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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 5 

Magnet LogoA Culture of Inquiry 

The practice of nursing and provision of patient care continues to evolve. These changes are driven by innovative and inquisitive nurses applying a scholarly approach to evaluate current practice. The aim of a culture of inquiry is to question  practice in an effort to enhance patient outcomes. Evidence-based practice and research review is the approach used to integrate existing research, quality data, and clinical expertise into care. Two questions have been raised in the practice area of pediatric falls and Pediatric Early Warning Score (PEWS). The authors will share a summary of evidence in the literature, its translation and application for further study and implications for practice at Children’s Hospital.

Carole CooperDoes use of a pediatric fall assessment tool decrease the rate of falls?

Carole Cooper, BSN, MHA, RN, CPN, NE-BC

Evidence Summary 

Patient falls constitute a major proportion of all incidents occurring in a hospital, with the potential to cause personal injury, extended length of stay, and increased health care costs (Rutledge, Donaldson, & Pravikoff, 2003). Common injuries associated with falls include superficial bruising, lacerations, fractures, dislocations and skull fractures. 

Unintentional falls are the leading cause of nonfatal injury among children (Rasmussen, 2004) resulting in more than 2.5 million emergency department visits for children age 14 years and under in the United States in 2001 (National Safe Kids Campaign, 2003). Injuries associated with falling are directly related to the developmental stage, ambulation capabilities of the child, and mechanism of fall. Children ages four and under are at the greatest risk of fall-related death (National Safe Kids Campaign, 2003). 

The most common mechanism of falls in infants is from furniture, infant carriers, falls down stairs with or without an infant walker, and those occurring when they are dropped. Falls from being dropped are most frequently in infants 0 to 2 months old, whereas falls from furniture occur most frequently among children from 3 to 47 months (Agran, Anderson, Winn, Trent, Walton-Haynes, & Thayer, 2003; Flavin, Dostaler, Simpson, Brison & Pickett, 2006; Pickett, Streight, Simpson & Brison, 2003).

Head injuries in children are associated with significant morbidity and mortality, especially among infants (Greenburg, Bolte & Schunk, 2009; Tarantino, Dowd, & Murdock, 1999), and boys are twice as likely as girls to die from fall related injuries (Yale Medical Group, 2004). Injuries are a leading cause of death and disability for children and adolescents in the United States with an estimated injury rate of 25/100 children through 21 years of age, and an estimated cost of $347 billion annually (Agran, Winn, Anderson, Trent, Walton-Haynes, 2001). Preventing injuries from falls is a public health concern.  

Although there has been extensive research regarding risk assessment tools and fall prevention strategies in adults, the published literature in the pediatric population is sparse. Currently there are two validated fall risk assessment tools for hospitalized pediatric patients: the General Risk Assessment for Pediatric Inpatient Falls (GRAF PIF©) (Child Health Corporation of America, July/August 2009) and the Humpty Dumpty Falls Scale (Hill-Rodriguez et al, 2009).



Preventing patient falls and related injuries continues to be a significant challenge for many healthcare organizations. Pediatric organizations have had significant challenges implementing effective fall reduction programs due to the current lack of supportive research.  

Collaboration among nurse researchers at children’s hospitals identify that there are multiple actions that can be implemented to help reduce the rate of patient falls. Accurately identifying patients at risk for falling, implementing strategies that prevent falls and fall-related injuries and critically evaluating the predictive validity of risk assessment tools should protect patients from harm. Continual efforts to identify effective strategies to involve other healthcare disciplines and involve families in fall prevention efforts are needed. Monitoring trends in fall data and utilizing external benchmarks to guide performance improvement initiatives within health care organizations should help to reduce the rate of falls among hospitalized children.


Integration into Practice

Ensuring Children’s fall risk assessment tool accurately predicts patients at highest risk for falling would promote effective utilization of nursing resources and contain costs. Further studies to validate the reliability and validity of the current fall risk assessment tool used at Children’s Hospital may improve the efficiency and effectiveness of care and promote a safe environment for our patients.  



Agran, P. F., Anderson, C., Winn, D., Trent, R., Walton-Haynes, L., & Thayer, S. (2003, June).
Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 111(6), 683-689.

Agran, P. F., Winn, D., Anderson, C., Trent, R., & Walton-Haynes, L. (2001, September).
Rates of pediatric and adolescent injuries by year of age. Pediatrics, 108(3), 45-56.

Child Health Corporation of America. (July/August 2009). Pediatric falls: State of the science.
Pediatric Nursing. 35(4), 227-231

Flavin, M. P., Dostaler, S. M., Simpson, K., Brison, R. J., & Pickett, W. (2006, July 18). Stages of development and injury patterns in the early years: a population-based analysis. BMC Public Health, 6(187), doi:10.1186/1471-2458-6-187.

Greenburg, R. A., Bolte, R. G., & Schunk, J. E. (2009, November). Infant carrier-related falls.
Pediatric Emergency Care, 25(2), 66-68.

Hill-Rodriguez, et al. (2009, January). The Humpty Dumpty Falls Scale: A case-control study.
Journal for the Society of Pediatric Nurses, 14(1), 22-32.

National Safe Kids Campaign. (2003, May). Report to the nation: Trends in unintentional childhood injury mortality 1987-2000. Retrieved from

Pickett, W., Streight, S., Simpson, K., & Brison, R. J. (2003). Injuries experienced by infant children: A population-based epidemiological analysis. Pediatrics, 111, 365-370.

Rasmussen, M. (2004, November 6). Morbidity and mortality trends for pediatric falls and traumatic brain injury. Retrieved from

Rutledge, D. N., Donaldson, N. E., & Pravikoff, D. S. (2003, December 31). Update 2003: Fall risk assessment and prevention in hospitalized patients. Online Journal of Clinical Innovations,  6(5), 1-55.

Tarantino, C. A., Dowd, D., & Murdock, T. C. (1999). Short vertical falls in infants. Pediatric Emergency Care, 15, 5-8.

Yale Medical Group (2004). Falls: injury statistics and incidence rates 2004.
Retrieved from


Mary Ann RobsonCan the use of a Pediatric Early Warning Score (PEWS) decrease the occurrence of Acute Care cardio-pulmonary arrests?

Mary-Ann Robson, BSN, RN, CCRN

Evidence Summary

Only 19-27 percent of children survive an in-hospital cardio-pulmonary arrest (Nadkarni, V., Larkin, G., Peberdy, M., Carey, S., Kaye, W. et al., 2006 and Reis, A., Nadkarni, V., Perondi, M., Grisi, S., & Berg, R. 2002). Advances in technology and scarcity in Pediatric Intensive Care Unit (PICU) beds have increased the acuity of children cared for in the acute care setting (Doman, M., Prowse, M., & Webb, C., 2004 and Haines, C., 2005). As a result Rapid Response Teams (RRTs) were developed to enable fast deployment of resources to the child’s bedside before they progressed to a cardio-pulmonary arrest (Berwick, D., Calkin, D., McCannon, C. & Hackbarth, A., 2006, cited in Subbe, 2007).

RRT’s have failed to show statistically significant reductions in pediatric cardio-pulmonary arrests, morbidity and mortality, (Brilli, R., Gibson, R., Luria, J., Wheeler, T., Shaw, J., et al., 2007 and Zenker, P., Schlesinger, A., Hauck, M., Spencer, S., Hellmich, T., 2007).

Children who suffer a cardio-pulmonary arrest or unplanned PICU admission have physiological abnormalities 1-24 hours before the event (Duncan, H., Hutchison, J., & Parshuram, C., 2006 and Tume, 2007). Tools have been developed to identify children at risk of deterioration known as Pediatric Early Warning Scores (PEWS), although only two have been previously validated (Duncan, H., Hutchison, J., & Parshuram, C., 2006, Haines, C., Perrott, M. and Weir, P., 2006).



While there are various early warning scores that have been validated in the adult population, there have been limited studies showing validity of a PEWS tool. There is some evidence that the use of a PEWS tool does have a positive impact on the number of acute care codes and unplanned admissions to the PICU.


Integration into Practice

A retrospective study was undertaken to determine which tool could most reliably predict adverse outcomes in our patients without overwhelming the organizational resources.

There is an opportunity to improve the assessment of acute care patients to allow for early identification and possible prevention of deterioration resulting in cardio-pulmonary arrest and admission to the PICU. 

Conduct additional research, a prospective study, to evaluate the use of PEWS in the acute care areas and its effectiveness in decreasing the number of acute care codes and unplanned admissions to the PICU.

It is possible that the implementation of PEWS could enhance the skills and knowledge of acute care nurses to enable them to effectively meet the increasing demands of their changing patient population.



Berwick, D., Calkin, D., McCannon, C. & Hackbarth, A. (2006). The 100,000 lives campaign Journal of the American Medical Association, 295, 324-327, cited in Subbe, C. (2007). The perfect score. Care of the Critically Ill, 23 (1), 21-25.

Brilli, R., Gibson, R., Luria, J., Wheeler, T., Shaw, J., Linam, M., Kheir, J., McLain, P., Lingsch, T.,   Hall-Hearing, A. and McBride, M. (2007) Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit, Pediatric Critical Care Medicine, 8 (3), pp. 236-246.

Doman, M., Prowse, M., & Webb, C. (2004). Exploring nurses’ experiences of providing high dependency care in children’s wards. Journal of Child Health Care, 8 (3), 180-197.

Duncan, H., Hutchison, J., & Parshuram, C. (2006). The pediatric early warning system score: a severity of illness score to predict urgent medical need in hospitalized children. Journal of Critical Care, 21, 271-279.

Haines, C. (2005). Acutely ill children within ward areas – care provision and possible development strategies. Nursing in Critical Care, 10 (2), 98-104.

Haines, C., Perrott, M. and Weir, P. (2006). Promoting care for acutely ill children-development and evaluation of paediatric early warning tool. Intensive and Critical Care Nursing, 22, 73-81.

Nadkarni, V., Larkin, G., Peberdy, M., Carey, S., Kaye, W., Mancini, M., Nichol, G., Lane-Truitt, T., Potts, J., Ornato, J. and Berg, R. (2006) First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults, Journal of the American Medical Association, 295 (1), 50-55.

Reis, A., Nadkarni, V., Perondi, M., Grisi, S., & Berg, R. (2002). A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style, Pediatrics, 109, 200-209.

Tume, L. (2007). The deterioration of children in ward areas in a specialist children’s hospital.
Nursing in Critical Care, 12 (1), 12-19.

Zenker, P., Schlesinger, A., Hauck, M., Spencer, S. and Hellmich, T. (2007). Implementation and impact of a rapid response team in a children’s hospital. The Joint Commission Journal on Quality and Patient Safety, 33 (7), 418-425.

In This Issue

Nursing Rights and Responsibilities

Nurse of the Year 2010

PICU Beacon Award

Critical Care Transport Excellence

A Culture of Inquiry

Nursing Governance Outcomes

Parents As Partners In Care

Professional Development

Contributions to Practice

Contributions to New Knowledge - Nursing Research

Leadership In Professional Nursing Organizations

Patient Satisfaction Comments