Implementing a Humpty Dumpty Pediatric Falls Assessment™ in

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 Children’s 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 children’s
hospitals; Florida 1st free standing children’s.
• 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.
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JCAHO National Patient Safety (NPSG)
Goal # 9 Falls Prevention!
• Reduce the risk of patient harm resulting
from falls.
• Assess and periodically reassess each
patient’s risk for falling, including the
potential risk associated with the patient’s
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.
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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.
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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
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Humpty Dumpty Scale Parameters
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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.
•O’Connell, 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.
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Review of Literature
•Britton, J.W. (2005). Kids can’t 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 Children’s Memorial Medical Center)
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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
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Falls Assessment Tool
(The Humpty Dumpty Scale™ )
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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, furniture’s 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.
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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
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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?
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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
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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%)
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Demographics
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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%)
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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
N
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
F
Sig.
Linear
2.492
1
2.492
.549
.461
Linear
290.508
64
4.539
Source
falls
falls
Error(falls)
Humpty Dumpty Falls Scale Comparison
Mean
Std. Deviation
N
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
F
Sig.
falls
Linear
19.314
1
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
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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 Children’s 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 MCH’s 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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