Over 2.2 million emergency room visits each year in the United States are directly related to a childhood fall. Childhood falls are the leading cause of unintentional injury for children. In comparison, over 1.6 million adults over the age of 65 sustain injuries due to a fall. Despite the large number of falls among pediatric populations, the majority of research and improvement efforts have historically focused on adult populations.

A fall can be defined as an unplanned descent to the floor, with or without patient injury. For over 7 years, the Joint Commission has stressed the importance of reducing falls in the inpatient setting. Patient falls were identified as an indicator that could be directly affected by nurse led interventions and initiatives. In short, the amount of patient falls can be directly influenced by the nursing teams within a health care organization.

The types of patient falls differ between infants and older adults. Infants are more likely to fall from furniture while adult populations are more likely to fall from tripping. In regards to risk: preschoolers, children older than the age of 10, and children with disabilities and minimal mobility are at a high risk to fall in a hospital setting.

• Preschoolers (age 2-5) are developing their physical mobility skills rapidly and are curious. The hospital setting, in most cases, is a new environment and beds and furniture seem like new fun things. Due to their developing motor skills and natural play characteristics, this age group has the highest percentage of hospital falls.
• Children older than the age of 12 (adolescents) are very mobile and can often misjudge their physical state. This age group has the second highest hospital fall percentage.
• Children with cognitive or motor impairments are at an increased risk of falls especially when they fall into one of the age groups discussed above. Inability to communicate or understand the new environment can attribute to falls in the hospital setting.
• Children with newly limited mobility are also at an increased risk of falls. This could include children with casts, crutches, canes, walkers, wheelchairs, amputated limbs, or discomfort which causes them to lean onto surrounding objects for support. The child’s balance and body weights may be different and they may misjudge space and effort needed.

For pediatric patients over 60% of all falls will occur either in the patient room, bathroom, or from the patient bed. Generally, male patients fall more often than female patients and the majority of falls occur in the evening hours.

In regards to pediatric falls, there are four types of general fall categories: Anticipated Physiological, Unanticipated Physiologic, Accidental, and Developmental.

Anticipated Physiological:

• The patient’s diagnosis or characteristics may predict their likelihood of falling (medications, unsteady gait, newly limited mobility, etc.). These patients are identified via a fall assessment scale.

Unanticipated Physiologic:

• This occurs when no obvious risk factors occur during the fall assessment yet a fall still occurs. This can happen when a fall occurs due to an unanticipated condition such as a reaction to specific medication, syncope, or a seizure.

Accidental:

• This is a fall associated to either an environmental hazard (wet floor, tangled chords on the floor, side rails not properly positioned, etc.) or a human accident such as a dropped infant.

Developmental:

• These are non-injurious falls associated for toddlers or infants who are learning to walk, run, pivot etc. These are “natural” falls associated with human learning of movement.

Reducing falls within a healthcare organization requires a multidisciplinary approach with participation from a variety of different parties (nursing teams, transport teams, patient families, etc.). The first necessary implementation step is to identify a way to identify patients at risk of falling. The best practice is to implement a fall assessment scale, either from an outside source or an internally produced one. Three of the most common pediatric scales being used nationwide are variations of the Humpty Dumpty Fall Scale, Cummings Pediatric Fall Scale, and the GRAF-PIF scale. The specific components and individual benefits of these scales will not be covered in this CNE course. If your health care organization has not yet adopted a basic fall assessment scale, the above listed options can be good evidence based starting points for the launch of a fall prevention program.

Regardless of which type of fall assessment scale you use, the key to continuous reduction of falls is continual updates of the assessment scale based on falls that occur and the continuous improvement of the nursing interventions that address patients who are at risk of falls.

For patients who have been identified as a high fall risk specific nurse interventions could include:

• Evaluate the patient’s medication times.
• Ensure that the patient’s bed is kept in the lowest position with the brakes locked on.
  • Although ergonomically the bed may need to be in a higher position to accommodate the health care provider, in regards to pediatric patient safety, the lowest position is the safest for a child in the event of an accidental fall.
• Check that the patient’s door is kept open at all times, unless a specific isolation procedure is in place³.
• The patient should be identified with some sort of visual identifier (brightly colored bracelet, sticker, or sign).
• The patient should be regularly checked each hour. The patient should have supervision/aid while ambulating and toileting needs should be addressed each hour.
• The patient’s family should be informed of the potential fall risk and educated about environmental and accidental fall hazards⁴.
• Patient should have on appropriate sized clothing, adequate non-skid foot wear, and the room should be clear of environmental hazards (toys on the floor, chords, etc.).
• Ensure that the side rails on the bed are up according to the patient’s size. Check for gaps where the child could slip through or get caught¹³.
• All fall prevention teaching and interventions should be documented

For patients who have been identified as a low fall risk specific nurse intervention could include:

• Ensure that the call light is within reach and that the patient and their family have been educated on its functionality.
• Checking that the environment is clear of hazards (toys on the floor, exposed chords, etc.) and that the furniture is in place.
• Both the family and patients need to be orientated to the room. Fall risks need to be explained and appropriate playing behavior should be discussed (not climbing on chairs, etc.).
• Bed is in a low position and has the brakes on¹³.
• Ensure that the patient has on appropriate sized clothing, non-skid footwear, and if the patient is using crutches or a wheelchair proper use should be reinforced. Patients who are using new equipment to ambulate are at a higher risk of falls.
• All fall prevention interventions should be documented.

One of the most common dimensions of fall causes is improper communication between health care professionals during shift changes and handoffs. Proper documentation of fall risk can help, but communication between all parties is crucial to reducing falls. Communication between registered nurses, nurse technicians, and transportation teams is necessary for reducing falls. Most health care organizations find that there is no easy way or defined process for communicating fall risk between different members of staff¹¹. Visual cues (colored signage above the bed, on the chart, on the doorway etc.) have been found effective in various adult populations and the simple process can help facilitate communication and information transfer between pediatric health care providers³.

Oncology:
Several specific factors could create fall risk patients:

• Child has taken a medication designed for sedation ². Their movement could become impaired very suddenly.
• Child has recently undergone an amputation of an arm or lower limb. This will affect the child’s mobility, body weight, balance, and the patient may experience phantom sensations ³.
• Child is undergoing IV treatment and is ambulating alongside an IV Pole. There is a potential here for tangled chords or loss of balance due to a sudden discomfort with the IV.
  • Interestingly, researchers found that children ambulating with an IV pole fell at a lower rate than children ambulating without an IV pole¹². This could be attributed to the fact that ambulating with an IV pole provides support and forces a patient to move slower and more cautiously so as not to disturb the IV.
• The patient may experience an unexpected reaction to a specific medication.

Orthopedic:

• The patient may have new mobility limitations. Crutches, canes, casts, walkers, wheelchairs, etc. may affect the patients balance and ability to safely ambulate. Proper observation is needed while moving in and out of bed, toileting, and playing.
• The patient may misjudge their strength or mobility due to a recent surgery or treatment. For example, pediatric patients who have recently undergone a shoulder surgery may need to be helped into and out of bed in order to minimize potential fall risk.

Newborns:

• The majority of newborn falls are accidental. One of the largest causes is parental fatigue. For example, the child could be dropped during holding during the night or the early morning hours¹⁰.
• Infant swings or scales can also be a source of potential accidents. Constant supervision and attention is necessary while performing any actions with a newborn¹⁰.
• Delivery room non-secured bassinets can also be another source of potential accidents.

• Several researchers have found that parental presence alone is not a significant deterrent of pediatric falls. Over 70% of the time a fall occurs within the presence of a parent³. This could be attributed to the fact that children often feel more comfortable around their parents and are more likely to avidly play and run.
• Properly informing and educating the patient’s parents is crucial to minimizing falls. Fall reduction is a multi-faceted issue that requires the parent’s help in order improve patient safety.

Reducing falls among pediatric populations is a continuous effort that requires the buy-in and participation of various staff groups in order to be successful. Should a fall occur, it should be looked at as a learning opportunity. Applicable unit staff should immediately meet and quickly discuss who fell, where they fell, why the fell, when they fell, and how a similar fall could be avoided in the future. These group huddles can then help bolster the fall information that is already being collected. These huddles will also help identify potential improvement opportunities that may be unique to a specific department or organization. Reducing falls, like any quality improvement initiative is a work in progress. It should be consistently updated and improved as specific issues occur.

1.Agency for Healthcare Research and Quality. Innovations Exchange: Bundle of interventions targeting high-risk patients with the aim of reducing falls and fall-related injuries on medical-surgical units. http://www.innovations.ahrq.gov/content.aspx?id=2611. Accessed December 27, 2013.
2.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.
3.Cummings, R. L. (2006, July 19). Creating a pediatric fall assessment tool. Paper presented at the Advancing Evidence - Based Nursing The4th International Evidence-Based Nursing Conference sponsored by Sigma Theta Tau International, Montreal, Quebec, Canada.
4. Ann Hendrich, MS, RN, FAAN (2006). Inpatient Falls: Lessons from the Field. Patient Safety and Quality Healthcare ; http://www.psqh.com/mayjun06/falls.html
5.Hill-Rodriguez D, Messmer PR, Williams PD, et al. The Humpty Dumpty Falls Scale: a case control study. J Spec Pediatr Nurs. 2009;14(1):22-32.
6.Protecting Children by Preventing Falls. (2012) American Nurse Today. Patricia R. Messmer, PhD, RN-BC, FAAN, and Arthur R. Williams, PhD, MA, MPA ; http://www.americannursetoday.com/article.aspx?id=9186
7.Graf E. Magnet children’s hospitals: leading knowledge development and quality standards for inpatient pediatric fall prevention program. J Pediatr Nurs. 2011;26(2):122-127.
8.Graf, E. (2008). Pediatric fall risk assessment and classification: Two hallmarks for a successful inpatient fall prevention program. SPN News 17(2), 3-5.
9.Messmer PR, Williams AR. Issues related to innovation: a case-control study of pediatric falls. American Academy of Nursing preconference, Washington, DC, November 11, 2010.
10.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
11.Neiman J, Rannie M, Thrasher J, Terry K, Kahn MG. Development and implementation of a comprehensive fall risk program. J Spec Pediatr Nurs. 2011;16(2):130-139.

12.Razmus, I., Wilson, D., Smith, R., & Newman, E. (2006, November-December). Falls in hospitalized children. Pediatric Nursing, 32 (6), 568-572.
13.Safe Kids USA. (2012). Fall prevention fact sheet. Retrieved from
http://www.safekids.org/ourwork/research/fact-sheets/falls-prevention-fact-sheet.html