When Kathleen Adlard, MN, RN, CCNS, CPON, clinical nurse specialist at The Cancer Institute at CHOC Children's, Orange, had an opportunity to serve on the Child Health Corporation of America Nursing Falls Study Task Force, she was eager to explore the issue along with other nurse experts. As the co-author of an article summarizing the results of the task force (Jamerson, P.A. et al. (2009). Pediatric falls: State of the science), she is a passionate advocate for safety in the pediatric inpatient setting.
In 2005, the Joint Commission issued a National Patient Safety Goal aimed at identifying fall risks in patients and developing strategies to reduce those risks. "While there were a number of validated fall risk screening tools for adults, the issue really hadn't been addressed in pediatrics," Adlard noted. "But the national patient safety goal required all hospitals, including pediatric hospitals, to assess patients' risk for falling upon admission and reassess on an on-going basis. We pulled together a process improvement team and developed a fall risk assessment tool we've been using ever since."
Adlard is aware nurses in her clinical specialty care for a number of high-risk children. "I work on an oncology unit, and most of our children fit 'traditional' risk criteria for falls," she said. "We know, for example, that a length of stay over 5 days is associated with a higher fall risk, and many children with cancer are here for weeks or even months. We currently use signs outside each child's door to indicate fall precautions."
The GRAF-PIF (General Risk Assessment for Pediatric Inpatient Falls) Scale developed by Elaine Graf, PhD, PNP, RN, is an evidence-based tool with some surprising implications. "Almost every assessment tool developed in-house by staff at pediatric hospitals incorporates the idea that children with IV poles are more prone to falls, but Elaine Graf found that the IV pole was actually more of a protective mechanism," Adlard explained. "Falls are occurring in children running up and down the hall more often than in those holding onto the IV poles while they walk around the unit.
"There was also a tendency to place all patients on narcotics or other analgesic on fall precautions, but that threw so wide a net that almost everyone was identified as high risk," Adlard continued. "Graf showed that the only medications associated with an increased risk of falls were seizure medications, so that helped narrow the criteria."
Adlard used internal data from CHOC Children's along with information from the task force to quickly identify an area where nurses can make a difference. "About three-fourths of our patients have a parent or other adult supervising them when they're in the hospital, but we haven't been teaching them in a formal way how to protect their children from falls," she said. "And parents aren't necessarily thinking about falls in a child who's normally active and independent outside the hospital; they're more concerned about pain, fever and vomiting. So I've developed a patient/family education tool called 'Preventing Patient Falls' that will be incorporated into the nursing care plan for each patient identified as a fall risk."
The education tool helps nurses cover the topic of fall risks in a common-sense and easy-to-read fashion. "They'll talk about why the child is at risk for falls here in the hospital, and how parents can partner with the staff to prevent falls," Adlard said. "For example, nurses will ask parents to be sure the child is wearing shoes or non-skid socks when he's out of bed, to let us know when they leave the child alone in the room and to make sure the call light is within reach at all times."
Amy Nichols, EdD, RN, associate professor of nursing at San Francisco State University and director of the Center for Nursing Excellence at Lucile Packard Children's Hospital (LPCH), Palo Alto, described the importance of teamwork to prevent injury in the pediatric setting. "Within the electronic medical records, we have a fall assessment that's done on every child admitted to pediatrics," she explained. "We get a score that identifies the kids at high risk for falls, and that information infiltrates into the care plan that's available to all members of the healthcare team. The information is discussed at rounds, and is part of the nurse-to-nurse hand-off reports as well. Everyone realizes fall risk is an important piece of information and adjusts their care accordingly."
LPCH also has a child development team that evaluates children and identifies factors that influence fall risk. "That can be anything from clothing to developmental delays, and the team can share their findings with the rest of the clinicians to help prevent falls in the inpatient setting," Nichols said. "If there are issues around fall risk following discharge, those are included in the parent information delivered prior to sending the child home."
Kara Jackson, BSN, RN, pediatric unit manager at The Children's Hospital at Legacy Emanuel in Portland, emphasized the need for ongoing assessment of fall risk in hospitalized children. "Pretty much all kids are at risk for falls and injuries, so we put some interventions in place for every child," she said. "We also assess every child at admission to pinpoint those at higher risk, including all of our inpatient rehab patients, who are considered higher risk due to their reason for admission. Some rehab patients come in with [fall] preventive orders already written after being identified as high-risk by the rehab physician or rehab intake coordinator."
|Kara Jackson, BSN, RN
Legacy nurses complete the Morse Fall Scale as part of every nursing admission assessment. "The scale assigns points to factors like a history of falls, a secondary diagnosis such as cerebral palsy, the use of assistive devices, an IV or heparin lock, and impairments in gait, understanding, memory or judgment," she said. "If the total points are above a certain number, we automatically open the Falls Standard of Care and implement preventive measures."
Since surgery or the use of pain medications can increase a child's risk of falls, assessment is ongoing. "The Falls Standard of Care is visible to any staff member who logs into our computerized medical record, and we also have magnetic signs we can post on the child's door," Jackson said. "We also use a falls icon on the computerized map of our unit that's shown on flat screens in the nurses station."
Sandy Keefe is a frequent contributor to ADVANCE.