous scale tested for adults has
never been validated in children and is inappropriately being used by pediatric nurses to assess
the fall risk of hospitalized pediatric patients. Testing is needed to validate the few
developmentally appropriate pediatric fall scales that are available for hospitalized pediatric
patients. Therefore, a descriptive exploratory study was done to examine the sensitivity and
specificity of the Cummings Pediatric Fall Assessment Scale, the characteristics frequently
identified with falls and the sensitivity of the commonly used adult Morse Fall assessment
Scale.
vi
Sources of Data
Retrospective chart review of 71 documented pediatric falls during hospitalization
was done on children who had fallen during their hospitalization, collecting characteristics
frequently identified with pediatric falls. Of the 71 charts, 47 charts were reviewed to examine
the sensitivity of the Cummings Pediatric Falls Assessment Scare and 34 charts were reviewed
to examine the sensitivity of the Morse Fall Scale tool. An additional 30 health records of
children who did not fall were examined to identify the specificity of the Cummings Fall
Assessment Scale.
Conclusions Reached
Children less than 5 years of age and adolescents comprised the majority of falls
reported. Male children fell more often then female children. Most falls occurred in the child’s
room. Parental presence was not a deterrent to the fall. Children fell more commonly in the
late morning and the early evening, with the majority of falls occurring within 72 hours of
admission. Our findings along with previous research a support a child’s maturing cognitive
and motor development plays a major factor in pediatric falls, as well as expands on new
knowledge to support the use of a developmentally appropriate fall risk assessment tool to
identify hospitalized children at risk for falls.
_______________________, Committee Chair Kelly Tobar RN, MS, EdD _______________________ Date
vii
DEDICATION
First and foremost, we dedicate this thesis to Margie Crandall RN, PhD. It has been an
honor to have her guidance with our study. She has taught us both consciously and
unconsciously how good research is done. We so appreciate all her contribution of time and
talent to make our masters experience so worthwhile.
The joy and enthusiasm she has for research was contagious and motivational, even in
tough times during the pursuit of our master degree. Margie’s high standard for excellence in
nursing practice has not only driven our practice but also taught us not to settle for anything
less. We are also thankful for the excellent examples she has provided as a dedicated pediatric
nurse whose ideals and concepts have had a remarkable influence on our career as pediatric
nurses and truly inspired us to pursue our masters in nursing.
viii
ACKNOWLEDGMENT
It is a pleasure that we take time to thank those who made this thesis possible.
We would first like to acknowledge Professor Mary Summers for her continued
support during our graduate school experience. We appreciate the time spent with us,
encouraging our progress through the program, advising us on our thesis project, and
pushing us to become the Master’s level nurses we are today.
Professor Jacqueline Tobar deserves special thanks as our thesis committee
member and advisor. Without her understanding, encouragement and personal
guidance it would have been impossible for us to have to complete our thesis.
Our deepest gratitude goes to our families for their love and support
throughout this thesis process. It is evident to us that this work would be simply
impossible without their encouragement and understanding.
Lastly, to each other for our mutual understanding and support, humor and
perseverance through the many hours we spent working on our thesis and the years of
graduate school.
ix
TABLE OF CONTENTS Page
Dedication…………………………………..…………………………………………………vii
Acknowledgment.………………………….….……………………………….……………..viii
List of Tables….…………………………………...…………………………………………..xi
Chapter
1. PROBLEM STATEMENT…………………………………………………………………1
Statement of Collaboration………………………………………………………….…1
Introduction………………………………………………………………………….....1
Problem Statement……………………………………………………………………..2
Research Questions…………………………………………………………………….3
Purpose of Study………..……………...………………………………………………3
Definitions……………………………...……………………………………………...3
Assumptions..……………………………...…………………………………………..4
Summary……………………………………………………………………………….5
2. LITERATURE REVIEW……..…………………………………………………………....6
Introduction …………………………………………………………………………...6
Incidence of Inpatient Pediatric Falls……………………………………………….…6
Characteristics of Pediatrics Hospital Falls……………………………………………7
Environment………………………………………...………………………………... 8
Age……..…………………………………………………………….………………...9
Time of day…………………………………………………………………………...11
Parental presence……………………………………………………………………...11
Patient characteristics………………………………………………………………....11
Related injuries……………………………………………………….………………12
Risk factors and pediatric fall risk assessment scales………………………………...13
Summary……………..………………………………..………….……….………….15
x
3. THEORETICAL FRAMEWORK………………………………………………………...17
Introduction……………………………………………………………….……….….17
Gesell’s Theory of Motor Development….………………………………….……….17
Piaget’s Theory of Cognitive Development.…………….…………………...………19
Summary……………………………………………………………………………...21
4. METHODOLGY……………………….…………………………………………………22
Design…………………………………………………………………………..….…22
Setting………………………………………………………………………………...23
Sample.……………………………………………………………………………….23
Measures……………………………………………………………………………...24
Procedure……………………………………………………………………………..25
Analysis………………………………………………………………………………27
5. RESULTS AND DISCUSSION…………………………………………………………...29
Characteristics ……….………………………………………………………………29
Sensitivity of Tools…………………………………………………………………..30
Specificity of Cummings Pediatric Fall Assessment Scale…………………………..31
Characteristics ……………...……………………..…………………….……...……31
Sensitivity and Specificity of Cummings Pediatric Fall Assessment ………………..35
6. CONCLUSIONS AND RECOMMENDATIONS………………………….…...….……...40
Overview…………………………………………………………………..…………40
Findings ..................................................................................................................... 40
Limitations ................................................................................................................ 40
Implications for Research.…………………………………………………………... 41
Implications for Practice.………………………….………………………………….41
Appendix A. Cummings Pediatric Fall Assessment Scale …………………………..……...44
Appendix B. Morse Fall Assessment………………………………………………………...45
References……………………………………………………………………………………..46
xi
LIST OF TABLES Page
1. Table I Characteristic Associated with the Fall……..…………………………..37
2. Table II Age in Years of Children Who Fell……………………………………..39
1
Chapter 1
PROBLEM STATEMENT
Statement of Collaboration
This project was a collaborative effort in which the work and decision making
was equally shared by both researchers.
Introduction
Promoting patient safety is a priority for all nurses. While most patient safety
issues require comprehensive interdisciplinary approaches, the responsibility for
prevention of patient falls is driven by nurse sensitive indicators. In 2005, The Joint
Commission established a National Patient Safety Goal for the assessment of patients
at risk for falling which later required the implementation and evaluation of a fall risk
prevention program (The Joint Commission [JC], 2006). An important aspect of a
hospitals patient safety and quality improvement is its ability to track and benchmark
quality indicators like fall rates. A critical component needed to identify patients at
risk for falls and to evaluate a fall prevention program is the availability of a valid fall
risk assessment scale. While validated adult fall risk assessment scales are available
(O’Connell & Meyer, 2002;Hendrich, 2007), there is only limited psychometric
testing for pediatric fall risk scales that are reportedly being used in hospitals (Child
Health Corporation of America Nursing Falls Study Task Force, 2009). Therefore,
fall risk assessment scales validated in adult populations are commonly
inappropriately applied to hospitalized children to determine their fall risks.
2
Problem Statement
In the adult population, characteristics of falls, valid fall risk assessment scales
and the efficacy of fall prevention programs are reported. However, adult fall risk
assessment scales, including the Morse Fall Scale, the most rigorous scale tested, were
never validated with children (Razmus, Wilson, Smith, & Newman, 2006). When the
Morse Fall Scale was tested with children, it did little better than chance in identifying
children’s fall risks (Razmus, et al. 2006). Nonetheless, adult fall risk scales including
the Morse Fall Scale continue to be applied to hospitalized children to identify fall
risk.
Interestingly, non-hospital related falls are the leading cause of unintentional
injury for children 14 years and younger (Safe Kids USA, 2009). In addition,
children’s fall risk factors are related to their age and development. While a
significant amount of information is known about non-hospital fall related injuries,
there is little in the literature about children’s falls in the pediatric acute care setting.
More importantly, the few developmentally appropriate fall risk scales proposed for
children have limited psychometric testing to support their use with children (Child
Health Corporation of America Nursing Falls Study Task Force, 2009). While some
proposed pediatric fall scales are associated with a monetary cost, the Cummings
Pediatric Fall Assessment Scale is available for use. Permission to use this tool can be
obtained by contacting Phoenix Children’s Hospital. Even though a National Safety
Goal was established to assess patients at risk for falls, adult scales are inappropriate
and further testing is needed to validate the few developmentally appropriate pediatric
3
fall scales available (Child Health Corporation of America Nursing Falls Study Task
Force, 2009).
Research Questions
The research questions are the following:
1. What are common children fall risk factors in the acute hospital setting?
2. In the pediatric acute care setting, what is the sensitivity of the Cummings
Pediatric Fall Assessment Scale in predicting hospitalized children’s fall risk?
3. In the pediatric acute care setting, what is the sensitivity of the Morse Fall
Scale in predicting hospitalized children’s fall risk?
Purpose of Study
The purpose of this study is threefold: (a) to identify common hospital fall risk
factors for hospitalized pediatric patients, (b) to assess the sensitivity validity of the
Cummings Pediatric Fall Assessment Scale and (c) assess the currently used adult
Morse Fall Scale’s sensitivity to predict pediatric falls in the acute care hospital
setting. The findings from this study will contribute to nursing knowledge regarding
pediatric fall risk factors and the use of a fall risk assessment scale that is sensitive in
predicting falls in the hospitalized pediatric patient. Therefore, pediatric fall
prevention would be enhanced by the inclusion of a pediatric sensitive fall assessment
scale for hospitalized children.
Definitions
Acute care hospitalized children. For the purpose of this study, we used the
admission criteria to the pediatric acute care unit at the institution where this study
4
was conducted. Patients who are sixteen years of age or less at the time of hospital
admission will be considered pediatric patients.
Fall. The Joint Commission leaves the definition of a fall up to the institution.
A fall is often defined as a sudden unexpected descent from standing, sitting, or
horizontal position including slipping from a chair to the floor (Hitcho et al., 2004).
The institution at which the data was collected defines a fall as sudden, uncontrolled,
unintentional, downward displacement of the body to the ground or other object,
excluding falls resulting from violent blows or other purposeful actions
(Patient Care Standard IV-05, UCDHS intranet website, 2010).
Fall Risk Assessment Scale. An instrument that quickly identifies patients at
risk for falls; thus, allowing for the implementation of preventive and protective
measures, as well as, to monitor the patient throughout their hospitalization
(Morse, 2006).
Assumptions
There are four assumptions related to children’s fall risks.
1. The novel and unknown hospital environment and equipment places
children at risk for falls.
2. Hospitalization is generally associated with impairments in children’s
motor and cognitive abilities.
3. Children’s motor and cognitive development influence their fall risk.
4. A fall risk assessment scale is a component of a comprehensive fall
prevention program.
5
Summary
Little is known about fall risks in hospitalized children. Therefore, a
descriptive research design was used to study the frequency of factors associated with
children’s falls, the sensitivity of a pediatric fall risk assessment scale and the
sensitivity of a frequently used adult scale to predict falls in hospitalized children.
Because children are at a developmental risk for injuries associated with falls,
conducting this study will provide insight for hospital nurses to develop a pediatric fall
risk assessment program.
6
Chapter 2
LITERATURE REVIEW
Introduction
Falls are a leading cause of injury in children with approximately two million
children experiencing fall related injuries annually (Safe Kids, 2009). A systematic
review of unintentional community fall injuries in children identified consistent risk
factors as children six years and younger, males and lower socioeconomic status
(Khambalia et al., 2006). Usual timing of falls is during the afternoon and early
evening hours (Safe Kids, 2009; Istre et al., 2003), relating to play activities. While a
significant amount of information on non-hospital falls exists, less is known how a
child’s development, illness and environment influence the risk of children’s falls in
the hospital. The following areas describe current knowledge regarding the incidence,
characteristics of pediatric hospital fall risks, subsequent injuries, and available
Pediatric Fall Risk Assessment Scales.
Incidence of Inpatient Pediatric Falls
Comparing the incidence of pediatric falls between hospital settings is
compromised due to both differences in fall definitions effecting both the tracking and
fall rate calculations (Child Health Corporation of America Nursing Falls Study Task
Force, 2009). Based on a written hospital survey reporting the responses from 29
pediatric units, the majority of hospitals (88%) defined falls as an unplanned descent
to the floor. In addition, the majority of hospitals calculated the incidence based on
7
counting the number of falls per 1,000 patient days (Child Health Corporation of
America Nursing Fall Study Task Force, 2009).
In 1987, Nimityongskul and Anderson were the first to publish the incidence
for hospital falls in children. Data collected over a five-year period for falls described
an incidence of one fall for every 118 pediatric admissions. All reported falls were
related to environmental risks (e.g., beds, cribs, and chairs). More recent studies
(Cooper and Nolt 2007; Monson, Henry et al. 2008; Hill-Rodriguez, Messmer et al.
2008), reported a similar incidence of inpatient pediatric falls. Cooper and Nolt
(2007) stated that a one-year incidence of falls at a large children’s hospital was 0.8
patient falls per 1000 patient days. Another large university children’s hospital
described fall rates ranged from 1.0 to 0.56 per 1,000 patient days over a three-year
period (Hill-Rodriquez et al., 2008).
While most studies report the incidence of falls based on a wide developmental
age range, Monson et al. (2008) described the incidence of newborn falls from an 18
hospital healthcare system. During a 3-year study period, the estimated incidence of
newborn falls was 0.16 falls per 1,000 births. Recent data suggests that the incidence
of children’s falls are comparably less than what is reported (2.3 to 7 falls per 1,000
days) for inpatient adult fall rates (Hitcho et al., 2004).
Characteristics of Pediatric Hospital Falls
Based on a review of the pediatric inpatient falls literature, characteristics of
fall risks are the following: (a) environment, (e.g., hospital environment),
8
(b) developmental age, (c) time of day, (d) parental presence, and (e) patient
characteristics.
Environment. Environmental falls in hospitalized children are related to
equipment, activities and settings. In 1977, Helfer, Slovis and Black were the first to
report on hospital environmental factors as risks to hospitalized children. Based on 88
incident reports of children five years old or younger, equipment, falls from beds,
chairs, and toys were identified. These findings are similar for wider age ranges,
longer collection times and multi-site studies. Collecting falls data over a five-year
period on 76 children, Nimityongskul and Anderson (1987) reported similar hospital
environmental equipment fall risks (e.g., bed, crib, or chair) occurred from birth to 16
years. Expanding upon earlier studies, a later multi-center eight hospital study of
children 6 years and younger (Levene & Bonfield 1991), reported that hospital falls
(i.e., falls from beds, struck by equipment) were the most common occurring accidents
(78%) in the hospital.
Children’s activities identified as fall risks were falling in and out of bed,
falling while ambulating or going to the bathroom, falling while being held on
someone’s lap, being struck by another person, walking and slipping on wet floors and
tripping over equipment (Helfer, Slovis et al. 1977; Levene & Bonfield 1991; Razmus,
Wilson et al. 2006; Cooper & Nolt 2007; Tung, Liu et al. 2009). Interestingly, more
falls occurred with children with no equipment (15%) compared to a child with an IV
and IV pole (9%) (Razmus, Wilson et al. 2006).
9
Various reports on location of children’s falls in the hospital are reported
(Razmus, Wilson et al. 2006; Cooper and Nolt 2007). It appears there is little
difference in the rate of falls between the outpatient and inpatient settings. The
frequency of falls pre and post implementation of a fall prevention program were
essentially the same between the inpatient (49%) and outpatient departments (52%)
(Cooper & Nolt 2007). More specific to individual outpatient and inpatient units, the
highest number of falls occurred in the emergency and physical therapy outpatient
departments, and inpatient general acute pediatric (81%) setting compared to the
Pediatric Intensive Care Unit (PICU), and inpatient rehabilitation and oncology units
(Razmus, Wilson et al. 2006; Cooper & Nolt 2007). Even more specific to the
inpatient setting, Razmus et al. (2006) identified that the majority of falls occurred in
the child’s room compared to the bathroom.
Age. Similar to community fall injuries, age is a risk factor for inpatient
pediatric hospital falls. Falls have been reported to occur more frequently with
toddlers (25%), followed by adolescents (23%) and school-age children (19%)
(Cooper & Nolt 2007). The findings for the higher incidence of inpatient falls with
younger children have been corroborated with other studies (Nimityongskul
&Anderson 1987; McGreevey, 2005; JC, 2006; Cumming 2006; Tung, Liu et al.
2009). One of the first studies to address age (Nimityongskul & Anderson, 1987)
examined falls in children, from birth to 16 years. Compared to older children,
younger children five years or less had the highest incidence of falls (75%). In two
10
other studies (Cumming 2006; McGreevey, 2005), that examined fall profiles of
hospitalized children, toddlers were reported to have a higher incident of falls.
A few studies provided similar inpatient pediatric fall reports that were more
specific to children’s chronological age versus developmental stage (Hill-Rodriquez et
al., 2008; Wood, 2006). Hill-Rodriquez, et al., (2008), compared 150 pre-school and
school age children who fell while hospitalized. They reported that most falls
occurred in children younger than three years (37%) and 13 years and older (30%).
These specific chronological age findings are similar to a review of 71 pediatric
inpatient data done by Wood (2006). Wood (2006) described the most falls occurring
in children under three years and older than 12 years. Wood (2006) went on to report
that older children falls were associated with a neurological impairment.
Inpatient pediatric falls are related to children’s developmental abilities and
environmental needs. A nine year longitudinal review of 205 inpatient charts showed
the majority of falls were younger children who often fell from cribs (60%) (Lyons &
Oates 1993). Older children tended to fall less frequently and most commonly fell
from the bed (40%). Other common falls were children under one year who fell from
gurneys and adolescents who fell while ambulating or performing activities in the
bathroom (Cooper & Nolt 2007). One study (Monson, Henry et al. 2008) specifically
examined falls in newborn infants. Falls occurred during holding (i.e., when the
parent fell asleep during the night and early morning hours), in the delivery room,
from non-secured bassinets, and infant swings.
11
Time of day. The few studies (Cummings, 2006; McGreevey, 2005; Levene
& Bonfield, 1991) exploring the time of day as a risk for inpatient falls identified the
late morning, evening and sleeping hours as high risk for falling. Despite the reported
timing of inpatient falls, only one study described the reason for the timing of the falls.
Levene and Bonfield, (1991) described that falls occurred more frequently during
sleeping hours due to falls from beds.
Parental presence. Many nurses may expect that when parents and family
members are present, the likelihood of children falling would decrease due to the
family’s monitoring of the child’s activities and safety. Interestingly, parental
presence was not a deterrent to hospital falls with the majority of falls occurring
during parental presence. Levene and Bonfield (1991) found that a parent was present
52% of the time when a child fell. Razmus et al., (2006) reported that parents were
present 83% of the time during their child’s fall. This may be explained by the fact
that children feel more comfortable when their family is present and tend to perform
more normal developmental activities (e.g., running, etc.). Parents may have
unknowingly contributed to adolescent falls by respecting their child’s privacy and
leaving them unattended in the bathroom.
Patient characteristics. The common inpatient characteristic fall risks
include mobility impairment, impaired mental status, history of falls, length of stay
and gender (Razmus et al., 2006; Cummings, 2005; Graf, 2005). More specifically,
mobility impairments increasing fall risk have been described as orthopedic diagnosis,
seizures, sedating medications, impaired gait, and physical and occupational therapy
12
needs. Use of sedating medications including anti-seizure and pain medications and
developmental delays are conditions classified as impaired mental status. History
of inpatient falls risk have been defined as either a recent fall or a fall that occurred
within three months (Cummings, 2006; Razmus et al., 2006).
It is unclear how children’s gender and their length of stay in the hospital have
an influence on their fall risk. While some studies reported males fall more frequently
(Levene & Bonfield, 1991; Lyons & Oates, 1993; McGreevey, 2005), one study
reported females fell more often (55%) compared to males (Cooper & Nolt, 2007).
In Hill-Rodriguez et al., (2008) a study, based on a retrospective chart review of 150
documented falls, there was no difference in gender risk. The child’s length of stay
had little influence on their risk for falling. One study reported that there was no
difference for children’s fall risks with a length of stay of nine days (Razmus et al.,
2006). However, another report described children’s fall risk increases with
increasing length of stay (McGreevey, 2005).
Related injuries. Helfer, Slovis, and Black, (1977) provided the first evidence
for fall related injuries. In a review of 85 hospital fall related injuries, the majority of
children under five years (67%) had no apparent injury from falls from heights of
approximately 90 cm (i.e., three feet). The most common injury was small cuts,
scratches and bloody noses (20%). One child experienced a skull fracture with no
apparent sequela. A later study (Nimityongskul & Anderson, 1987) examined 76
children, from birth to 16 years of age, reported similar findings. Children’s fall from
13
surfaces, one to three feet, are generally associated with minor injuries (e.g., scalp
hematoma and facial lacerations). No spine or extremity injuries were noted.
Lyons and Oates (1993), chart review of 270 children identified that injuries
occurred in only 11% of the children who fell from 25 to 54 inch heights. Of the
injured children, the majorities of injuries were minor (94%) and involved the head
(e.g., contusions, small lacerations of the face or extremity). Two injuries involved
a fractured clavicle and skull. There was no difference between the non-injured
and injured children based on their weight or fall height. A later study
(Cooper & Nolt, 2007) provided further corroboration that the majority of children,
from birth to 18 years of age, experience minor injuries (51%) involving abrasions,
bruising and hematoma. Specific to newborn related hospital fall injuries (Monson,
Henry, Lambert, Schmitz, & Christensen, 2008) three out of fourteen newborns
experienced a depressed skull fracture or a small subgenera hematoma. There were no
deaths or abnormal examination at time of discharge. Serious injuries subsequent
from children’s falls of three feet or less in hospitals are extremely rare (Helfer et
al.1977; Nimityongskul & Anderson, 1987).
Risk factors and pediatric fall risk assessment scales. The majority of
pediatric fall risk tools were developed internally (81%) by hospital staff with little to
no validation (The Child Health Corporation of America Nursing Falls Study Task
Force, 2009). A major reason for internally developed scales is that the few newly
proposed pediatric fall scales have limited psychometric testing supporting their
sensitivity and specificity. Currently, four pediatric fall risk tools have reports of
14
preliminary testing supporting their application in the hospital setting. The tools
include the GRAF PIF, CHAMPS, Humpty Dumpty Fall Prevention and Cummings
Pediatric Fall Assessment Scale. Due to the recent development of these risk
assessment scales, only two tools (i.e., CHAMPS and the Humpty Dumpty Fall
Prevention) have validity testing published in peer review journals (Hill-Rodriguez et
al., 2009; Razmus et al. 2006). Other risk tools validation results are cited as
presentations at national conferences (Cummings, 2006: Graf, 2005). All fall risk
assessment tool report content validation by retrospective chart reviews comparing
children who fall with matched controls of children who did not fall.
Razmus and Wilson, (2006) developed the CHAMPS Pediatric Risk
Assessment Tool, comparing 100 children who fell to a match control. The CHAMPS
is comprised of reported best predictors of pediatric fall risk. These include change
in (a) mental status, (b) history of falls, (c) age less than 36 months and (d) mobility
impairment. No reports on the tool’s sensitivity or specificity were reported.
Graf (2005) study of 100 documented falls matched with 100 control subjects
reported that children with (a) history of a fall, (b) increasing length of stay,
(c) orthopedic diagnosis, (d) physical/occupational therapy needs, (e) seizure
medications and (f) being free of an IV/heparin lock were all variables that predicted
84% of falls in the study sample. While these fall risk categories comprised the
GRAF PIF Falls Risk Assessment Tool, no further testing of the tool was found.
The Humpty Dumpty Scale is comprised of six categories including (a) age,
(b) gender, (c) diagnosis, (d) cognitive impairment, (e) environmental factors, and
15
(f) response to surgery/sedation/anesthesia and medication usage (Hill-Rodriguez,
2008). Using a matched control design, a chart review of 153 children who fell and
153 controls reported that the tool’s high-risk children fell twice as often as low-risk
children did. However, the authors reported that the tool’s implementation did not
consistently improve fall rates. In addition, the tools sensitivity and specificity have
not been reported.
In 2005, at Phoenix Children’s Hospital in Phoenix, Arizona, Roni Cummings
developed the Cummings Pediatric Fall Assessment Tool. Based on pilot testing of 78
matched controls, six categories placing children at fall risk were proposed and make
up the categories of the Cummings Pediatric Fall Assessment Scale. The scale
categories include (a) history of falls, (b) physical alterations/impairments,
(c) functional status, (d) equipment, (e) impaired cognitive/psychological status and
(f) administered medications that potentially alter equilibrium (Cummings, 2006).
No data on sensitivity, specificity or effectiveness was provided.
Summary
Similarities in risks exist between community and inpatient pediatric falls (e.g.,
age, developmental environmental risks). In the pediatric hospitalized patient setting
multiple fall risks have been reported. Although the reported incidence and associated
injuries of inpatient falls appears lower for children than for adults, they still represent
risk for trauma and put an institution at risk. Therefore, all patients including children
need to be assessed for fall risk. While clinicians may consider children’s risk of a fall
low, a developmentally appropriate fall risk scale will help clinicians identify the most
16
vulnerable population and focus awareness and resources more appropriately to
prevent falls. Healthcare organizations must assure that the fall risk scales that they
are using are reliable and valid to predict falls in hospitalized children. There is
paucity of knowledge regarding pediatric inpatient falls related to inconsistent
definitions, classifications and measurement and injury rates used by hospitals (Child
Health Corporation of America Nursing Falls Study Task Force, 2009). Although
there are a few pediatric fall risk assessment scales developed, all need further
psychometric testing to support reliable and valid use of the scale.
17
Chapter 3
THEORETICAL FRAMEWORK
Introduction
In addressing pediatric falls, a developmental framework is needed to
understand how a maturing child’s development is a factor in pediatric falls for this
study. The works of two theorists were chosen to support our theoretical framework.
Gesell’s theory on motor development and Piaget’s theory on cognitive development
best support our findings.
Gesell’s Theory of Motor Development
It takes time to mature and this amount of time is expressed by age. Gesell’s
work (Gesell, 1969) contributed to the establishment of a theory of developmental
milestones, which has continued to be used by child health professionals. Gesell states
development is a continuous process, following a pattern of equilibrium and
disequilibrium interweaving in a steady progression to maturity. The equilibrium
periods can be looked at as a time when the child is consolidating learning and
mastering skills. They are the plateaus in development. The disequilibrium period
often occurs as the child is entering a new, quick time of growth and development,
when he is mastering new task and working new abilities. It is processed stage by
stage in an orderly sequence with each stage representing a degree of maturity. The
pattern of equilibrium and disequilibrium begins in infancy and progresses in rapid
cycles to a period of equilibrium and consolidation at age five. Gesell’s theory
consists of, (a) motor development, (b) adaptive behaviors, (c) language and
18
(d) personal social behavior. Since pediatric falls commonly occur with younger
children (e.g., toddlers) and likely relate to mobility independence, for the purpose of
this study we will focus on motor development. The progression of movement is most
commonly referred to as motor development.
Gross motor development involves full body movements involving the trunk
and legs, culminating in independent walking, running, and climbing. In the first
quarter of the first year, the infant gains control of his 12 oculomotor muscles. In the
second quarter, between 16-28 weeks the infant comes in command of the muscles
that support his head and moves his arms. In addition, the infant begins reaching out
for things to hold and learning to sit by leaning on hand (Gesell, 1969). The third
quarter, between 28-40 weeks, midline trunk stability allows the infant to sit and grasp
and transfer objects. The fourth quarter or between 40-52 weeks further motor
development of the infant’s legs allows independent sitting, creeping, and pulling to
stand. While by 12 months, infants are able to walk with help, and cruise around
furniture, independent walking without falling occurs around 18 months. Motor
development is further observed by infants running by two years, standing on one foot
by three years, skipping on one foot (hopping) by four years, and skipping on
alternating feet by five years (Gesell, 1969).
The motor development of early childhood helps to explain the infant’s
dependence on caregivers for their safety and the greater potential for younger
children falling as they take risks to progress through their normal motor development.
In addition to normal developmental risks to falls, hospitalized children who
19
experience motor impairments subsequent to disease or injury may exhibit varying
levels of motor instability as seen in early childhood. Therefore, both developmental
age and reason for hospitalization leading to motor instability place children at risk for
falling in the hospital setting.
Piaget’s Theory of Cognitive Development
Children’s developmental cognition and understanding influences their ability
to communicate with others, reason and understand consequences. These abilities
likely influence pediatric fall risks in the hospital. Jean Piaget defines how a child
cognitively adapts to its environment (i.e. intelligence). Behavior (adaptation to the
environment) is controlled through mental organizations called schemes (i.e. ideas or
perceptions) that the child uses to represent the world and designate actions (Huitt &
Hummel, 2003). Piaget describes two processes the child uses in attempt to adapt:
assimilation and accommodation. By assimilation, children incorporate new
knowledge, skills, ideas and insights into cognitive schemes already familiar to them
(Mussen, 2006). Children learn these skills to enable them to accommodate to new
situations. Accommodation is defined by Piaget as changing and organizing to
existing schemas to solve more difficult tasks and form new schemas (Mussen, 2006).
Both of these processes are used throughout life as the child adapts to the environment
in a more complex manner. There are two major aspects to his theory: the process of
coming to know and the stages we move through as we gradually acquire this ability.
Piaget also states that children under stress regress downward on the developmental
scale, which would make them more vulnerable to sustaining a fall.
20
Piaget described four stages of cognitive development and relates them to a
person's age and ability to understand and assimilate new information. The four stages
are the following: (a) Sensorimotor stage that occurs in Infancy (b) Pre-operational
stage seen in toddler and early childhood (c) Concrete operational that occurs in
elementary and early adolescence, and (d) Formal operational stage seen in
adolescence and adulthood (Mussen, 2006).
During the sensorimotor stage of infancy, the child learns about himself and
his environment through motor and reflex actions. He can differentiate self from
objects and recognizes self as agent of action and begins to act intentionally. During
the preoperational stage, toddlers and pre-schoolers apply their new knowledge of
language. The child is still egocentric and has difficulty taking the viewpoint of
others. Elementary and early adolescents or concrete operations can think logically
about objects and events. In adolescence and adulthood or formal operations,
individuals can think logically about objects and events and is concerned with the
hypothetical situations, the future, and ideological problems. Based on this theory,
younger children are most vulnerable in the hospital setting due to their limited
understanding and experience.
Developmental risks (e.g., falls) may occur due to the child’s inability to
understand the consequences of their actions. Similar situations may occur with
children experiencing cognitive impairments due to injuries or illness. Therefore,
similar to motor abilities, cognitive abilities as influenced by both normal
development and/or impairments may place children at risk for falls.
21
Summary
Based on these two theories, family members and nurses need to consider
normal childhood development, particularly the stages of early childhood
development (i.e. 1-5 years), and impairments to developmental abilities regardless
of age when determining a hospitalized child’s risk for falling. While normal
developmental growth may explain why younger children have the highest incidence
of hospital fall, the cognitive and motor impairments commonly seen in hospitalized
adolescents who have experienced traumatic brain injury or neurological impairment
may explain why this age group is reported to have the second highest incidence of
falls.
22
Chapter 4
METHODOLOGY
Design
Very little psychometric testing has been reported on the Cummings Pediatric
Fall Assessment Scale. Therefore, a descriptive exploratory study was done to
describe the following:
1. Hospitalized children’s characteristics frequently documented with falls in
the acute hospital setting.
2. The sensitivity and specificity of the Cummings Pediatric Fall Assessment
Scale and Morse Fall Scale in predicting hospitalized children’s fall risk on
admission to the hospital and at the time of the fall.
3. The specificity of the Cummings Pediatric Fall Assessment Scale in
predicting hospitalized children’s fall risk on admission to the hospital
and at the time of discharge.
This descriptive exploratory study will examine factors surrounding pediatric falls,
examine the sensitivity of two scales to identify hospitalized children who are high
risk for falls and explore the specificity of one pediatric fall risk scale. A fall tool
needs to be sensitive to identify patients who are at high risk for sustaining a fall
during their hospitalization and specific to correctly identify patients who are not at
risk for sustaining a fall during their hospitalization.
23
Setting The facility is a 110 bed children’s hospital within a university teaching
hospital. There are 33 areas of pediatric medical specialties including pediatric
hematology oncology, pediatric physical medicine and rehabilitation, trauma and
critical care. This institution is the only Level One Pediatric Trauma Center for inland
Northern California. The pediatric unit is a 36-bed unit with an all RN staff that
serves approximately 3,200 pediatric patients annually with an average length of stay
of 3.5 days. The nurse cares for children with diverse illnesses, ranging from trauma,
oncology, and rehabilitation to chronic illness.
Sample
A retrospective chart review of 102 pre-existing health records, between
January 1, 2004 through December 31, 2008, was conducted to identify patient
characteristics and circumstances surrounding pediatric falls and to examine the
sensitivity or validity of Cummings Pediatric Fall Assessment Scale and the Morse
Fall Scale to identify children who are high risk for falling. Inclusion criteria included
all children between the ages of 3 months to 19 years experiencing a documented fall.
Based on inclusion criteria, a total of 72 charts reported were identified that
had documented falls between January 1, 2004 and December 31, 2008 using the
incident reporting system. One chart was a duplicate, reducing the total charts to 71
that provided data for the children’s characteristics frequently documented with
hospital falls. In addition, only 47 charts were reviewed for the Cummings Pediatric
Fall Assessment Scale’s sensitivity to identify children at high risk for falls and 34
24
charts were reviewed to examine the sensitivity of the Morse Fall Scale. These
reductions in the charts reviewed were due to missing documentation for the child’s
fall risk in the chart.
Lastly, a convenience sample of 30 preexisting heath records of children who
did not fall between January 1, 2004 through December 31, 2008 were reviewed.
Based on this sample, the Cummings Pediatric Fall Assessment Scale was used to
score the pre-existing health records of children on day of admission and day of
discharge to examine the scale’s specificity. This sample was obtained to examine a
sample of hospitalized children who did not fall to explore the scales specificity to
screen for low risk hospitalized children.
Measures The Cumming Pediatric Fall Assessment Scale is easy to use, and the clinician
can quickly add the score from the categories to determine the child’s risk for falling.
It is estimated to take approximately 2-3 minutes to score a child. The Cummings
Pediatric Fall Assessment Scale is a six-item scale that can be used with children as
young as three months (see Addendum A). The scales six items screen for the
existence of the following: (a) a history of falls within 3 months, (b) physical
alteration and impairment, (c) functional status, (d) equipment, (e) cognitive/
psychological impairments, and (f) medications that alter equilibrium. A child is
screened for each of the six items and receives a numeric score ranging from 0 to 16
depending on their health status. For each of the items, a score of 0 is assigned to a
“no” response and a “yes” response is assigned a score ranging from 1-3. The six
25
items on the scale are totaled. A total score of zero is “no risk”, a total score between
1-7 is low risk and a total score equal to or greater than 8 is “high risk.”
The Morse Falls Scale is a simple and quick method of assessing a patient’s
likelihood of falling (see Addendum B). It is estimated to take approximately three
minutes to rate a patient. It consists of six variables that screen for a patient’s risk of
falling. A score of 0 is assigned for a “no” response, and for each existing
characteristic with a “yes” response. The score ranges from 15-30. Characteristic that
are associated with an increased likelihood of falling have a higher numeric value
assigned to the scale. The total score of the six characteristics provides the total score,
which a risk level is assigned. A total score of 0-24 is classified as no risk; a total
score of 25-50 is considered low risk and a total score greater then 50 place the patient
as high risk for falling. A significant limitation of the Morse Falls Scale is that
previous testing of the scale to predict falls has focused only on the adult population.
The scale’s applicability to predict falls in children is highly questionable.
Procedure
This was a retrospective patient record review. An informed consent was not
obtained for the chart review. This project was reviewed and approved by the
institution’s Institutional Review Board in the Office of Research. In addition, this
project was submitted to the CSUS Committee for the Protection of Human Subjects.
As part of the institution’s ongoing efforts to ensure quality of care of all patients, no
patient identifies were collected. The information was used in the form of
26
aggregate data. To preserve confidentiality of each child a case number was assigned
to each data collection tool corresponding to the incident report number,
Pending Human Subjects approval, a retrospective review was done on 72
charts of children who had fallen and met our inclusion criteria. It was noted that one
of the 72 falls documented with an incident report was a duplicate report, leaving 71
charts for review. Therefore, a total of 71charts were reviewed to collect data on
patient characteristics.
However, during the screening process, 24 pre-existing health records, from
January 1, 2004 thru December 31, 2004, were excluded from the study, as there was
no documentation of a fall score either at admission or at the time of the fall. It was
not until January 1, 2005, following the Joint Commissions Patient Safety Goal
requiring that hospitalized patients be screened for risk of a fall did this the pediatric
unit implement assessing children with the Morse Fall Scale. This resulted in 47
charts being able to be review for fall risk using the Cummings Pediatric Fall
Assessment Scale.
This institution’s fall assessment criteria (i.e. Morse Fall Scale) was used to
score only children who were 5 years of age or older. This approach to assessing and
documenting falls excluded 13 patient records, between the ages of 8 months and 5
years of age who fell. Therefore, only 34 patient charts were used to examine the
Morse Fall Assessment score from admission and at the time of the fall.
Once the retrospective review was completed, an additional 30 charts during
the same time period were reviewed for children who did not fall. These charts were
27
scored and reviewed with Cummings Fall Assessment Scale to examine the scale’s
specificity.
Based on the literature, a data collection tool was developed to document
specific patient characteristics of children who fell in the hospital. Characteristics
included the child’s age, gender, diagnosis, medical service, medications
(e.g., anticonvulsants, chemotherapy, and opiods), family and/or clinician presence,
the time of day, time of all since admission in days, and location of the fall
(e.g., bedroom, bathroom, or hallway). In addition to the falls score, data was
collected regarding any injury as well as the severity of the injury that occurred due
to the fall.
The data was collected from the electronic medical record and electronically
filed incident reports documenting the falls. Since the documentation was electronic,
the data collection was relatively easy as the information was located in the same part
of the chart.
Analysis
Analysis was done using SPSS version 16. Data analysis involved basic
statistics to describe patient characteristics. Based on children who were documented
as falling, sensitivity of the Cummings and Morse Scales was calculated using
proportions. Sensitivity was based on the number of patients identified by the scale as
high risk divided by the total number of patients who fell. Sensitivity analysis was
done twice, once at the time of admission and again at the time of the documented fall.
To analyze differences in sensitivity to identify children a high risk for falling in the
28
hospital, a Z score was performed to determine any proportional statistical differences
between the two scales. Specificity of the Cummings Pediatric Fall Assessment Scale
was calculated by the scale’s identification of no or low risk fall patients divided by
the total sample representing children who did not fall. This was done at the time of
admission and the time of discharge.
29
Chapter 5
RESULTS AND DISCUSSION
Characteristics
A total of 71 documented falls were reported and analyzed for demographics
and characteristics (see Table I). Children’s mean age was 8.3 years (SD=5.34) and
ranged from 8 months to19 years. To see distribution percentages according to
specific age (see Table II). Male children were more likely than females to fall
(54.9%) vs. (43.7%), respectively. Children hospitalized on seven different medical
services accounted for all falls occurring on the pediatric unit. Children admitted to
the General Pediatrics service (50.7%) with a medical diagnosis (40.8%) had the
highest incident of falls. Of the 71 children who sustained a fall 63% had
medications administered within the past 12-24 hours. The two most common
medications administered associated with high fall frequency were opiods (29.6%)
and anticonvulsants (12.7%).
The largest proportions of falls reported occurred in the patient’s room
(32.4%), followed by the patient’s bathroom (29.6%). The majority of time a family
member was present (36.6%), usually the mother (46.5%), during the fall. Eighteen
falls occurred in the presence of a clinician with the majority of falls occurring with a
volunteer, student nurse, or sitter (44%). The most common time of day that the fall
occurred was between the hours of 11am and 3 pm (23.9%) followed by 7pm to 11pm
(22.5%). The majority of children fell (45.1%) within 3 days of their admission to the
hospital. Of the 71 falls reported, 45% sustained a documented injury. The majority
30
of these injuries (84%) were classified as minor (i.e., red mark or bruising).
Interestingly, the first 24 charts reviewed between January 1, 2004 and December 31,
2004, a period that preceded the pediatric unit’s implementation of a falls prevention
program. A total of thirteen injuries were documented, and two of these injuries were
classified as serious. In contrast, during the subsequent 4 years (2005-2008) after a
falls program was implemented, 47 falls were reported. Eight children sustained
documented injuries, three were classified as serious. More specifically, more injuries
were documented during the first year (54%) when there was no falls prevention
program, compared to only 17% of falls injuries that were reported for the subsequent
four years with an implemented falls program.
Sensitivity of Tools
There were differences in the sensitivity of the Morse Fall Scale and the
Cummings Pediatric Fall Assessment Scale in identifying a patient as a high falls risk.
At the time of admission and again at the time of the documented fall, The Cummings
Pediatric Fall Assessment Scale sensitivity at the time of admission was 83% (39/47)
and at time of fall 87% (41/47). The sensitivity of the Morse Fall Scale for children
over the age of 5 at the time of admission was 29% (10/34) and at the time of fall 47%
(16/34). Since the Cummings Pediatric Fall Assessment Scale, compared to the Morse
Fall Scale, received higher sensitivity scores, statistical analysis using Z scores was
done to determine any proportional statistical differences between the two scales.
Statistically significant differences in sensitivity were found between the Cummings
and Morse Scales at the time of admission (Z = 4.68, p = .05) and at the time of the
31
fall (Z= 3.64, p= .05). Therefore, one can be 95% confident that the Cummings
versus the Morse scale is statistically more sensitive in identifying hospitalized
children’s fall risk both at the time of admission and at time of fall. These findings
provide evidence that the Cummings Pediatric Fall Assessment Scale is statistically
more sensitive in predicting pediatric patients at high risk for falls than the Morse Fall
Scale.
Specificity of Cummings Pediatric Fall Assessment Scale
Based on the convenient sample of 30 preexisting heath records of children
who did not fall, the specificity of the Cummings Pediatric Fall Assessment Scale was
50% (15/30) at the time of admission and 70% (21/30) at the time of discharge in
identifying children who were no or low risk for falls. Therefore, the Cumming
Pediatric Falls Assessment Scale is highly sensitive in identifying hospitalized
children for either high risk, low or no risk for falls.
Discussion
Characteristics
Similar to previous studies (Hill-Rodriquez et al. 2008; Razmus et al. 2006;
Cummings, 2006; Graff, 2005) age was a factor for inpatient pediatric falls. Younger
children had highest incident of falls during their hospitalization. Our study supports
previous findings (Cooper & Nolt 2007; Cumming 2006; McGreevey 2005) that
younger children (i.e., less than 5 years of age) and adolescents comprised the
majority of reported falls in the hospital setting. Since the largest proportion of
children who were less then 5 years of age fell, this further supports a developmental
32
component to a fall assessment scale. One could conclude that the child’s maturing
cognitive and motor development plays a major factor in hospital falls risk. Although
unknown, in this study, the high frequency of adolescent falls could be related to this
setting’s high trauma and rehabilitation population, lending itself to motor and
cognitive impairment and subsequent vulnerability to falls. Further investigation of
this population is needed.
In relationship to gender, our study provided future evidence that gender is a
risk factor for pediatric falls in the hospital (Cooper & Nolt, 2007; Cummings, 2006;
Graf, 2004; Lyons & Oates, 1993; McGreevey, 2005; Razmus et al., 2006). Males
appear to be at greater risk for inpatient falls. This gender difference risk may be
explained by this research setting’s admission rates that are higher for males versus
female. Therefore, compared to females, males are more likely to fall.
Our findings support the Cooper and Nolt’s findings (2007) that there is a
higher frequency of falls in the general pediatrics population with children who have a
medical diagnosis compared to children admitted with a surgical diagnosis. However,
comparisons with other studies is impossible. This is due to the different sample
populations studied and to inconsistent diagnostic categories used by researchers
(Cummings, 2006; Graf, 2004; Hill-Rodriguez et al., 2008). However, when sampling
categorizing is similar as seen in this study and that of Cooper and Nolt (2007) similar
findings are reported.
Medications have been associated with factors leading to falls. Use of sedating
medication including anticonvulsants and pain medication has been previously
33
identified as risk factors leading to a fall for hospitalized children (Cummings, 2006;
Graf, 2004; Razmus et al., 2006). Our study supports these findings with opoids
identified as most frequently administered medications associated with pediatric falls.
One might conclude that the frequency of opioid administration may be due to the
large trauma population seen at this Level One Trauma Center and the clinicians’
analgesic treatment of the subsequent pain children experience after a traumatic injury.
Levene and Bonfield (1991) reported that in regards to hospital falls, falls from
beds were the most common occurring accident. Razmus et al., (2006) identified that
most falls occurred in the child’s room compared to the bed. Our findings show that
most falls occurred while the child was out of bed in the child’s room. Therefore, this
study supports the previous findings by Razmus et al., (2006).
Regarding parental/family presence at the time of the hospitalized child’s fall,
our findings support previous studies (Levene & Bonfield, 1991; Razmus et al., 2006)
that parental presence is not a deterrent to pediatric falls in the hospital setting.
Several explanations may exist for this finding. While in the presence of their parents,
children may feel more comfortable with performing their normal developmental
activities (e.g., climbing and running). Therefore, they take more risks placing them at
a higher fall risk. Also, parental respect for their adolescent’s privacy may encourage
parents to leave the adolescent unaccompanied in the bathroom.
A more significant factor may be that nurses have neglected to appropriately
educate families to the significant fall risk children and adolescents face in the hospital
setting. The importance of parental education and communication regarding fall risks
34
of hospitalized children has previously been identified and described by Cooper and
Nolt (2007). These researchers described that along with clinician communication,
parents/family members have an integral role in a falls risk prevention program.
Interestingly, this study is one of the first studies to report clinician presence at
the time of the child’s fall in the hospital. Although the majority of hospitalized
children’s fall occurs without the presence of a clinician, when a clinician is present
the fall usually occurs in the presence of non-licensed personnel (i.e., student nurse,
volunteer, or sitter). While hand-off reports occur between license personnel
(e.g., RN / therapist), it may be overlooked with other staff who are involved in the
child's care. This again emphasizes the importance of falls prevention education, not
only with the parents/ family members, but also with non-license personnel who are
involved with the child during their hospitalization.
There is growing evidence regarding the time of day that falls frequently
occur. Our findings supports previous studies (Cummings, 2006; McGreevey, 2005;
Levene & Bonfield, 1991) that children’s falls commonly occur late in the morning
and in the early evening. While Levene and Bonfield (1991), identified that children
frequently fell out of bed at night, subsequent to this publication hospitals have made
numerous safety interventions to prevent children’s falls from hospital beds. These
are recently implemented strategies (e.g., new bed design, family education, side rail
policy bathroom nightlight) and may be an explanation for the low percentage of falls
from beds, as well as, the low incident of nighttime falls.
35
Inconsistent findings are reported for length of stay (LOS) and frequency of
hospitalized children’s falls. Although differences exist for children’s falls risk for
length of stay (Graf, 2004; McGreevey, 2005; Razmus et al., 2006), this study
suggested the majority of falls occur within 72 hours of hospital admission. Because
of the inconsistency between LOS and the fall risks reported, there needs to be future
examination of the relationship between the units average length of stay and fall
frequency. More specifically, for this institution the average length of stay was
3.5 days, which may account for the higher frequency of falls for this time period.
Therefore, at this time based on the current evidence, all children on admission and
subsequent shifts require screening for falls.
Minor injuries subsequent to falls have been commonly reported
(Cooper & Nolt 2007). In this study, the majority of injuries sustained subsequent to
falls were minor. Minor injuries are described as a red mark, abrasions, or bruising.
Injuries of a more serious nature were laceration that required suturing or increased
clinical monitoring. While injury severity classification is inconsistent, these findings
support previous studies that the majority of children experiencing falls have minor
injuries (Cooper & Nolt, 2007; Lyons & Oates, 1993; Nimityongskul & Anderson,
1987)
Sensitivity and Specificity of Cummings Pediatric Fall Assessment Scale
Findings from this study support the Cummings Pediatric Fall Assessment
Scale’s sensitivity and specificity to identify hospitalized children’s fall risk. Based
on this study’s preliminary findings, it appears that the Cummings Pediatric Fall
36
Assessment Scale is the preferred tool to identify hospitalized children’s fall risk and
replace the adult Morse Fall Scale that is currently being used to assess hospitalized
children’s fall risk. Since the completion of this study, a recent study (Harvey,
Kramlich, Chapmann, Parker, & Blade, 2010) was published providing further
evidence to support the clinical use of the Cummings Pediatric Fall Assessment Scale
to assess fall risk for hospitalized children. This study compared five pediatric fall
assessment tools including the Cummings for reliability and validity. This study was
done as the authors recognized that all five tools have had little statistical testing to
support their clinical use. Based on a small sample of hospitalized pediatric patients,
the authors concluded that the Cummings tool had acceptable internal consistency
(Cronbach’s alpha =0.68), high nurse interrater reliability and was efficient in
identifying children who fell.
37
Table I Characteristic Associated with the Fall
Descriptions n (%) Gender Male 40 (56.3) Female 31 (43.7) Medical Diagnosis Medical 29 (40.8) Neurological 22 (31.0) Trauma 17 (23.9) General Surgery 3 (4.2) Medical Service General Pediatrics 36 (50.7) Pediatric Oncology/Hematology 9 (12.7) Pediatric Physical Med and Rehabilitation 18 (25.4) Trauma Surgery 4 (5.6) ENT Surgery 2 (2.8) Neurosurgery 1 (1.4) Pediatric Surgery 1 (1.4) Medication Opioids 21 (29.6) Anticonvulsant 9 (12.7) Chemotherapy 3 (4.2) Laxitive 2 (2.8) Sedative 1 (1.4) Antihypertensive 1 (1.4) Benzodiazepine 1 (1.4) Diuretics 1 (1.4) Opioid combined with sedative 3 (4.2) or anticonvulsant or laxative Anticonvusant combine with laxative 2 (2.8) Antiypertensive combined with diuretic 1 (1.4) Location of Fall Patient Room 23 (32.4) Bathroom 21 (29.6) Bed 10 (14.1) Hallway 8 (11.3) Other (wheelchair, gurney, chair) 5 (7.0) Playroom 4 (5.6) Which Family Member was Present Mother 33 (46.5) Father 8 (11.3) Other Family Member 3 (4.2) Both Parents 1 (1.4)
38
Table I Characteristic Associated with the Fall
Descriptions n (%) Clinician Presence During the Fall No Clinician 53 (74.9) Registered Nurse 4 (5.6) Other (student nurse, volunteer, sitter) 8 (11.3) Physical Therapist 4 (5.6) Child Life 2 (2.8) Time of Fall Rounded to Nearest Hour 7am- 11am 12 (16.9) 11am-3pm 17 (23.9) 3pm-7pm 13 (18.3) 7pm-11pm 16 (22.5) 11pm-3am 7 (9.9) 3am-7am 6 (8.5) Time Since Admission that Fall Occurred in Days 0.2 1 (1.4) 0.5 1 (1.4) 1 10 (14.1) 2 11 (15.5) 3 9 (12.7) 4 3 (4.2) 5 4 (5.6) 6 4 (5.6) 7 3 (4.2) 8 2 (2.8) 9 3 (4.2) 11 2 (2.8) 12 1 (1.4) 13 2 (2.8) 14 2 (2.8) 15 3 (4.2) 16 1 (1.4) 18 1 (1.4) 20 1 (1.4) 21 1 (1.4) 24 1 (1.4) 29 1 (1.4) 44 1 (1.4) 66 1 (1.4)
39
Table II Age in Years of Children Who Fell
Age n (%) 0.6 1 (1.4) 0.66 1 (1.4) 1 1 (1.4) 1.5 3 (4.2) 1.6 1 (1.4) 1.75 1 (1.4) 2 6 (8.5) 3 6 (8.5) 4 4 (5.6) 5 3 (5.6)
6 3 (4.2) 7 3 (4.2) 8 3 (4.2) 9 3 (4.2) 10 3 (4.2) 11 3 (4.2) 12 4 (5.6)
13 8 (11.3) 14 4 (5.6) 15 4 (5.6) 16 1 (1.4) 17 3 (4.2) 18 1(1.4) 19 1(1.4)
40
Chapter 6
CONCLUSIONS AND RECOMMENDATIONS
Overview
The adult tested Morse Fall Score is currently used to screen pediatric patients
for fall risk due to the limited or lack of validation for the current pediatric fall risk
tool. Using a developmental framework, this study explored characteristics
surrounding pediatric falls, the sensitivity and specificity of the Cummings Pediatric
Fall Assessment Scale, and the sensitivity of the Morse Fall Score to identify
hospitalized children’s high risk for falling. Statistical differences in the sensitivity of
the Cummings Pediatric Fall Assessment Scale and the Morse Fall Score were
examined to identify hospitalized children at high risk for falls. The methodology
used was a descriptive exploratory design to examine the research questions.
Findings
While similarities of pediatric falls characteristics were found between this
study and previous research, this study provides new evidence that supports the
sensitivity and specificity of the Cummings Pediatric Fall Assessment Scale to
identify hospitalized children’s fall risk. In addition, compared to the Morse Fall
Score, the Cummings Pediatric Fall Assessment Scale was found to be statistically
more sensitive to identify children at high fall risk.
Limitations
Limitations to this study exist. The data was limited to a single inpatient
pediatric unit. The sample size was small and there were uneven distribution within
41
the developmental age groups. In addition, this was a retrospective chart review.
Other limitations include the fact that the documentation of falls was limited to self-
reporting documentation that was collected as part of an established incident reporting
system. The event reporting system does not always capture the pertinent data related
to the fall. In addition, falls related to normal growth and development may be under
reported or not reported. The clinician caring for children may not recognize this as
abnormal or reportable.
Implications for Research
Additional research needs to be conducted with statistical analysis to further
validate the Cummings Pediatric Fall Assessment Scale. Future studies need to
consider conducting prospective research with larger and more diverse populations. In
addition, investigation need to be carried out to explore the behaviors of children with
parents who are present verses those whose parents are absent and the relationship to
falls.
Implications for Practice
The Joint Commission require hospitals to collect and trend patent safety
indicators. An important component of a hospitals patient safety and quality
improvement is its ability to track and benchmark quality indicators like fall rates.
Implementation of this tool would allow all hospitalized children to be properly
assessed for fall risk and the institution would be able to track and benchmark
pediatric falls. Both are critical for a successful pediatric fall prevention program.
42
Incorporation of this tool into the electronic medical record would also allow
the nurse to quickly identify children at the greatest risk for fall so they can implement
appropriate fall precaution measures. In addition, documentation in the electronic
medical record would communicate the child’s fall risk to nurses and other
clinicians/caregivers who are involved in the child’s care.
The implementation of this tool into clinical practice would enhance the
pediatric fall prevention program by supporting a developmentally appropriate
identification of high-risk children to initiate fall prevention measures. The ability to
benchmark data with other children’s hospitals would facilitate the sharing of
successful practice initiatives related to fall with the common goal of improving
patient safety for hospitalized children. Based on this study and our current
knowledge, compared to the current use of the adult Morse Fall Score, the Cummings
Pediatric Fall Assessment Scale is the preferred tool to identify fall risks in
hospitalized children.
43
APPENDICES
44
APPENDIX A
45
APPENDIX B
S.5 Morse fall scale Morse Fall Scale
(Adapted with permission, SAGE Publications)
Item Scale Scoring 1. History of falling; immediate or within 3 months No 0
Yes 25 ______
2. Secondary diagnosis No 0 Yes 15
______
3. Ambulatory aid Bed rest/nurse assist Crutches/cane/walker Furniture
0 15 30
______
4. IV/Heparin Lock No 0 Yes 20
______
5. Gait/Transferring Normal/bedrest/immobile Weak Impaired
0 10 20
______
6. Mental status Oriented to own ability Forgets limitations
0 15
______
The items in the scale are scored as follows: History of falling: This is scored as 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen, this is scored 0. Note: If a patient falls for the first time, then his or her score immediately increases by 25. Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed on the patient’s chart; if not, score 0. Ambulatory aids: This is scored as 0 if the patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture for support, score this item 30. Intravenous therapy: This is scored as 20 if the patient has an intravenous apparatus or a heparin lock inserted; if not, score 0.
46
REFERENCES
Child Health Corporation of America Nursing Falls Study Task Force. (2009, July-
August). Pediatric Falls: State of the science. Pediatric Nursing, 35(4),
227-231.
Cooper, C. L., & Nolt, J. D. (2007, April-June). Development of an evidence-based
pediatric fall prevention program. Journal Nursing Quality Care, 22(2),
107-112.
Cummings, R. (2005). Cummings pediatric fall assessment scale unpublished scale ©.
from Phoenix Children’s Hospital, Phoenix, AZ
Cummings, R. L. (2006, July 19). Creating a pediatric fall assessment tool. Paper
presented at the Advancing Evidence-Based Nursing The 4th International
Evidence-Based Nursing Conference sponsored by Sigma Theta Tau
International, Montreal, Quebec, Canada.
Dedoukou, X., Spyridopoulos, T., Kedikoglou, S., Alexe, D. M., Dessypris, N., &
Petridou, E. (2004, October). Incidence and risk factors of fall injuries among
infants. Arch Pediatric Adolesc Med, 158, 1002-1006.
Desapriya, E. B., Joshi, P., Subzwari, S., & Nolan, M. (2008). Infant injuries from
child restraint safety seat misuse at British Columbia children’s hospital. 50,
674-678. doi: 10.1111/j.1442-2000X,2008.02635.
Dolan, D., Chapman, J., & Hyrkas, K. (2007, July 11-14). Examination of
methodological and practical challenges to falls risk assessments. Paper
47
presented at the 18th International Nursing Research Congress Focusing on
Evidence-Based Practice, Singapore, Asia
Gesell, A. (1969). Developmental diagnosis: Normal and abnormal child
development, clinical methods and pediatric application. New York: Harper
and Row.
Graf, E. (2004, March). Identifying predictor variables associated with pediatric
inpatient fall risk assessments. Poster session presented at the 5th Annual
Evidence -Based Falls Conference, Clearwater, FL.
Graf, E. (2008). Pediatric fall risk assessment and classification: Two hallmarks for a
successful inpatient fall prevention program. SPN News 17(2), 3-5.
Greenberg, R. A., Bolte, R. G., & Schunk, J. E. (2009, February). Infant carrier-related
falls an unrecognized danger. Pediatric Emergency Medicine, 25(2), 66-68.
Harvey, K., Kramlich, D., Chapmann, J., Parker, J., & Blade, E. (2010). Exploring and
evaluating five paediatric falls assessment instruments and injury risk
indicators: An ambispective study in a tertiary care setting. Journal of Nursing
Management, 531-541. doi: 10:1111/j.1365-2834.201001095.x
Helfer, R. E., Slovis, T. S., & Black, M. (1977). Injuries resulting when small children
fall out of bed. Pediatrics, 60(4), 533-535.
Hendrich, A. (2007, November). Predicting patient falls using the Hendrich II Fall
Risk Model in clinical practice. AJN, 107(11), 50-58.
48
Hill-Rodriguez, D., Messmer, P. R., Williams, P. D., Zeller, R. A., Williams, A. R.,
Woods, M., & Henry, M. (2008, June 25). The humpty dumpty falls scale: A
case-control study. Journal for Specialist in Pediatric Nursing, 22-32.
Hitcho, E. B., Krauss, M. J., Birge, S., Dunagan, W. C., Fischer, I., Johnson, S., ...
Fraser, V. J. (2004, July). Characteristics and circumstances of falls in a
hospital setting a prospective analysis. JGIM, 732-739.
Huitt, W., & Hummel, J. (2003). Piget’s theory of cognitive development. Educational
Psychology Interactive Valdosta, GA: Valdosta State University. Retrieved
from htt://www.edupsycinterative.org/topic/cogsys/piaget.html
In preventing falls, children are no less deserving of protection then the elderly. (2005,
August). Health Care Risk Management. Retrieved from
http://ww.ahcmedia.com/hot_topics
Istre, G. R., McCoy, M. A., Stowe, M., Davies, K., Zane, D., Anderson, R. J., &
Wiebe, R. (2003). Childhood injuries due to falls from apartment balconies and
windows. Injury Prevention, 9, 349-352. doi: 10.1136/ip.9.4-349
Keefe, S. (2010, May 28). Reducing pediatric falls: Ongoing assessment and family
education are essential to ensuring safety in the inpatient setting. Advance for
Nurses. Retrieved from http://nursing.advanceweb.com/Regional-
Articles/features/Reducing -Falls-in-Pediatrics
Khambalia, A., Joshi, P., Brussoni, M., Raina, P., Morrongiello, B., & Macarthur, C.
(2006). Risk factors for unintentional injuries due to falls in children age 0-6
49
years: a systematic review. Injury Prevention, 12, 378-385. doi:
10.1136/ip2006.12161
Kingston, F., Bryant, T., & Speer, K. (2010, June). Pediatric falls benchmarking
collaborative. The Journal of Nursing Administration, 40(6), 287-292.
Levene, S., & Bonfield, G. (1991). Accidents on hospital wards. Archives of disease in
childhood, 66(9), 1047-1049. doi: 10.1136/adc.66.9.1047
Lyons, T. J., & Oates, R. K. (1993, July). Falling out of bed: A relatively benign
occurrence. Pediatrics, 92, 125-127.
Macarthur, C., Hu, X., Wesson, D. E., & Parkin, P. C. (2000). Risk factors of sever
injuries associated with falls from playground equipment. Accident Analysis &
Prevention, 32, 377-382.
Macgregor, D. M. (2000, June). Injuries associated with falls from beds. Injury
Prevention, 6, 291-292.
McGreevey, M. (2005, September). Examining inpatient pediatric falls:
Understanding the reasons and finding the solutions. Joint Commission
Perspectives on Patient Safety 5 (9), 5-6.
Messmer, P. R. (2010, July 12-16). A closer look at pediatric falls. Paper presented at
the 21st International Nursing Research Congress, Orlando, FL. Abstract
retrieved from
htt://stti.confex.com/stti/congrs10/webprogram/Paper45739.html
50
Monson, S. A., Henry, E., Lambert, D. K., Schmutz, N., & Christensen, R. D. (2008,
August). In-hospital falls of newborn infants: Data from a multi-hospital health
care system. Pediatrics, 122(2), e277-e280. doi: 10.1542/peds.2007-3811
Morse, J. M. (2002, October). Enhancing the safety of hospitalization by reducing
patient falls. American Journal of Infection Control, 30, 376-380. doi:
10.167/mic,2002,125808
Morse, J. M. (2006). The safety of safety research: The case of patient fall research.
CJNR, 38(2), 74-88.
Mussen, P. (Ed.). (2006). Piaget’s theory. Handbook of child psychology (6th ed.,
Vol.1). New York: Wiley.
Nimityongskul, P., & Anderson, L. D. (1987). The likelihood of injuries when
children fall out of bed. Journal Pediatric Orthopedics, 7(2), 184-186.
Oliver, D., Daly, F., Martin, F., & McMurdo, M. E. (2004). Risk factors and risk
assessment tools for falls in hospital in-patient: A systematic review. Age and
Ageing, 33, 122-130. doi: 10.1093/ageing/afh017
O’Connell, B., & Meyer, H. (2002). Research in brief: The sensitivity and specificity
of the morse fall scale in an acute care setting. Journal of Clinical Nursing, 11,
134-136.
Patient Care Standard IV-05, UCDHS intranet website. (2010).
http://intranet.ucdmc.ucdavis.edu/policies/pcs/IV-05.htm
51
Picket, W., Steight, S., Simpson, K., & Brison, R. (2003). Injuries experienced by
infant children: A population-based epidemiological. Pediatrics, 111, e365-
e370. doi: 10.1524/peds.111.4.e365
Pillai, S. B., Bethel, C. A., Besner, G. E., Caniano, D. A., & Cooney, D. R. (2000,
June). Fall injuries in the pediatric population: Safer and more cost-effective
management. The Journal of Trauma: Injury Infection and Critical Care, 48,
1048-1050. doi: 0022-5282/00/4806-1048
Razmus, I., Wilson, D., Smith, R., & Newman, E. (2006, November-December).
Falls in hospitalized children. Pediatric Nursing, 32(6), 568-572.
Safe Kids USA. (2009n.d.). Fall prevention fact sheet. Retrieved from
http://www.safekids.org/our-work/research/fact-sheets/falls-prevention-fact-
sheet.html
The Joint Commission. (2006). National patient safety goals. Retrieved from
http://www.jointcommission.org/
PatientSafety/NationalPatientSafetyGoals/npsg_intro.html
Tung, T., Liu, M., Yang, J., Syu, W., & Wu, H. (2009). Useful methods of preventing
accidental falls from the bed in children at the emergency department. Eur
Journal of Pediatrics, 1323-1336. doi: 10.1007/s00431-009-0928-x
Woods, M., Messmer, P., Henry, M., Salani, D., Vazquez, D., Soto, M., ... Hill-
Rodriguez, D. (2006, July 19). Implementing a humpty dumpty fall scale for
pediatric patients. Paper presented at the Advancing Evidence- Based Nursing
the 4th International Evidence-Based Nursing Conference sponsored by Sigma
52
Theta Tau International, Montreal, Quebec, Canada. Abstract retrieved from
http://www.nursinglibrary.org/Portal/main.aspx?pageid=4040&PID=10140
