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Nursing Excellence

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

Denise VermeltfoortEvaluation 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 Children’s 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 Children’s Hospital, Florida, demonstrated a sensitivity and specificity of 0.85 and 0.24, respectively.3


The Children’s 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 Children’s 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 patient’s 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 Children’s 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



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 children’s 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 child’s 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 nurse’s station would further decrease the rate of falls and protect the child from injury.5  Further research to support refinement of the current Children’s Hospital Central California Humpty Dumpty Fall Risk Screening Tool would ensure children at greatest risk for falling are properly identified and protected from injury.



  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 master’s 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