The Humpty Dumpty Falls Scale:

First received
Blackwell July 1, Inc
Publishing 2007; Revision received March 14, 2008; Accepted for publication June 25, 2008.

A Case–Control Study

Deborah Hill-Rodriguez, Patricia R. Messmer, Phoebe D. Williams, Richard A. Zeller, Arthur R. Williams,
Maria Wood, and Marianne Henry

PURPOSE. The purpose of this descriptive study Deborah Hill-Rodriguez, MSN, ARNP, CNS-BC,
is Magnet Project and Clinical Outcomes Coordinator,
was to assess whether the Humpty Dumpty Falls Miami Children’s Hospital, Miami, FL; Patricia R.
Messmer, PhD, RN-BC, FAAN, is Director, Patient Care
Scale (HDFS) identifies hospitalized pediatric Services Research, Children’s Mercy Hospitals & Clinics,
and Adjunct Professor, University of Missouri-Kansas
patients at high risk for falls. City School of Nursing, Kansas City, MO; Phoebe D.
Williams, PhD, RN, FAAN, is Professor of Nursing,
DESIGN AND METHODS. The study was University of Kansas, Kansas City, KS; Richard A. Zeller,
PhD, is Statistical Consultant, College of Nursing, Kent
a matched case–control design. A chart review of State University, Kent, OH; Arthur R. Williams, PhD,
MA, MPA, is Director of Health Outcomes & Health
153 pediatric cases who fell and 153 controls who Services Research, Children’s Mercy Hospitals & Clinics,
and University of Missouri-Kansas City Medical School,
did not fall were pair-matched by age, gender, Kansas City, MO; Maria Lina “Bing” Wood, ARNP,
MSN, is Director of Pediatric Intensive Care Unit, Miami
and diagnosis. Children’s Hospital, Miami, FL; and Maryann Henry,
MBA, BSN, RN, CPN, LHCRM, is Risk Management
RESULTS. High-risk patients fell almost twice Specialist, Miami Children’s Hospital, Miami, FL.
as often as low-risk patients (odds ratio 1.87,

confidence interval = 1.01, 3.53, p = .03).

S afety in hospitals is a continuous focus and concern for
healthcare providers, especially for those of pediatric patients,
because pediatric patients are exposed to many tests, medica-
PRACTICE IMPLICATIONS. A Falls Prevention tions, and a new and unfamiliar environment. New exposures
coupled with a patient’s diagnosis, current mental status, and
Pediatric Program with the HDFS tool addresses the dependencies of childhood produce concerns for patient
safety, especially concerns about medical errors and falls
the Joint Commission Patient Safety Goals, (American Nurses Credentialing Center, 2005; Institute for
Healthcare Improvement, 2008; Joint Commission, 2008;
but further research is needed to examine National Center for Patient Safety, 2008).
This paper is primarily concerned with reduction in
risks of falls for pediatric and adolescent inpatients. While
HDFS sensitivity-specificity.
there is considerable literature on fall-reduction programs in
the adult population (Sherrod & Good, 2006), little attention
Search terms: Fall prevention, fall risk has been given to pediatric patients. A falls prevention
program for hospitalized children should be innovative and
assessment tool, Pediatric Falls Prevention include risk-reduction strategies, particularly education for
the patient, family, and nurses. The hospitalization of children
Program, Pediatric Falls Tool provides an opportunity to reinforce parent/caregiver infor-
mation and education concerning normal psychological and
motor development of small children, which is related to falls
First received September 4, 2007; Revision received December 15, risks and other hazards both inside and outside the hospital
2007; Accepted for publication January 11, 2008. (Agran et al., 2003; Buick & Purser, 2007; Cooper & Nolt,

22 © (2008), The Authors

Journal Compilation © (2008), Wiley Periodicals, Inc.
2007; Graf, 2005a,b; Hill-Rodriguez, Messmer, & Wood, 2007; 2005; Rutledge, Donaldson, & Pravikoff, 2003; Tzeng & Yin,
Macgregor, 2003; Miller & Zhan, 2004; Park, Cho, & Oh, 2004; 2007, 2008). These actions, however, can be costly, and
Patterson, 1999; Powell & Tanz, 2002; Smith, 2006). methods, such as pediatric risk assessment of falls, could help
better target patients for such interventions or actions, thereby
Purpose containing costs, improving the efficiency and effectiveness
of care, and providing better safety protection to patients.
The purpose of this study was to assess relationships Indeed, our ultimate goal for the HDFS was to provide a
between the Humpty Dumpty Falls Scale (HDFS), as cur- usable fall-risk-assessment instrument that would benefit
rently developed, and the actual event of a fall, using a pediatric patients.
case–control design. The scale assesses pediatric inpatients’ The literature on falls in adults and in children is
risk for falls. This study was a pilot of the HDFS, developed reviewed separately below. The literature on adults is
through literature reviews and intensive discussion among substantial, but we will only briefly cite it here. While this
nurses with many years of pediatric and adolescent medicine literature is important in that it has influenced the desire
inpatient experience. Case–control studies have been very to develop similar tools and programs for children, we will
helpful in the early evaluation and development of useful direct our attention to the modest literature directly relevant
screening-diagnostic tools (Schlesselman, 1982; Rothman, to children.
Greenland, & Lash, 2008). Further studies of the HDFS are
underway, including its use and acceptance by nurses and Adult/Geriatric Falls Tools
patients and examinations of potential improvements in
its screening properties. In this report, we are exclusively Several tools to identify at-risk patients have been
concerned with whether the current HDFS high-risk score developed and demonstrate valid scores within the adult
was, indeed, strongly associated with an actual fall in the population. These tools have led to programs that have
case–control study. reported providing some fall protection to the adult patient
(Coker & Oliver, 2003; Hendrich, Bender, & Nyhuis, 2003;
Humpty Dumpty* Milisen, 2007; Morse, 1993, 2002, 2006a,b; Tinetti, 2003). Some
researchers have questioned the validity of the screening
Humpty Dumpty sat on a wall, tools now available (Meyers & Nikoletti, 2003). O’Connell and
Humpty Dumpty had a great fall. Myers (2002) indicated that further work on the Morse Fall
All the king’s horses and all the king’s men Scale was necessary to improve its sensitivity and specificity.
Couldn’t put Humpty together again. Studies using the Tinneti Falls Risk instrument also indi-
cated that there were opportunities to improve the assessment
*English nursery rhyme and management of risk factors and to improve patient edu-
cation (Fortinsky et al., 2004, 2008; Tinneti, Gordon, Sogolow,
Literature Review Lapin, & Bradley, 2006). Attempts to use adult instruments in
settings with children have been disappointing (Razmus,
Falls of hospitalized patients vary from 25% to 84% of all Wilson, Smith, & Newman, 2006).
incident reports submitted to health agencies, and are the
second most costly type of injury (Department of Defense Pediatric Falls Tools
Patient Safety Center, 2008). Falls have consistently been
the largest single category of hospital inpatient reports The published pediatric literature in this area is very
published since the 1940s (MacAvoy, Skinner, & Hines, limited. Injuries to children are an important health con-
1996; Tommasini, Talamini, Bidoli, Sicolo, & Palese, 2008). cern, yet there are few population-based analyses from
The Joint Commission’s 2008 National Patient Safety Goals which to develop prevention initiatives (Pickett, Streight,
include the provision for patients and their families to report Simpson, & Brison, 2003). Although falls are the leading
concerns about safety, including falls. McClure and col- cause of unintentional injury for children, published
leagues (2007) indicated that a population-based approach reports are scarce on the validation of tools that assess falls
to the prevention of fall-related injury can be effective, but risk in the pediatric population.
Tzeng and Yin (2007) caution that family visitors cannot Razmus et al. (2006) reported that the CHAMPS Pediatric
replace nurses in effectively preventing inpatient falls. Fall Risk Assessment Tool had four risk factors: change in
A considerable body of literature now exists concerning mental status, history of falls, age less than 36 months, and
actions that might be taken by nurses or others to prevent or mobility impairment, but they indicated that further study
reduce pediatric patient falls (Boswell, Ramsey, Smith, & was needed to validate the tool. However, Razmus (personal
Wagers, 2001; DiLoreta, 2002; McCarter-Bayer, Bayer, & Hall, communication, January 14, 2008) indicated that fall rates in

JSPN Vol. 14, No. 1, January 2009 23

The Humpty Dumpty Falls Scale: A Case–Control Study

children tended to range from 2.5% to 3.0% per 1,000 patient Hendrich (2007) indicated that in the pediatric popula-
days. Graf (2005a) developed the GRAF-PIF predictor model tion (younger than 10 years), the majority of falls correlate
based on chart reviews of 200 pediatric patients who fell, with environmental conditions such as cribs, rails, play-
matched with a control group of 100 patients who were from rooms, and well intentioned but forgetful parents who leave
the facility where this current study was conducted. Graf con- children unattended or the side rail down while a child is
cluded that falls in the pediatric population were associated alone. The number one strategy, according to Hendrich, is to
with anticipated physical/physiologic factors (61%), accidental integrate injury prevention messages with developmental
factors (33%), and unanticipated physiological falls (6%). assessment of the child. Hendrich asserts that those chil-
Accidental falls in the pediatric population occurred at a 2:1 dren’s hospitals with high case-mix index and severely ill
rate over adults, even with parents present 57% of the time. children should see a small percentage of true intrinsic falls
Children younger than 10 years had more accidental falls with similar risk factors as those in adults such as confusion,
than adolescents, while adolescents had more physiolog- weakness, or dizziness. Halfor, Eggli, Van Melle, and Vagnair
ical falls compared to the younger age groups. Unanticipated (2001), comparing outcomes between different settings, also
physical/physiological falls can be caused by conditions have suggested that pediatric patient mix is critically related
such as an undiagnosed seizure disorder or a pathological to falls.
fracture. Using 2000 falls data at her facility, Graf reported The HDFS and Patient Falls Safety Protocol was devel-
that the diagnoses of respiratory/pulmonary and neurological oped at one metropolitan children’s hospital as a component
(seizures) were associated with an increased incidence of its Humpty Dumpty Falls Prevention Program™ (see
of falls. Figure 1; Hill-Rodriguez et al., 2007). The HDFS differenti-
Patients with a diagnosis of epilepsy were at the highest ates the pediatric hospital population into categories of
risk for falls in Graf’s facility; seizures resulting in falls either low or high risk for falls based on specific factors.
increased the likelihood of concussion and other injuries These risk factors are the patient’s age, gender, diagnosis,
(Wirrell, Camfield, Camfield, Dooley, & Gordon, 1996). cognitive impairments, environmental factors (history of falls,
Higher seizure frequency, lack of a prolonged seizure-free bed placement [age appropriate or not age appropriate],
interval, comorbid attention-deficit disorder, or cognitive equipment/furniture, and use of assistive devices), response
disability may also increase the risk of injury in children with to surgeries/sedation/anesthesia, and medication usage.
epilepsy (Wirrell, 2006). Scores are assigned within each risk factor and then summed:
low risk scores are 7–11 and high risk are 12–23. The focus of
Pediatric Falls Programs the current study is whether this early version of the HDFS
successfully captures a fall event when its score is elevated
Children under the age of 10 years have the greatest risk (high risk); that is, an actual event or case in this study should
of fall-related death and injury because curiosity and motor be associated with the higher HDFS risk score.
skill development are associated with falls along with paren-
tal inattention (Britton, 2005; Murray et al., 2000; Safe Kids Gap in the Knowledge
Worldwide, 2008; Tarantino, Dowd, & Murdock, 1999; Vilke
et al., 2004). There is a paucity of studies regarding the In the white paper prepared by the Pediatric Data
effectiveness of prevention-of-fall-related injury in children Quality Systems Collaborative among the Child Health
(McClure, Nixon, Spinks, & Turner, 2005; Pillai, Bethel, Corporation of America (CHCA), the Medical Management
Besner, Caniano, & Cooney, 2000). In the past, falls among Planning (MMP), and the National Association of Children’s
hospitalized children were the result of the improper use of Hospitals and Related Institutions (NACHRI), falls preva-
cot (crib) sides; that is, the sides were only partially raised or lence was not selected as one of the nursing sensitive indi-
incorrectly secured (Levene & Bonfield, 1991). Most falls cators for monitoring Children’s Hospitals Care Quality.
occurred in children younger than 5.5 years, even when The reason given for this was the issue of definition (CHCA,
parents were present. MMP, & NACHRI, 2007). Neither NACHRI nor CHCA col-
King (1991) reported the use of a hospital discharge lects fall-rate data on their member children’s hospitals, and
database for pediatric injury surveillance. Cooper and falls were not selected as one of the pediatric indicators of
Nolt (2007) implemented a Falls Prevention Program and the National Database of Nursing Quality Indicators (Lacey,
reported that children younger than 1 year tended to fall Klaus, Smith, & Dunton, 2006). Even the Joanna Briggs Insti-
out of gurneys, whereas adolescents tended to fall while tute’s Falls in Hospitals does not specifically differentiate
ambulating to or performing activities in the bathroom. between adult and children’s hospitals (1998). Oliver, Daly,
Some falls were unrelated to hospital activities but were Martin, and McMurdo (2004) reviewed the literature on all
associated with the child’s developmental age, such as falls published reports on risk factors and risk-assessment tools
on the hospital playgrounds. for falls in hospital inpatients; they found that only two

24 JSPN Vol. 14, No. 1, January 2009

Figure 1. Humpty Dumpty Tool and Protocol. This figure appears in color in the online version of the article
[10.1111/j.1744-6155.2008.00166.x]

JSPN Vol. 14, No. 1, January 2009 25

The Humpty Dumpty Falls Scale: A Case–Control Study

Figure 1. Continued

instruments met the criteria of prospective validation, with gender, diagnosis, and unit location. One case and one
odds ratio (OR) analyses and sensitivity/specificity assess- control were eliminated because it was a “drop” case and not
ment. Both instruments are for adults. an actual fall.

Methodology Procedure

Research Design The study setting was a free-standing pediatric teach-

ing facility. Patient data were collected from five (medical,
The study purpose was to determine whether a high-risk surgical, respiratory, neurology, and oncology) in-patient units
designation on the HDFS was associated with a documented and the pediatric intensive care and cardiac intensive care
fall using a matched case– control design (Polit & Beck, 2008). units. Exclusion criteria were those falls of visitors or patient
During the years 2005 – 2006, a chart review of 308 patients falls from the other units not included in the study, such as
was done: 153 were children who fell while hospitalized (cases) outpatient and the neonatal intensive care units. A selected
and 153 were children who did not fall (controls or control group of advanced nurse practitioners, clinical nurse special-
group). The cases and controls were pair-matched for age, ists, directors, and a staff nurse conducted the review of 308

26 JSPN Vol. 14, No. 1, January 2009

charts and did the HDFS scoring. Interrater reliabilities in Data Analysis
scoring the HDFS were all at acceptable levels (over 70%
agreement). Descriptive analyses of the sample characteristics were
done. The study purpose was addressed using epidemio-
Protection of Human Subjects logic case–control procedures including calculation of an
OR, confidence limits, and level of statistical significance
Since the study presented no more than minimal risk to (Schlesselman, 1982).
subjects and utilized chart and quality occurrence report data, The OR is an unbiased estimator of the relative risk of
expedited review was granted by the facility’s institutional having a disease or event in a case –control study. Unfortu-
review board. No data were gathered by the researchers nately, it is only an estimator because the case– control
directly from patients or parents. design cannot provide information about the true incidence
of an event within a population, and an estimate of inci-
Instrument dence is required to calculate the true relative risk (RR).
Nevertheless, the OR often has been interpreted in a manner
The HDFS was created by an interdisciplinary team similar to the RR; that is, an OR > 1.0 is a marker of excess
comprised of expert clinical nurses from inpatient, out- risk (McHugh, 2007; Rothman et al., 2008; Simon, 2008).
patient, and emergency department areas along with Furthermore, an OR of 3.0, for example, suggests that cases
risk management and rehabilitation services. Historical have approximately three times the risk or odds of having the
fall-reporting data at a metropolitan children’s hospital were event occur compared to the controls.
used. These data included process improvement data and
a review of actual falls to identify parameters to be included Results
on the scale. The HDFS safety protocol (for the prevention
program) for low-risk and high-risk patients evolved from Sample Characteristics
parameters with risk factors criteria and scoring matrices.
After pilot testing in all inpatient units, the instrument was Tables 1–3 show the sample characteristics of cases and
comprised of seven assessment items: (a) age, (b) gender, controls pair-matched by diagnosis, age group, and gender.
(c) diagnosis, (d) cognitive impairments, (e) environmental Table 1 also shows that, among cases, most falls occurred
factors, (f) response to surgery or sedation or anesthesia, with children admitted with a neurological diagnosis, such
and (g) medication usage (see Figure 1). Flavin, Dostaler, as seizure disorders, followed by gastrointestinal or dehy-
Simpson, Brison, and Pickett (2006) indicated that boys expe- dration with vomiting, and respiratory/asthma. Children
rience higher rates of injury than girls. The range of scores is with respiratory disorders had a higher HDFS mean score of
7–23 (minimum score of 7 and maximum score of 23). Dur- 15.16; children with neurological diagnoses had an HDFS
ing the pilot study period, 13 of the 38 patients who actually mean score of 14.84; children with renal diagnoses had an
fell had HDFS scores of 12–13. The score of 12 was used as HDFS mean score of 14.40; and children with gastrointestinal
the “cut point” for high risk for falls. Thus, the low-risk proto- diagnoses had an HDFS mean score of 13.44.
col was identified with scores 7–11, while a high-risk protocol Table 2 shows that, among cases, most falls occurred in
was identified with scores of 12 and above. children younger than 3 years and in those who were
The HDFS was designed to be child friendly. When 13 years and older. Those younger than 3 years had the
children are assessed for their risk of falls, all children are highest HDFS mean score of 15.70; the 3- to 6-year-old age
identified with a potential fall risk and basic precautions group had a mean of 14.36; the 13-year and older group had
are implemented at the low-risk category. A score of 12 or a mean of 13.29; and the 7- to 12-year-old group had the
above indicates a pediatric patient is at-risk for falling, and lowest mean of 12.38.
this patient will have the high-risk Humpty Dumpty Falls Table 3 shows that falls among cases were 50% in females
safety protocol implemented. The high-risk safety proto- and 50% in males (data for gender were missing in three
col consists of Humpty Dumpty signage (Figure 2) placed cases). Prior to the implementation of the Humpty Dumpty
in visible locations (sticker on the shirt or gown, crib, or bed protocol, fall evidence was 0.989 and 1.0 per 1,000 patient
and chart). The signage notifies all healthcare professionals days (2003–2004) and ranged from 0.989 to 0.989 and 1.0 per
that the child is at risk for falling and ensures that the falls 1,000 days for the postimplementation (2005–2006). Buick
safety protocol is implemented and all precautions are and Purser (2007) reported that their outcomes were not
taken. Other fall-prevention components include medication improved significantly. Their fall rate was 0.48 preimplemen-
administration review, increased assessment time frames, and tation of a falls-prevention program and 0.47 postimplementa-
placing patients closer to the nurse’s station as well as pro- tion. In this institution, the fall rate for inpatients decreased
viding one-to-one care when indicated. significantly in 2007 to 0.56 per 1,000 patient days, which

JSPN Vol. 14, No. 1, January 2009 27

The Humpty Dumpty Falls Scale: A Case–Control Study

Figure 2. (a) Humpty Dumpty Sign on At-Risk Child. (b) Humpty Dumpty Sign on Crib. (c) Humpty Dumpty Sign on
Chart. This figure appears in color in the online version of the article [10.1111/j.1744-6155.2008.00166.x]

suggests that the Humpty Dumpty Falls Prevention Pro- month time interval of postimplementation follow-up. Only
gram™ has merit and value. 4 of the 308 charts reviewed had missing HDFS scores.
While the HDFS captures some of the real risk of falling
Study Purpose Addressed among hospitalized pediatric patients, further assessment
of the instrument is necessary. The reported sensitivity
Table 4 shows the OR using the current HDFS cut-off point was 0.85, the specificity was 0.24 with the positive predic-
of 12 and current scoring procedures. This table shows that tive power at 0.53 and negative predictive power at 0.63;
children in the low-risk category were less likely to fall (37 did the overall percentage of patients correctly classified as to
not fall) as compared to children in the higher risk category their risk of a fall was 59.3%. It is difficult to interpret the
(115 did not fall). Conversely, there were a larger number of meaning of the false positives in the Humpty Dumpty
children with high-risk scores who fell (128) as compared to Falls scores due to the intervening implementation of the
the low-risk children who fell (22). There were three missing Humpty Dumpty Falls Prevention Program™ and fall-
cases for those who fell and one missing case for those who reduction strategies implemented by the nursing staff. The
did not fall. The OR obtained was significant (OR = 1.87; 95% false-negative cases (scores less than 12 among the cases
confidence interval = 1.01, 3.53; p = .03). OR of patients is 1.87 who by definition did fall, n = 22) gave an inaccurate indica-
when an HDFS score is greater than or equal to 12. tion that these patients were not likely to fall, thereby sug-
gesting the need for further refinement of the tool. If further
Limitations refinement of the HDFS is completed and these “low-risk
fallers” are captured, the sensitivity of the tool should be
This retrospective study was conducted in one geo- maintained (ability to identify children at risk for falls) while
graphic setting with one hospital’s falls data. The analysis the specificity is increased (ability to identify those not at
included 2 years of inpatient data on actual falls with a 6- risk) (Frankenburg & Camp, 1975; Simon, 2008).

28 JSPN Vol. 14, No. 1, January 2009

Table 1. The Humpty Dumpty Falls Scale (HDFS) by Diagnosis: Mean HDFS Fall Risk Scores of Cases and Controls

Cases Cases’ mean HDFS Controls Controls’ mean HDFS

Diagnosis (n) falls risk scores (n) falls risk scores

2 Respiratory 19 15.16 18 15.00

1 Neurological 71 14.84 71 14.47
4 Renal 11 14.40 15 14.07
3 Gastrointestinal 18 13.44 18 13.06
5 Cardiac 8 13.50 7 15.57
6 Oncology 10 13.40 11 12.64
9 Other/Infections 10 13.20 7 12.14
8 Orthopedic 5 10.20 4 9.50
7 Surgical 1 10.00 2 9.50
Total/mean 153 13.13 153 12.88

Notes: Cases are children who fell; Controls are children who did not fall (matched for age, gender, diagnosis, and unit location with cases).
Uneven observations on cases and controls arise from incomplete information on which to calculate an HDFS score. Of the 308 records, one
case-matched control was dropped because it was not classified as a fall.

Table 2. The Humpty Dumpty Falls Scale (HDFS) by Age Group: Mean HDFS Falls Risk Scores of Cases and Controls

Cases Cases’ mean HDFS Controls Controls’ mean HDFS

Age groups (n) falls risk scores (n) falls risk scores

Younger than 3 years 56 15.70 55 15.83

3–6 years 25 14.36 27 14.59
7–12 years 24 12.38 24 12.21
13 years or older 45 13.29 46 12.20
Total/mean 150 13.93 152 13.70

Table 3. The Humpty Dumpty Falls Scale (HDFS) by Gender: Mean HDFS Falls Risk Scores of Cases and Controls

Cases’ mean HDFS Controls’ mean HDFS

Gender Cases (n) falls risk scores Controls (n) falls risk scores

Female 75 (50%) 13.37 78 (51%) 13.28

Male 75 (40%) 15.07 74 (49%) 14.64
Total/mean 150 (100%) 14.22 152 (100%) 13.92

Discussion studies where data allowed calculation of OR and confidence

intervals. This study evaluates the Humpty Dumpty fall
The significance and size of the OR in this study suggest instrument properties within a pediatric population.
that the HDFS identifies pediatric patients at high risk for In 2000, using the falls data from the same facility as the
falls. The odds of high-risk patients falling are almost twice current study, Graf (2005a) also reported that the diagnosis
that of low-risk patients. of respiratory/pulmonary and neurological (seizures) con-
In a literature review, Oliver and colleagues (2004) ditions were associated with increased incidence of falls.
identified all published papers on risk factors and risk- Likewise, Wirrell et al. (1996) reported that accidental injury is
assessment tools for falls in hospital inpatients. They found a serious risk in children with typical absence epilepsy.
that only two instruments met the criteria of prospective These findings are consistent with the current study; that is,
validation, including OR, and required sensitivity/specificity; patients with diagnoses of neurological conditions including
both studies were done on adult instruments (Morse, 1985; epilepsy were more often among the cases (children who
Oliver, 2006). The review article by Oliver and colleagues fell). Although the institution’s case-mix index (1.52) is
provides a table with an excellent summary of adult-falls one of the lowest for NACHRI hospitals, some children in

JSPN Vol. 14, No. 1, January 2009 29

The Humpty Dumpty Falls Scale: A Case–Control Study

Table 4. Odds Ratio of the High- and Low-Risk Groups Conclusions/Recommendations

(Children Who Fell and Those Who Did Not Fall)
The study findings suggest that the HDFS may be a valid
Falls tool for recognizing high-risk pediatric patients in the
inpatient units. The findings also suggest that children with
Risk group Yes (did fall) No (did not fall) neurological (such as seizure disorders), respiratory/asthma,
gastrointestinal (including dehydration or vomiting), and
High risk 128 115
renal diagnoses are at high risk for falls. As to age, children
Low Risk 22 37
Total 150 152 younger than 3 years old and children 13 years and older
with neurological diagnoses (such as seizures) may be at
Odds ratio = 1.87; confidence interval = 1.01, 3.53; p = .03. highest risk and should be closely monitored. Clearly, the
fall-rate prevalence is high among these two groups at the
study institution. The HDFS currently may be the best fall
scale now available for children. The HDFS score gives
healthcare providers a point of reference when assessing
the current study who fell were confused, weak, dizzy, and
children at risk for falls.
experienced seizure activity.
Current practice does not usually identify pediatric
Preventing falls in the pediatric population is difficult
patients who have a history of falls. Using the HDFS as part
due to the unpredictability of falls as a result of a pediatric
of the assessment scale on admission, on every shift, and
patient’s cognition, growth, and development. It was
upon change of patient level of care may increase staff
observed that, in some cases, the nurses were not observing
awareness of patients with high-risk scores for falls. This
the patients in a holistic manner; that is, they relied on the
identification process can promote staff compliance with
patient’s present condition only and did not assess other
falls education to families or guardians. A prospective study
underlying factors (such as the factors on the HDFS) that
at several sites using the HDFS should be conducted to
could put patients at a higher risk for falls. The OR findings
determine if its use in practice would indeed help to reduce
linking high-risk-falls scores and incidence of falls suggests
the incidence of falls and associated costs. Measurement
that the HDFS is a tool that might be used to identify risks
properties of the HDFS, including possible improvements in
of a fall.
its predictiveness as a screening tool, should be carefully
examined in prospective studies.

It was observed that, in some cases, the nurses

were not observing the patients in a holistic manner;
that is, they relied on the patient’s present condition How Do I Apply These Findings
only and did not assess other underlying factors to Nursing Practice?
(such as the factors on the HDFS) that could put Implementing a patient-falls-safety/prevention protocol
patients at a higher risk for falls. should include assessment of the risk for falls in pediatric
patients. This would reduce the incidence of falls and directly
address important Joint Commission patient safety goals.
A fall rate of 2.3 – 6.5 falls per 1,000 patient days was Using tools such as the HDFS and the implementation of
reported in an academic medical center; however, higher fall the Humpty Dumpty Falls Prevention Program™ might be
rates of children in adult facilities have been reported helpful; however, use of such tools does not obviate the
(Boyle, Miller, Gajewksi, & Dunton, 2005; Hitcho et al., need for exercise of the nurse’s best clinical judgment. Such
2004; Oliver, 2006). One hospital also reported a fall rate of judgment remains a valuable resource in decreasing the
3.1 falls per 1,000 patient days with 3.1% of the falls with incidence of falls and falls-related injury. Properly identifying
serious injury in women and infants, but it should be patients at risk for falls ensures that all disciplines, parents,
noted that infants were not listed separately (Fisher et al., and visitors have an increased awareness of the risk of injury
2005). Reported children’s hospital’s fall rates are well to the patient. Increased awareness results in better patient
below the rates of adults, but falls may not be as carefully outcomes, including reduction in potential issues related to
monitored in pediatric as compared to adult facilities. increased costs and increased length of stay. Additionally, use
Fall rates are derived generally from voluntary reporting of this tool may assist nurses in providing safe, noninvasive
mechanisms. Rates may vary due to reporting rather care, anticipatory guidance to parents and other informal
than the actual number of falls. caregivers, and health promotion.

30 JSPN Vol. 14, No. 1, January 2009

Acknowledgments. Dania Vasquez ARNP, MSN; Maria E. Fortinsky, R. H., Iannuzzi-Sucich, D. I., Baker, D. I., Gottschalk, M.,
Soto, ARNP, MBA, MSN; Deborah Salani, ARNP-BC, MSN, King, M. B., Brown, C. J., et al. (2004). Fall-risk assessment and
management in clinical practice: Views from healthcare providers.
CPON; Cheryl Minick, RN-BC, BSN; Jacqueline L. Gonzalez, Journal of American Geriatrics Society, 52, 1522–1526.
ARNP, MSN, CNAA-BC, FAAN, Sr VP/CNO Miami Frankenburg, W. K., & Camp, B. W. (1975). Pediatric screening tests.
Children’s Hospital, Miami, FL, and nursing staff for their Springfield, IL: Thomas.
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