Implementation of a Fall Prevention

Bundle on a Pediatric Neurology Unit

Item Type DNP Project

Authors Habib, Olimatu I.

Publication Date 2019-05

Abstract Evidence/Background: Many times the nursing staff may not be

readily available at the bedside to prevent falls. Falls continue to
place a tremendous burden on patients and financial burden on
the institution. A multifaceted approach to decrease fal...

Keywords Humpty Dumpty Fall Scale; pediatric neurosurgical unit; Child,

Hospitalized; Accidental Falls--prevention & control; Patient Care
Bundles

Download date 17/05/2021 16:58:57

Link to Item http://hdl.handle.net/10713/9538

Running head: IMPLEMENTATION OF A FALL BUNDLE 1

Implementation of a Fall Prevention Bundle on a Pediatric Neurology Unit

by

Olimatu I Habib

Under Supervision of

Ann Hoffman DNP, CPN, CNE

Second Reader

Charon Burda DNP, PMHNP-BC, CARN-AP

A DNP Project Manuscript

Submitted in Partial Fulfillment of the Requirements for the
Doctor of Nursing Practice Degree

University of Maryland School of Nursing

May, 2019
 IMPLEMENTATION OF A FALL BUNDLE 2

Abstract

Evidence/Background: Many times the nursing staff may not be readily available at the
bedside to prevent falls. Falls continue to place a tremendous burden on patients and
financial burden on the institution. A multifaceted approach to decrease falls in a pediatric
hospital setting was implemented with a fall bundle. Included in this fall bundle is the
Humpty Dumpty Fall Scale, a validated and reliable tool that is specifically sensitive to
neurology patients and an education plan focused on families and staff. The Humpty
Dumpty Fall Scale included a wide variety of medications and anesthesia/sedation
influences to assess the risk of falls. Education to families has been identified as important
in preventing falls.
Local Problem: Pediatric patients are at an increased risk for falls in the hospital setting.
Nursing staff and caregivers play an important role in preventing falls yet little is known on
how to best prevent falls rates in the pediatric acute care setting through evidence - based
interventions. The Joint Commission, the certifying body for health organization, now
requires that a fall prevention program be implemented to prevent falls in all hospital
setting. The purpose of this quality improvement project is to decrease the pediatric fall rate
through the implementation of a pediatric fall bundle.
Intervention: This quality improvement project took place on an 18-bed pediatric acute
care unit at a large freestanding pediatric facility on the East Coast. The Neurosurgical unit
pediatric patients were included in this quality improvement project. The pediatric fall
bundle included implementation of education on fall prevention in children to staff and
caregivers, the introduction of a new pediatric fall risk assessment scale, the Humpty
Dumpty Fall Scale, and fall risk bracelet/band identifiers.
Results: Quantitative data comparing fall risk and occurrence of falls was collected to
assess the effectiveness of the fall bundle on the neurosurgical unit. Sixty patients met the
inclusion criteria and were included in this quality improvement project. All sixty patients
risk for a fall was assessed using the Humpty Dumpty Fall Scale. In 2018 there were a total
of seven falls reported on the neurosurgical unit. Prior to implementation of the fall bundle,
four falls were reported on the neurosurgical unit. During the implementation of the fall
bundle, there was a decrease in fall rates with only one reported unwitnessed fall resulting
in no injuries. Two additional falls occurred post implementation of the fall bundle on the
unit.
Conclusions: This DNP project was intended to improve the quality of patient care and
promote fall safety to pediatric patients admitted to the neurosurgical unit. There was a
decrease in rate of falls on the unit during implementation. This QI project increased
awareness of neurological assessments pertaining to patient falls. Nursing staff reported
including fall prevention in their daily plan of care after receiving fall prevention
education. This QI project promoted a change in practice that heightened fall risk
awareness and included fall risk education, a pediatric-specific fall scale, and patient
identifiers in an effort to decrease the fall rate of patients on the neurosurgical unit.
 IMPLEMENTATION OF A FALL BUNDLE 3

Overview and Framework

Introduction. Background, and Significance of the Problem

Within the healthcare system, patients’ safety remains a high priority in the hospital

setting. Falls continue to be a major sensitive nurse indicator, which is tracked by

different organizations including: National Database Nursing Quality Indicator (NDNQI),

Maryland Indicator Project, California Nursing Outcome Coalition (CalNOC), the National

Quality Forum (NQF), and the Joint Commission National Patient Safety Goal

(DiGerolamo & Davis, 2017). In 2006 hospitals were required to implement and evaluate

the efficacy of fall reduction programs (Joint Commission, 2015). Falls place a tremendous

burden on patients and their families. Hospital fall costs exceed 105.6 million dollars

annual (Healthy People 2020, 2014). The Center for Medicare and Medicaid Services no

longer takes responsibility for the financial cost associated with falls that occur while

patients are admitted to inpatient units (Avanecean et.al, 2017). As for the healthcare

facility, they are now responsible for the financial burden for required treatment resulting

from falls.

Falls occur in all settings; however pediatric patients are at an increased risk for

injuries from falls due to their developmental level. Little research is available on the rate

of falls in the pediatric acute care setting as well as appropriate interve ntions to prevent falls

in this setting. It is imperative that a strategic plan is implemented to prevent falls in the

hospital setting. Nursing staff and caregivers play an enormous role in preventing falls on

in-patient units. Depending on the acuity of the unit and nurse to patient ratio, nursing staff
 IMPLEMENTATION OF A FALL BUNDLE 4

may not be readily available at the bedside, so it is important that families are educated on

fall prevention.

Pediatric patients are at an increased risk of falls in the hospital setting due to

physiological factors, medical equipment, sedating medication, and toileting needs

(Kobayashi et. al, 20017). Hill-Rodriguez et al. (2009) argued that there is an increase of

fall occurrences in children younger than 3 years old and older than 13 years old with

neurologic diagnoses with no significance in gender. Wallace (2015) assessed the rate of

falls in newborns up to 30 days old from July 2004 through December 2013 and estimated

the rate of falls range from 0.4 to 3.8 newborns per 10,000 live births. A total of 272 falls

were pulled from the Pennsylvania Patients Safety Reporting System (PPSRS) on newborns

falls. All reported falls occurred on the acute care inpatient setting while the patients were

under the care of their families. To decrease the rate of falls staff began to educate parents

on fall prevention on admission, the start of each shift, and as needed.

A thorough literature search was performed on the implementation of the Humpty

Dumpty Fall Scale (HDFS) and the importance of including and educating caregivers on fall

prevention tactics in the hospital setting. The HDFS is a pediatric fall scale that was

designed by the nursing staff at Nicklaus Children’s pediatric hospital in 2006 (Gonzalez,

2016). This pediatric-specific fall assessment tool identifies a patient’s risk for falls, taking

into special consideration patients with neurologic diagnoses and assess and patients who

are within 48 hours post sedation, surgery, or anesthesia (Gonzalez, 2016). The

neurosurgical unit uses a modified Morse fall scale to assess each patients risk for fall for

patients from birth to 17 years old. The Morse fall scale is the most tested and used fall

scale (Baracoa et al. 2017). Typical procedures ordered for neurological conditions includes
 IMPLEMENTATION OF A FALL BUNDLE 5

sedated magnetic resonance imaging (MRI), sedation for lumbar punctures (LP), and varies

surgery which is not necessarily assessed in precise details using the current modified

pediatric fall assessment tool. In addition to sedation for procedures, the majority of the

patients on the unit routinely receive sedating medication for routine and daily treatment.

The purpose of the DNP project was to implement and evaluate the effectiveness of a

pediatric fall bundle on an acute care pediatric in-patient unit. This project improved the

unit’s rate of fall by identifying and protecting patients from falls and injuries resulting

from falls. The fall bundle included the implementation of the HDFS by nurses, the use of

fall prevention bracelets and fall prevention education and safety to the staff. Short-term

goals of this DNP project included: 1. decreasing the occurrence of falls on the unit 2.

Educate neurosurgical nurses (RN) of fall policy and appropriate fall interventions 3.

Nursing staff will use the HDFS to identify each patients risk for fall. Long-term goals of

this DNP project include eliminating falls on the unit, preventing all injuries related to falls,

and the sustainability of the HDFS on the unit.

Theoretical Framework

The Knowledge-to-Action (KTA) framework was used in the assessment and

implementation of the fall bundle on the Neurology unit. This particular framework was

chosen because it permits the ability to adjust and address changes during each phase of the

cycle. The KTA framework has two components: knowledge creation and knowledge

application (White, 2016). The KTA model was designed to allow new knowledge to move

through each phase until it is adopted and sustained in use (White, 2016). Each step of the

knowledge creation allows the implementing team the ability to better address the research

question or end users’ needs to adopt knowledge. The action cycle of the KTA cycle define
 IMPLEMENTATION OF A FALL BUNDLE 6

the activities which implements or apply the knowledge (White, 2016). Feedback in the

KTA cycles can occur within all phases of the knowledge and action phase. The KTA

cycles benefit all members including internal and external stakeholders, clinicians, patients

and their family.

Knowledge in the KTA cycles represents gathered knowledge and research. In

addressing the first phase in the KTA cycle, adequate evidence has been gained through

multiple studies along with actual data from the unit to bring awareness of fall rates on the

unit. Data gathered from the unit includes: incidents report from January of 2018-

December 2018, the total number of falls per patient days, and score from the quarterly

NDNQI and Press Ganey scores for the unit. A unit survey provided an assessment on

staff’s opinions and beliefs of the effectiveness of the unit current fall assessment

tool. Management and leadership play a vital role in gaining Nurse “buy-in” and are

essential in the successful implementation of the fall bundle.

The adaption of knowledge consists of gathering the evidence to determine how it

can be translated and used on the unit. Unit Champions freely volunteered and provided

guidance, encouragement, and support to nursing staff using the HDFS. The KTA cycle

promotes constant assessment and the use of a multidisciplinary team includi ng unit

leadership (unit Director, unit Manager, Shift Coordinator, Professional Practice Specialist,

and Nurse Educator), primary RN, Patient Care Technician (PCT), and Unit Communication

Assistance (UCA). During implementation, the unit champions was a support system for

nursing staff completing hard copies of the HDFS and promoted caregiver education on fall

preventions. The results of the QI project will remain transparent to nursing staff and

leadership. The nursing staff was encouraged to participate and was included in the
 IMPLEMENTATION OF A FALL BUNDLE 7

decision-making process during the implementation of the fall bundle. Once barriers are

addressed and changes have been made the final step was to maintain stability and

acceptance of the HDFS on the unit.

Literature Review

The implementation of an accurate and valid fall assessment tool is essential in the

pediatric acute care setting. When implementing a fall assessment tool, emphasis should be

placed on providing adequate education to both bedside staff and caregivers. This literature

review will focus on the implementation of the Humpty Dumpty Fall Scale (HDFS) and the

importance of providing education to both staff and caregiver to reduce the occurrence of

falls on a pediatric acute care neurology unit. The literature review began with evidence

supporting fall bundles to prevent fall rates in the hospital setting. Then the discussion was

followed by the importance of patient and family education in preventing falls in the

hospital setting. Discussion continued to explain the reliability and validity of the

HDFS. Finally, the literature review synthesized current evidence to implement a well-

known pediatric specific fall scale in addition to providing both staff and caregivers

education to reduce falls and injuries on an inpatient pediatric unit.

Analysis of the literature

Parents and staff must understand that the hospital environment is different from

their home environment thus require different precautions to assure safety. Kobayashi et al.

(2017) reported a study which examines the prevention of falls as a result of interventions

from a fall workgroup. The fall workgroup were comprised of doctors, nurses,

physiotherapists, pharmacist, information management technicians, and administrative

staff. The study took place at a pediatric advance treatment hospital and emergency medical
 IMPLEMENTATION OF A FALL BUNDLE 8

center. Falls were assessed from April 2012 to March 2017 and included a total of 212,617

inpatients charts pulled from a database in the hospital event reporting system. Within the

five years, falls continued to decrease from 2.1% to 1.3% in 2012 and 2016 respectively

(Kobayashi et al, 2017). One of the listed intervention used to prevent falls included

caregivers education via verbal communication and DVD video. The fall working groups

successfully reduce the overall rate of falls during the implementation of the fall

workgroup.

Fujita et al. (2013) completed a quality improvement study to assess multiple ways to

prevent pediatric falls in the hospital setting and stressed the necessity to educate parents

and nursing staff in addition to a fall scale to reduce the occurrence of falls. Alims et al.

(2017) highlighted the importance of caregiver’s in reducing hospital falls within the

pediatric population. Increasing staff monitoring, educating families, and making families

aware of the occurrence of falls can reduce the rate of falls (Wallace, 2015). Multiple

quality improvement projects duplicated similar results in the inpatient hospital setting that

the intervention of education in combination with a fall assessment tool can successfully

reduce the rate of falls.

Hill-Rodriguez et al (2008) conducted a descriptive study to assess the validity of the

HDFS in accurately identifying inpatient pediatric patients at high risk for falls . The design

of the study was a matched case-control design which included a chart review of 306

charts. Of the selected charts 50% of the patients had a reported fall from 2005-2006 at a

freestanding pediatric teaching facility. Prior to the implementation of the fall scale fall

rates were 0.989 and 1.0 per 1000 patient day. In the study protocol, once the patient were

identified, HDFS signage were placed in visible locations (sticker on the patient, sign on the
 IMPLEMENTATION OF A FALL BUNDLE 9

crib, and in the chart). In 2007 the fall rate were measured at 0.56 per 1000 patient days

proving that the scale has merit and value. High-risk patients were identified with a score of

12 or more. In addition, Hill-Rodriguez et al. (2008) result revealed that most falls occurred

in children with neurological diagnosis, gastrointestinal problems, and respiratory/asthma

respectively. Kobayashi et al. (2017) reported a similar study concluding that patients with

neurologic disease accounted for the majority of falls which were reported in the

study. Neurologic diseases require specific monitoring and assessment which are assessed

within the HDFS.

Synthesis of the literature

Multiple studies reported strong evidence to support the reliability and validity of the

HDFS at adequately identifies pediatric patients at high risk for falls in the acute care

setting. Although the HDFS alone will not prevent falls, evidence support bundling staff

and caregiver education with a reliable pediatric assessment tool have drastically reduced

the rate of falls in the in-patient pediatric population. Although there are other fall scales

available evidence support the HDFS as the best pediatric scale available to identify patients

at risk for falls.

Implementation plan

Method

The design of this DNP project was a quality improvement project that focused on

improving patient safety with the implementation of a fall bundle. This DNP project was

carried out on a pediatric neurosurgical acute care 18-bed inpatient unit at a large free-

standing pediatric facility on the East coast. The fall bundle identified a patients risk for

falls using the Humpty Dumpty fall scale (HDFS) and provided language appropriate fall
 IMPLEMENTATION OF A FALL BUNDLE 10

education for staff to further discuss with families. This quality improvement project

included a sample size of (N=66) patients admitted to the Neurology unit and a second

sample size of (N=44) Neurology trained staff (RN, PCT, UCA, and SC).

Procedural timeline

This QI project was extended over a fourteen week period beginning in September

of 2018 through December of 2018. The implementation was divided into three

phases. The actual implementation of the fall bundle went from October to mid- November

of 2018. Phase one consisted of assessing the needs and culture of the unit, phase two

included the implementation of the HDFS on the unit, and the final phase consisted of data

collection. In addition to data collection in phase three, the feasibility and sustainability of

the HDFS on the unit was assessed. In mid-September, study coordinator attended several

meetings with the Director of the unit, Manager of the unit, and members from the unit

leadership team to discuss unit fall rates, and the reliability and validity of the HDFS. The

Registered Nurses (RN) completed an anonymous fall survey to assess their understanding

and comfort with the HDFS fall assessment tool. The staff perception of unit safety and fall

preventions was assessed in the survey. The DNP lead attended Septembers Shared Nursing

Leadership (SNL) monthly meeting to inform SNL members of the reliability and validity of

the HDFS.

During week three, the DNP project lead recruited, educated, and trained four RN’s

to become unit champions during the implementation of the fall bundle. The unit

champions attended 15 minutes in-service (see Appendix C) led by DNP leader and onsite

representative. The HDFS (see Appendix D) was introduced to the team and staff was

informed of the important role patients and families play in preventing falls in the hospital
 IMPLEMENTATION OF A FALL BUNDLE 11

setting. In-service included a power point presentation, verbal discussion and return

demonstration on how to accurately assess a patients risk for fall using hard copies of the

HDFS. A teach-back method was used to assess understanding and proper use of the HDFS

at the end of each in-service. During week four, the DNP lead and unit champions led a 10-

minute power point presentation in-service to unit staff on units current fall rate, the

reliability and feasibility of the HDFS, and expected timeline of implementation of th e fall

bundle on the unit. During weeks five through eleven, RN’s used the HDFS in addition to

hospitals current pediatric fall assessment tool to assess patients risk for falls. During the

pilot of the HDFS, the DNP lead attended the units morning huddle once a week and

addressed all barriers and staff concern regarding the fall bundle.

Data collection and analysis

The HDFS was the tool used to assess and identify patients at risk for falls. Each

patient was scored and identified as a low or high fall risk. The HDFS is divided into seven

categories assessing the patient’s age, gender, diagnosis, cognitive impairments,

environmental factors, response to surgery/sedation/anesthesia, and medication usage (Hill -

Rodriquez et al., 2009). Each category can earn a score ranging from 1-4 points totaling an

average score ranging from 7-23 points. For the purpose of this quality improvement

project, any score above a 12 was considered a high risk of fall. Hill-Rodriguez et al.

(2009) assessed the validity of the HDFS in accurately identifying inpatient pediatric

patients at high risk for falls. Only trained neurosurgical nurses were asked to use the

HDFS to assess every patient admitted under the neurosurgical medical team from birth to

17 years of age, risk for fall every shift.

 IMPLEMENTATION OF A FALL BUNDLE 12

To protect human subjects during implementation, the HDFS did not have any

patient identifiers. Copies of the scales were kept in a plastic binder in a locked password

protected nurse server located in each room. The nurse server carts were always locked and

contained medical supplies not readily available at the bedside. Completed HDFS forms

were kept in two different locations, in a folder in the nurse server cart or in an envelope on

the Manager’s door. The DNP lead visited the site weekly to assess staff compliance and

gather data. An assessment on nursing compliance with fall prevention education and safety

awareness to patients and family’s was assessed using patient education notes in the

electronic health record (EHR).

Data was translated onto an excel spreadsheet to assess quantitative

analysis. Descriptive information included the total completed HDFS and the fall rate on

the neurosurgical unit for the 2018 calendar year. The percentage of falls that occurred for

the 2018 calendar year for this quality improvement project was quantified. Data was

analyzed using electronic incident reports of all falls. A bar graph was used to determine

trends of fall occurrences.

Human Subject Protection and IBR Process

To protect human subjects a project description was submitted to the University of

Maryland Baltimore Institutional Review Board for a Non -Human Subjects Research

determination. A second approval from the intuition’s institutional review board was gained

before the initiation of the fall bundle. No patient information was identified or collected

during the implementation or evaluation of this DNP project. A portion of the data was

collected electronically from an encrypted password protected computer.

 IMPLEMENTATION OF A FALL BUNDLE 13

To ensure sustainability leadership was involved and updated on the progress of the

quality improvement project. The fall bundle was discussed twice a day during unit huddle

prior to the start of each shift. Last quarter, the unit fell below the benchmark for the

NDNQI assessment for patient safety for falls. Results and continuing education of the fall

bundle was provided to staff, management, and stakeholders bi-weekly. When used

correctly, the HDFS has proven reliable at identifying patients at increased risk for

fall. Without the support of the unit manager, the implementation of the HDFS was not

sustainable on the unit despite evidence supporting the reliability of the HDFS to decrease

fall rates on the unit.

Results

Structures and Process

Implementing the fall bundle on the unit required multiple revisions. After receiving

feedback from the staff and unit champions, multiple revisions were made to increase

compliance and staff buy-in to accept changes implemented within the fall bundle. Staff

reported accidentally neglecting to complete hard copies of the HDFS on patients due to the

physical location of the scale and the time consuming process of completion. HDFS

signage were then placed on all computers as a reminder for the nurses to complete hard

copies of the fall scale on every patient meeting inclusion criteria. In attempts to increase

compliance, the implementing team suggested altering the process and safekeeping of t he

completed HDFS forms. The frequency of completing the HDFS was modified to daily and

nurses were given the option of leaving completed copies of the HDFS back in the locked

nurse server cart or in an envelope on the manager’s door.

Descriptions of results
 IMPLEMENTATION OF A FALL BUNDLE 14

A total of forty-four neurology staff members attended the fall prevention in-

services. Fifty-nine percent of the staff were neurology trained nurses, thirty-two percent of

the staff were neurology trained PCT’s, and nine percent of the staff were neurology trained

UCA’s. A total of sixty- six charts were collected during the six-week implementation

period. Of the sixty- six chats, 9.1% (6 of the 66) charts did not meet inclusion criteria and

were excluded from the study. A total of sixty charts met inclusion criteria, 41.6% (25 of

the 60) of the charts were completed on female patients and 58.3% ( 35 of the 60) charts

was completed on male patients A total of seven falls occurred on the neurosurgical unit

from January to December of 2018 (See Table 1.). The rate of falls was transcribed into an

excel spreadsheet as a bar graph (See Figure 1.). Zero falls occurred in September during

staff education on fall prevention, fall education and training of proper use of the

HDFS. Zero falls occurred in October during peak implementation of the fall bundle. Two

unwitnessed falls occurred in November, one during implementation and one post

implementation of the fall bundle. Both incident reports were pulled via electronic records

without personal identifiers to maintain anonymity. The fall that occurred during

implementation happened in the morning prior to the change of shift. Parents were in the

room at the time but not directly by the bedside. No injuries resulted from the fall and using

the HDFD, the patient was marked as a high-risk for fall.

Association of interventions and outcomes

Staff buy-in was positively affected by the lack of support from leadership. The

Director of the unit agreed that the HDFS is a sensitive tool and its use will benefit the

pediatric population on the unit; however, she expressed uncertainty in introducing a brand

new fall assessment tool on the unit. She expressed concern of hospital leadership (CNO,
 IMPLEMENTATION OF A FALL BUNDLE 15

Director of falls, Director of Quality and Improvement) not accepting a new fall assessment

tool and did not feel comfortable asking the neurosurgical nurses to complete the HDFS in

addition to the facility’s pediatric fall scale. The organization currently uses a modified

Morse fall scale. The Morse fall scale was modified by selected trained staff within the

organization. A meeting was held with the Director of falls and members of the quality

improvement division who were supportive and suggested interventions that would support

the fall bundle on the unit. The involvement of other leadership from different departments

within the organization brought attention to the possibility of the fall bundle successfully

decreasing the unit rate of falls, which increased unit leadership support in implementing

the fall bundle and staff compliance in using the HDFS in their daily plan of care.

Unintended Consequences

Unit champions provided the most support and were the main facilitators during the

implementation of the fall bundle. The site representative was always available and played

a tremendous role in staff buy-in. Although there was a decrease in falls, this QI project

failed to gain staff buy-in to adopt the HDFS on the unit. A lack of support from

management and leadership lead to the lack of staff buy-in of the HDFS within the six

weeks. Nurses reported incorporating fall education and safety in their plan of care with

every patient. The implementing team was unable to gather and or quantify staff’s

compliances and frequency of fall prevention and safety education within the electronic

health records. A positive unintended benefit of the fall bundle was the adoption of the fall

risk bracelets on the unit. Nurses also reported increase fall situational awareness after

attending in-service of the culture on the unit in regards to falls. There was no cost

associated with the project.

 IMPLEMENTATION OF A FALL BUNDLE 16

Discussion
Similar to other quality improvement projects on falls with the use of the HDFS, there

was a significant decrease in fall rates on the pediatric acute neurology floor. Nurses agreed

that the HDFS was sensitive and a better tool at identifying neurosurgical pediatric patients

risk for fall. Different from other studies, this QI project was implemented over a short time

frame after multiple failed fall prevention programs were introduced to the unit. Nursing

staff expressed fatigue from constant change within the last six months. The Neurology unit

was dealing with high patient census, high patient acuity, and a shortage of neurosurgical-

trained nurses during implementation. This particular QI project was distinctive from other

quality improvement publication because of our specific targeted population of neurology

patients. Results concur with previous studies using fall bundles combining both the HD FS

and fall prevention education in successfully decrease fall rates on pediatric inpatient

unit.

Anticipated outcomes

The environment on the neurology unit during implementation was not conducive to

initiate a new fall bundle which included the adoption of a completely new fall scale. The

neurology unit was under surveillance during the implementation of the fall bundle by

multiple leaders in the hospital including the CNO, for their current fall rates. Prior to the

introduction of the fall bundle, the unit went through two failed fall interventions so the

nursing staff was exhausted from constant change. Gaining staff buy-in and support of the

fall bundle was difficult. Although the HDFS is intended for all pediatric patients, this

quality improvement project only used the HDFS on patients diagnosed with neurologic

disorder limiting the sample size and generality of the results. The specific inclusion

criteria of the QI project negatively affected the sample size.

 IMPLEMENTATION OF A FALL BUNDLE 17

Strengths of the project

Utilizing a well-known evidence-based pediatric-specific fall scale on the unit helped

gain buy-in from leadership and support from nursing staff. Providing research of

successful fall bundles sparked interest in the early adopters on the unit which str engthen

the support of the fall bundle on the unit. The fall risk bracelets were well accepted on the

unit and increased fall awareness within the organization. Float nurses and ancillary staff

noticed and inquired about fall risk bracelets and its success in preventing falls on the

unit. Staff satisfaction of the fall bracelets led to the adoption of the fall bracelets

throughout the organization. Fall bracelets are now stocked in central supply for all units to

order if appropriate for their specific patient population.

Limitation

Limitations arose and were unavoidable during the implementation of the fall

bundle. The implementing team aimed to be an available resource to all staff during

implementation of the fall bundle; however, it was not feasible to always have a member of

the implementing team on every shift. Prior to the initiation of the fall bundle, the unit dealt

with a high nurse turnover rate of their experienced neurosurgical nurses. The nurse

shortage consequently limited the available nurses who could be trained on proper use of the

HSFS. During implementation, a majority of the staff nurses on the floor floated from

another unit so never received training on the HDFS, and were unaware of the presence of

the fall risk bracelet available on the unit to be used as a fall intervention.

Nursing involvement in the QI project was 100% voluntary with no penalty for not

participating. Although leadership was open to implementing the HDFS, there was no

support from leadership to add the HDFS in the electronic health records. Nurses had to
 IMPLEMENTATION OF A FALL BUNDLE 18

then use hard copies of the HDFS during implementation, which affected compliance. In

addition to adding paperwork to their already hectic schedules, the nurses were expected to

complete the institution’s approved Morse’s modified pediatric fall scale and hard copies of

the HDFS on every patient who met inclusion criteria. To protect patient identifiers, hard

copies of the HDFS were kept in the nurse server cart located in each patient’s room. The

compartment of the nurse server cart where the copies were kept is rarely used by the

nursing staff, which further decreased compliance with completing the HDFS.

Multiple interventions were used to minimize and adjust all limitations observed during

the implementation of the fall bundle. The DNP lead was present on the unit once a week to

support all staff and collect data. The DNP lead constantly communicated and updated the

site representative and management of data collected and new knowledge as they aros e

during implementation. In an attempt to increase compliance, the frequency of completing

the HDFS was decreased to once a day. The location of completed fall scales was relocated

at a central location where nursing staff commonly congregated to complete patient

documentation.

Conclusion

Overall the fall bundle was beneficial on the pediatric neurology unit. The fall

bundle definitely increased fall awareness for all staff on the neurology unit. No falls

occurred on the unit when the implementing team initiated fall prevention education and

training to the staff on the unit. Zero falls occurred in the month of October during peak

implementation of the fall bundle. One unwitnessed fall occurred during implementation in

November. The unit had a total of seven falls that occurred from January 1, 2018-December

31, 2018. This QI project increased awareness of neurological assessments pertaining to

 IMPLEMENTATION OF A FALL BUNDLE 19

patient falls. Nursing staff reported including fall prevention in their daily plan of care after

receiving fall prevention education from DNP lead. Nursing staff reported initiating fall

prevention education when placing fall bracelets on each patient. This QI project promoted

a change in practice that heightened fall risk awareness and included fall risk education, a

pediatric-specific fall scale and patient identifiers in an effort to decrease the fall rate of

children on a neurology unit.

Due to positive results from the fall bundle the institution has adopted the use of fall

risk bracelets on all units. Arm bracelets are currently available for any interested unit to

order within the organization. The implementing team recognized the need to educate float

nurses to the neurological floor to better utilize the HDFS in patient assessment . A larger

sample size and longer implementation period on the unit is needed before the sustainability

of the fall bundle on the unit can occur. It is suggested that evidence on the validity and

reliability of the HDFS be presented to influential stakeholders including staff in the

research department, staff within quality improvement department, and staff from fall

department.
 IMPLEMENTATION OF A FALL BUNDLE 20

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Implementation Reports, 15(12), 3006-3048. doi:10.11124/JBISRIR-2016-003331

Bóriková, I., Tomagová, M., Miertová, M., & Žiaková, K. (2017). Predictive Value of the

Morse Fall Scale. Central European Journal of Nursing & Midwifery, 8(1), 588–595.

DiGerolamo, K., & Davis, K. F. (2017). An Integrative Review of Pediatric Fall

Risk Assessment Tools. Journal Of Pediatric Nursing, 3423-28.

doi:10.1016/j.pedn.2017.02.0364

Fujita, Y., Fujita, M., & Fujiwara, C. (2013). Pediatric falls: effect of prevention

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JJNS, 10(2), 223-231. doi:10.1111/jjns.12004

Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding
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and patient falls: what factors boost success?. Nursing, 45(2), 25-30.

doi:10.1097/01.NURSE.0000459798.79840.95

Gonzalez, J. (2016). From Evidence to Outcomes: Promoting Pediatric Fall Prevention

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doi:10.1097/NNA.0000000000000335

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Injuries in health care facilities. Retrieved from:

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_55_Falls_4_26_16.pdf

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Measures and effects on prevention of fall: The role of a fall working group at a university
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hospital. Nagoya Journal of Medical Science, 79(4), 497-504.

doi:10.18999/nagjms.79.4.497

Kramlich, D. L. (2016). Development of a pediatric fall risk and injury reduction program.

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and healthcare (2nd ed.). Springer Publishing Co. ISBN-13: 978-0-8261-1784-7 P(41)
 IMPLEMENTATION OF A FALL BUNDLE 23

Figure 1.
Fall Rate by Month on the Pediatric Neurology Unit

January
February
March
2018 Calendar Year

April
May
June
July
August
September
October
November
December
0 1 2 3
Number of Falls

(Red bar graph for November includes the one fall that occurred during implementation).
 IMPLEMENTATION OF A FALL BUNDLE 24

Table 1.

2018 Fall Rates on the Neurology Unit

# of falls % of falls

Pre-Implementation 4 57.1 %

Implementation 1 14.3 %
Post-Implementation 2 28.6 %
Running head: IMPLEMENTATION OF A FALL BUNDLE 25

Appendix A
Evidence Review Table: Pediatric Fall Bundle
Author, Study Design Sample (N) Outcomes Results *Level
year objective/intervention studied (how and
or exposures measured) Quality
compared Rating
Avanecean To evaluate the Systemic Review Five A through Patient center III, B
et. al, 2017 effectiveness of patient on a medical or randomized literature intervention
center interventions on medical surgical control review was did prove to
falls in the acute care unit studies were completed. provide better
setting. used outcome in
reducing
inpatient falls.
The study did
lack high
quality
evidence thus
further studies
are necessary.
DiGerolamo To assess the Integrative 12 articles Comprehensive It is essential I, B
& Davis, specificity and review/ Systemic meet literature that the facility
2017 sensitivity of multiple review inclusion review and picks a fall
pediatric fall criteria. comparison of assessment tool
prevention tools used Articles of article results. that is specific
within multiple patients aged to the
pediatric hospital 0-24 months population they
setting old were server.
included. Due to the
All articles different
occurred on measurement
a pediatric in each
unit in a pediatric fall
hospital tool an
setting. accurate
comparison is
difficult.
 IMPLEMENTATION OF A FALL BUNDLE 26

Fujita et. al, To assess and Quality Cross A 1.36/1000 III, B

2013 determine multiple improvement sectional questionnaire patient days
ways to prevent design with that assessed was the fall
pediatric falls. 162 random the rate for the
general characteristic pediatric
hospitals in of the ward and patients. The
Japan. whether proper resulted
steps were revealed that
taken to further
prevent falls. education
should be
provided to
parents and
novice nurses.
A fall scale is
necessary for
high risk
patient and a
valid risk
assessment
tool.
Gonzalez, The purpose of this Informative Not Information
2016 project was to identified. was gathered Since the VII, B
implement a pediatric Article throughout the implementation
fall prevention discussed the years and of the HDFPP
program and policy on use of the measured by at Nicklaus
an inpatient pediatric humpty the yearly rate Children’s
unit. Intended goal: dumpty fall of falls per hospital in
decrease pediatric falls scale from 1000 patients’ 2006, they
2005-2016 admission have reported a
days. Success tremendous
was also drop in fall
measures based rated in their
off of the pediatric
global patients. In
acceptance and 2009 falls were
adaptation of measure at
 IMPLEMENTATION OF A FALL BUNDLE 27

the humpty 1.03 per 1000

dumpty fall patient days
scale compared to
worldwide. 2015 measured
An estimated fall rate of only
1200 hospitals 0.42 falls per
including over 1000 patient
90 ANCA days measuring
magnet at a 41% fall
hospital have rate
implemented
and
successfully
used the
HDFPP to
assess and
prevent at risk
pediatric
patients.
Hill- The purpose of the Descriptive A chart A chart review The HDFS IV, B
Rodriguez study was to assess study. A match review of of 308 charts suggest
et al, 2009 whether the Humpty case control 306 charts from 2005- reliability and
Dumpty Fall Scale design (153 were 2006 at a free that it remains
identifies pediatric controls standing a valid tool at
high risk patients in which no fall pediatric recognizing
the hospital setting occurred teaching high risk
compared to facility. pediatric
153 patients Selected patients in the
with advance nurse inpatients
documented practitioners, units. Children
falls). clinical nurse with
specialist, neurologic
directors and deficit are at an
nurse increased risk
coordinators of of fall.
charts and Although there
applied the is still room for
 IMPLEMENTATION OF A FALL BUNDLE 28

HDFS scoring
to the patients
chart.
Kobayashi The purpose of the Retrospective, Took place Reports were Efforts put III, C
et al, 2017 study is to examine chart review at an pulled from the forth by the fall
prevention of falls advanced hospital web working group
after implementing treatment based event did reduce the
intervention from a fall hospital and reporting overall
work group in the emergency system. The incidence of
organization center. For working group fall in the
the purpose developed a hospitals. Falls
of this study fall assessment that occurred in
a total of which was high risk
212, 617 completed patients
patients from routinely on (graded 3) did
all wards admission, not have a
within the weekly, at the reduction in
hospital time of fall, falls.
were used and with
from April patient status
2012-March change.
2017 Interventions
include:
colored coded
wrist band,
provided
information to
staff) signage,
video), and fall
information
was provided
to staff.
Wallace Stressed the Quality Charts were Staff begins to The hospital VI, D
(2015) importance of family Improvement pulled from educate parents experienced
education and Pennsylvania of fall safety improvement
monitoring of staff to Patient upon in the rate of
newborn babies. Safety admission, falls by
IMPLEMENTATION OF A FALL BUNDLE 29

system from beginning of families aware

July 2004- each shift, as that falls do
December needed. Staff occur and
2013 also discussed increasing
collecting a the use of the monitoring by
total of 272 call bell and staff
newborn the importance
falls to call staff for
assistances
 IMPLEMENTATION OF A FALL BUNDLE 30

Appendix B
DNP Project Name: Pediatric Fall Bundle

DNP Project Purpose Statement: The purpose of the DNP project is to implement and evaluate the effectiveness of a pediatric fall bundle on an acute care
pediatric in-patient unit. This project will improve the unit by identifying and protecting patients from falls and injuries. The fall bundle will include the
implementation of the HDFS and the education of caregivers in reducing their child’s risk of falls in hospital setting.

Short-Term SMART Objective:

By August 27, 2018 a meeting with will be held with the director of the unit, unit manager, unit educator, professional practice specialist (PPS), and unit medical
director to discuss the relevance of a new fall assessment tool.
By September 1, 2018 100% of nursing staff will be will attend an in-service on unit current fall rates and new fall bundle.
By October 15, 2018 there will be a 10% reduction in the number of injuries related to falls on the unit.
By October 15, 2018 there will be a 15% reduction in the number of falls
Long-Term SMART Objective:
By November 30, 2018 the unit will have a decreased number of falls on the unit by 30%.
By November 15, 2018 there will be decrease incidents of injuries related to falls 20%.
By December 15, 2018 the evidence based fall bundle will be 100% implemented and sustain on the unit.
By December 15, 2018 100% of patients will have a documented humpty dumpty fall scale assessment within 12 hours of admission

Population/Context: Acute care pediatric neurology unit. The unit cares for neurological disorders in children from birth to 21 years old.

Mobilize: List if core team members- Direct of the unit, Manager of the unit, Registered Nurse (RN), Patient care tech (PCT), nurse educator, nurse practitioner (NP),
professional practice specialist (PPS), child life specialist (CPS), physical and occupational therapist (PT, OT)

 meeting will be held with multiple members and stakeholders within the facility including: the director of falls, unit director, unit manager and a nurse
representative from the falls department
 Work with staff from the fall department (will grant access to incident reports to gaining understanding of reasons for falls and injuries related to fall)
 A separate meeting will be held with the director of falls to discuss the acceptance of the HDFS on the unit and within the organization.
 Hold a meeting with the director of the unit, unit manager, unit educator, and unit PPS.
 Once the director of the unit is involved a meeting will be held with shared nursing leadership (SNL)- a committee on the unit comprised of different specialist
including: Registered Nurse (RN), Patient care tech (PCT), nurse educator, nurse practitioner (NP), PPS, child life specialist (CPS), physical and occupational
therapist (PT, OT)
 Attend a monthly SNL meeting and address common safety concerns, promote unit and staff safety, and encourages evidence base practice on the unit.
 Working closely with SNL to incorporate the unit’s current vision and goals for falls will help bring acceptance of change while allowing the involvement and
ideas from frontline staff
 Internal review board (IRB) will review and approve the implementation of the fall bundle on the unit.
 IMPLEMENTATION OF A FALL BUNDLE 31

Assess:
 A board meeting including all stakeholders including unit manager, members from the nursing staff and the unit educator to set realistic and measurable
goals in developing an evidence base fall bundle. To date the current unit has the highest rate of fall within the organization.
 To gain a better understanding of why falls occur, the rate of falls will be compared to different in-patient units within the organization.
 Falls rate will then be compared on a national level against different organizations including the national databases of nursing quality indicators
(NDNQI) and Joint commission:
 Results will be compared to Sentinel Event Alert #55: Preventing falls and fall-related injuries in health care facilities, and the Nursing Advisory
Council (NAC).
 The unit currently uses the pediatric fall assessment tool to identify patients at risk for falls; however, falls still occur.
 Evidence show that family involvement and education are essential in reducing the rate of falls and injuries related to falls. This is something that can
be changed on a nursing level.
 Pledging safety of patients and preventing falls is a task that can be fixed under the nursing scope of practice. The unit currently falls below bench
mark for the NDNQI assessment for patient safety and culture.
 Incident reports will be used to assess cause of falls, injuries related to falls, and occurrence of falls.
 The EHR can provided data of both compliance and documentation of the HDFS and patient and family education.
 Satisfaction survey consisting of a five point Likert scale completed by staff to address staffs opinions and suggestion to prevent barriers.
 The NDNQI assessment will be used to measure progress of the fall bundle over an extended time on the unit.

Plan:
 Once all concerns are addressed a fall bundle including the implementation of the humpty dumpty fall scale and caregiver education will be introduced
to the unit.
 The DNP student will work closely with the PPS to add the humpty dumpty fall scale into current documentation and develop a standardized fall
education. The ultimate vision of this DNP project is to reduce the incidence of fall on this neurology unit. The implementation of the HDFS will begin
in the first two weeks of September.
 Education will be provided within the first week of September and discussed daily during nursing rounds.
 Unit Champion will be identified and trained the last week of August before the introduction of the fall bundle to the unit. The unit champions will
consist of a team of registered nurses and patient care technicians who will be available on each shift if possible.
 An in-service will be made available daily every shift for the first weeks to educate nursing staff of changes that would be made and to bring awareness
that falls remain an issue on the unit.
 Unit champions will be proficient user of the HDFS and will provide guidance to support staff buy-ins.
 A reminder of the importance of compliance with the fall bundle will be discussed twice a day during shift huddle.
 Unit champions will be available to teach and guide staff member who may have not been able to attend in-service.
 In-service will be available weekly to assure that every staff is aware and taught how to properly use the HDFS scale.
 Pre and post- test will provided at the end of the each in-service to assess staff understanding and comprehension of the HDFS and fall prevention
teaching.
 IMPLEMENTATION OF A FALL BUNDLE 32

 It will be ideal for the HDFS to be a part of the electronic health record (EHR) but paper documentation of the HDFS will be made available in each
room.
 Staff will be taught to avoid placing patient identifiers on any documentation. All papers will be placed in a secure location in the PPS office. Paper
documentation will be collected daily and assessed weekly for compliance. Family education will be assessed via nursing documentation weekly.
 Once the patient score is identified paper documentation will be shredded on the unit and removed using the hospital current paper destruction to
protect sensitive patient information.
 Smalls signs will be placed on every computer on the unit as a friendly reminder for nursing to complete the HDFS on each patient every shift.
 A meeting will be held bi-weekly with the PPS and selected members from the unit nursing staff to discuss barriers of using the humpty dumpty fall
scale and their perception on educating families in preventing falls.

Plan Developed by (List all contributors): Olimat Habib -DNP leader, Lisa Williams-Greely- site representor, Jodi Murray- unit manager, and Catherine Williams- unit
director,
___________________________________________________________________________
The Institute for Perinatal Quality Improvement (PQI) grants the University of Maryland School of Nursing permission to utilize and make modifications to
PQI’s MAP-IT worksheet to support the DNP students learning.
For permission to further modify or utilize PQI’s MAP-IT worksheet in other settings contact: [email protected].
Reference: Guidry, M., Vischi, T., Han, R., & Passons, O. MAP-IT: a guide to using healthy people 2020 in your community. U.S. Department of Health and
Human Services. The Office of Disease Prevention and Health Promotion, Washington, D.C. https://www.healthypeople.gov/2020/tools-and-resources/Program-
Planning
Running head: IMPLEMENTATION OF A FALL BUNDLE 33

Appendix C
Lesson plan for in-service

Learning Content Outline Method of Time Spent Methods of

Objectives Instructions Evaluation
1. By the end 1. Humpty 1. Power point 10-15 minutes Teach-back
of the Dumpty 2. Group method
session Fall Scale discussion
Participants 2. Fall
will be able education
to identify
patients at
risk for
falls.
2. By the end
of the
session
participants
will be able
to list the 7
categories
within the
HDFS
 IMPLEMENTATION OF A FALL BUNDLE 34

Appendix D
 IMPLEMENTATION OF A FALL BUNDLE 35

Appendix E
Project Proposal Summary

Pediatric patients are at an increased risk for falls in the hospital setting. Nurs ing
staff and caregivers play a significant role in preventing falls while in the hospital setting. It
is imperative that a strategic plan is implemented to prevent falls from occurring.
Oftentimes the nursing staff are not be readily available at the bedside, so it is important
that patients and their family receive fall safety and fall prevention educated upon
admission. The purpose of this quality improvement (QI) project was to implement and
evaluate the effectiveness of a pediatric fall bundle on the Neurosurgical unit (NSU) at
Children’s National Medical Center (CNMC).
This quality improvement project was implemented on an 18 bed acute care
neurology unit at Children’s National Medical Center in the District of Columbia. The
Humpty Dumpty Fall Scale (HDFS) will be used on all pediatric patients from birth to 17
years old with a neurologic diagnosis from October 2018 to December 2018. In addition to
identifying the patients that are at increased risk of falls, patients will receive fall risk
bracelets and fall prevention education will be provided to patients and their families. Prior
to the implementation of the fall bundle, I worked alongside the Director of fall, Director of
Research and Quality Improvement, Director of NSU, and NSU Manager to discuss fall
rates. An in-service training for Registered Nurses (RN) was held to discuss and
demonstrate accurate use of the HDFS, criteria for applying fall risk bracelets, and fall
education. The RN’s were provided with evidence-based resources and language
appropriate fall education.
Descriptive statistics were calculated for the sample size of the nurse and patients
who participated in the fall bundle using excel SPSS. Quantitative data comparing fall risk
and occurrence of falls was transcribed into a bar graph using excel SPSS. This DNP
project was intended to improve patient care and promote fall safety to pediatric patients
admitted to NSU. The tools and workflow of this QI was adjusted to meet specific policies
and procedure mandated by Children’s National Medical Center and is therefore not
generalizable.
To protect human subjects during implementation, the HDFS tool did not include any
patient identifiers. Copies of the scales were kept in a plastic binder in a locked password
protected nurse server located in each room. The nurse server is locked cart that contains
medical supplies not readily available at bedside. Data collected will be de-identified of all
patient identifiers. To protect human subjects a project description will be submitted to the
University of Maryland Board of Non-Human Subjects Research determination
(NHSR). Approval would be gained from Children’s National Nursing Research Advisory
committee (NRAC) to determine NHSR before submission to Children’s national medical
center institutional review board (IRBear). Results of the quality improvement project was
disseminated via local conference, discussed in professional meeting, and didactic
presentation to all members of NSU, the Director of Falls, and the Director of the Research
and Quality Improvement at Children’s .
 IMPLEMENTATION OF A FALL BUNDLE 36

Appendix F
Seeking permission of the Humpty Dumpty Fall Scale:

June 14, 2019

Olimatu Habib
DNP Candidate
University of Maryland
School of Nursing
[email protected]

Ms. Habib –

We sincerely thank you for your interest in utilizing the Humpty Dumpty Inpatient Scale as part of your research
endeavors. This letter serves as permission for you to use this scale for your stated purposes. In turn, we require that
you:
• Report summary findings to us from the use of the Humpty Dumpty Inpatient Scale.
• Credit the use and our development of the Humpty Dumpty Inpatient Scale in any presentation or publication
of the research involving the scale and provide us with the citations.
• Notify us of any changes in your intentions to use the Humpty Dumpty Inpatient Scale. Namely, if you choose
to implement the Humpty Dumpty Inpatient Scale as part of practice within your facility, a licensing agreement will be
required.
Please don’t hesitate to call upon us if you have any questions or to discuss your work with the scale. Thank you again
for your interest in the Humpty Dumpty Inpatient Scale. Good luck with your research!

Sincerely,

Deborah Hill-Rodriguez, MSN, ARNP, MBA-HMA, NE-BC

Clinical Nursing Director- 2 East/Case Management/Admitting
Humpty Dumpty Program Lead
786.624.3315
[email protected]