Morse Fall Scale

Fall Risk is based upon Fall Risk Factors and it is

more than a Total Score. Determine Fall Risk Factors
and Target Interventions to Reduce Risks.
Complete on admission, at change of condition,
transfer to new unit, and after a fall.

Variables
Score
History of
Falling
no
yes
0
25
______
Secondary
Diagnosis
no
yes
0
15
______
Ambulatory
Aid
None/bed rest
/nurse assist
Crutches/cane/
walker
Furniture
0
15
30
______
IV or IV
access
no
yes
0
20
______
Gait
Normal/bed rest/
wheelchair
Weak
Impaired
0
10
20
______
Mental
status
Knows own limits
Overestimates or
forgets limits
0
15
______
Total ______
Safety Factors

- Maintain bed in low position, bed alarm when needed

- Call bell, urinal and water within reach.
Offer assistance with elimination needs routinely
- Buddy system
- Wrist band identification
Am
b
ulate with assistance
- Do not leave unattended for transfers / toileting
- Encourage patient to wear non-skid slippers or
own shoes
- Lock bed, wheelchairs, stretchers and commodes

Assessment
- Assess patients ability to comprehend and follow
instructions
- Assess patients knowledge for proper use of
adaptive devices
- Need for side rails: up or down
- Hydration: monitor for orthostatic changes
- Review meds for potential fall risk (HCTZ,
Ace inhibitors, Ca channel blockers, B blockers)
- Evaluate treatment for pain

Family/Patient Education
- PT consult for gait techniques
- OT for home safety evaluation
- Family involvement with confused patients
- Sitters
- Instruct patient/family to call for assistance
with out-of-bed activities
- Exercise, nutrition
- Home safety (including plan for emergency
fall notification procedure)

Environment
- Room close to nurses station
- Orient surroundings, reinforce as needed
- Room clear of clutter
- Adequate lighting
- Consider the use of technology (non-skid floor mats,
raised edge mattresses)

all Risk Screening Tool

Nursing Excellence
The Online Newsletter for Children's Nurses
e-Edition, Issue 8

Evaluation of the Humpty Dumpty Fall Risk

Screening Tool at Children's Hospital Central California
By Carole Cooper, MHA, MSN-C, RN, CPN
Discover the Evidence
Research on pediatric inpatient falls has increased since implementation of the Childrens
Hospital Central California Humpty Dumpty Fall Risk Screening Tool in April 2006. A review of
the literature has identified several fall risk screening tools for hospitalized pediatric patients. All
tools were developed in single-study sites and have demonstrated variable results, making it
difficult to effectively identify patients at risk for falling. Two tools have been validated by nurse
researchers through a retrospective pair-matched, case-control method of research. Graf
developed and validated the General Risk Assessment for Pediatric Inpatient Falls (GRAF PIF)
Tool.1 The tool demonstrated a sensitivity and specificity of 0.75 and 0.76, respectively.2 The
Humpty Dumpty Falls Scale (HDFS) developed by an interdisciplinary team of expert clinical
nurses from Miami Childrens Hospital, Florida, demonstrated a sensitivity and specificity of
0.85 and 0.24, respectively.3

The Childrens Hospital Central California Humpty Dumpty Fall Risk Screening Tool was
originally developed utilizing an evidence-based approach. Key variables were abstracted from
the adult literature and identified by members of the Nursing Research Committee to have
clinical significance in predicting children at risk for falling during hospitalization.4 Additional

research was recently conducted to ensure the current screening tool is effectively identifying
children at greatest risk for falling and protected from injury. The purpose of the research study
was to identify the following: statistically significant variables associated with hospitalized
children at risk for falling; the demographic, physical and environmental characteristics
associated with pediatric falls of hospitalized children; and the prevalence of falls in hospitalized
children 0-18 years of age at Childrens Hospital Central California.

A pair-matched, case-control methodology was used to identify significant risk factors between
106 hospitalized pediatric patients who fell and 106 non-fallers matched according to age,
gender, and diagnosis during May 1, 2008, through December 31, 2009. Physiological and
environmental variables, fall risk status, and additional information pertaining to the fall event
were abstracted.5

Evidence Summary
Descriptive statistics were used to evaluate differences between fallers (cases) and non-fallers
(controls).There were no significant differences detected in gender, age, ethnicity and diagnosis.
Findings from the Evaluation of a Pediatric Fall Risk Assessment Tool study identified
adolescents (11-18 years of age) with a hematologic/oncologic primary diagnosis had the highest
incidence of falls (28 percent). The second highest incidence of falls occurred among 2-3 year
olds with a primary diagnosis of infectious disease (23.6 percent). Interestingly, falls occurred
most frequently during the first four days of hospitalization (59 percent); during weekend shifts
(e.g., Friday, Saturday, and Sunday) (49 percent) and between the hours of 1100 and 2300 (55.6
percent). The most common sites of falls occurred in the patients room (42.7 percent), the
bathroom (33.0 percent) and the hallway (11.3 percent). Falling or rolling off an object, either
the bed (12.3 percent) or crib (5.7 percent), occurred frequently (35.8 percent).5

Most falls occurred when children were supervised (52.8 percent), frequently with the parent in
attendance (50.9 percent). Twenty-three percent of supervised falls occurred while children were
ambulating, 15 percent while playing, and 11 percent while toileting. Injuries associated with
falling were minor, although patients who fell once during the hospital stay had an increased
incidence of falling again during hospitalization.5

A statistical analysis of the current Childrens Hospital Central California Humpty Dumpty Fall
Risk Screening Tool demonstrated a sensitivity rate of 64 percent, and a specificity of 53 percent.
Sixteen variables were evaluated. Two variables, continuous narcotic analgesic infusion (p = .
013) and patients receiving either physical therapy or rehabilitation services (p = .012) were

identified to be significant between fallers and non-fallers.5

Translation
The study revealed that children who fell frequently were less than 4 years of age and had a more
severe illness with secondary co-morbid conditions, most frequently with oncologic or
hematologic diagnoses. There are limitations to the study as data collection was retrospective,
limiting the completeness and accuracy of the data. Missing information due to inconsistent
documentation of risk factors and incomplete descriptions of fall events may have impacted the
results. Although the study has limitations, it did help to identify a revision of the tool is needed
to enhance the sensitivity and specificity. Revision of the current tool would facilitate a reduction
in fall rates, improve the efficiency and effectiveness of care and ensure a safe environment for
hospitalized children.

Implications for Nursing

The prevalence rate of inpatient falls in the study was 1.44 falls/1000 patient days.5 This is
similar to other childrens hospitals which range from 0.64 to1.54 falls per 1,000 patient days.2
Preventing falls among hospitalized children is challenging due to the childs growth and
development, play activities and parental interactions. Although it is difficult to prevent children
from falling, preventing serious injury can be accomplished.

Protecting children from injury during falls does require a multifaceted approach. It is important
for care providers to recognize that the hospital is a strange environment with multiple
distractions, placing the child at a greater risk for falling. Orientation to the environment,
demonstrating crib safety and reinforcing the importance of not leaving the infant unattended,
even for a short period of time, would decrease the rate of falls. Instructions to patients and
families to call for assistance when getting out of bed or going to the bathroom, especially after
receiving pain medications, should be reinforced frequently. Acquiring beds with bed alarms
would help to alert the nurse when the child is attempting to get out of bed without assistance.
Becoming proactive by implementing comfort care and safety rounds, toileting prior to pain
administration, and moving the high risk patient close to the nurses station would further
decrease the rate of falls and protect the child from injury.5 Further research to support
refinement of the current Childrens Hospital Central California Humpty Dumpty Fall Risk
Screening Tool would ensure children at greatest risk for falling are properly identified and
protected from injury.

References
1. Graf, E. (2005). Examining inpatient pediatric falls. Joint Commission Perspectives on
Patient Safety, 5(9), 5-6.
2. Graf, E. (2008). Pediatric fall risk assessment classification: Two hallmarks for a
successful inpatient fall prevention program. Journal for the Society Pediatric Nurses,
17(2), 3-5.
3. Hill-Rodriguez, D., Messimer, P.R., Williams, P.D., Zeller, R.A., Williams, A.R., Wood,
M., et al. (2009).
The Humpty Dumpty Falls Scale: A case-control study. Journal for the Society of
Pediatric Nurses,
14(1), 22-32.
4. Cooper, C. L., & Nolt, J. D. (2007). Development of an evidence-based pediatric fall
prevention program. Journal of Nursing Care Quality, 22(2), 107-112.
5. Cooper, C.L. (2011). Evaluation of a Pediatric Fall Risk Assessment Tool
(Unpublished masters thesis). California State University, Fresno.

In This Issue
Nursing Yesterday, Today & Tomorrow - Making A Difference
Nursing Through The Generations
Family Footsteps: Generations of Influence
Family Footsteps: Born To Be
Family Footsteps: Nursing, It's In The Family

It's Not Your Grandma's Student Program

Nurse of the Year 2011

Evaluation of the Humpty Dumpty Fall Risk Screening Tool
Enhancements to Nursing Professional Practice
Contributions to Practice
Leadership in Professional Nursing Organizations

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Enhancements to Nursing Professional Practice
Contributions To Practice
Leadership In Professional Nursing Organizations

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