PAEDIATRIC FALLS RISK

ASSESSMENT (PFRA) SCALE

MINISTRY OF HEALTH
MALAYSIA
 PRESENTATION OUTLINE

1
Paediatric Fall Risk Assessment (PFRA) Scale

2
Paediatric Fall Scale Risk and
Action Plan
 WHY DO WE USE PAEDIATRIC
FALLS RISK ASSESSMENT(PFRA)
SCALE?
 All children admitted to the Paediatric
WHOM wards
SHOULD WE
ACCESS Age of more than 36 months and less than 18
years

On Admission

WHEN TO Significant change of neurological status or

conscious level
ACCESS
Following a fall
 HOW TO USE PFRA SCALE
PARAMETERS

1. Age 4 Marks

2. Gender 2 Marks

3. Diagnosis 3 Marks
SCORING
4. Fall History 3 Marks

5. Environmental Factors 2 Marks

6. Surgery / Sedation /
3 Marks
Anaesthesia
7. Medication Usage 3 Marks
 1.AGE 2.GENDER
AGE SCORE GENDER SCORE

<2 years old Male 2

4

2 to 5 years old
3 Female 1
5 to <12 years /Others
old 2

≥ 12 years old
1
 3.DIAGNOSIS
Neurological Diagnosis

DIAGNOSIS SCORE • 1.Seizure, Head trauma, Hydrocephalus,

Cerebral palsy
• 2. Patients being worked up for neurological
Neurological 3 diagnosis.
Diagnosis
Behavioural Disorders

• 1.Impulse control disorders, attention-

Behavioural 2 deficit/hyperactivity disorder
• 2.Mood disorders (Major Depression Disorder,
disorders
Bipolar Disorder).

Other Disease
Other Disease 1 1. Anything that doesn’t fall into the previous
categories for example Acute bacterial
tonsilitis.
 4.FALL HISTORY 5.ENVIROMENTAL FACTORS
ENVIROMENTAL SCORE
FALL SCORE FACTORS
HISTORY Using aids (e.g., IV Line,
wheelchair , IV Stand) 2
≥3 Falls over past 3
Not using aids (e.g., IV Line,
3mth wheelchair , IV Stand) 1

1 – 2 Falls over 2
past 3mth Enviromental Factors

• 1. Patient uses assistive devices, -crutches, walkers,

canes, splints (such as leg splint or ankle brace)
No Fall 1 • 2. Any devices that limits the patient movements such as
IV line and stand.
 6. SURGERY / SEDATION / ANAESTHESIA
SURGERY/SED
ATION/ANAEST SCORE
HESIA • 1.The parameter assesses the child
risk according to recent surgery /
< 24 Hours 3 sedation/anaesthesia that the child
received within a certain period of
time.
• 2. Highest mark (3 marks) is given if
24-48 Hours 2
patient undergone such procedure
within 24 hours, 2 mark is given if it is
between 24-48 hour and the rest is 1
≥ 48 Hours or none 1 mark.
• 3.This does not include bedside
procedures without anaesthesia.
 7. MEDICATION USAGES
MEDICATION USE SUCH
AS: SCORE
SEDATIVES , BARBITURATES , HYPNOTICS ,
• 1. The parameter assesses the
PHENOTHIAZINE , LAXATIVES , DIURETICS ,
HYPOGLYCEMIC AGENTS , ANTIHISTAMINES child risk according to medication
usage that might cause an
alteration level of consciousness
or affect cognitive awareness of
≥ 2 of the medications 3 the child.
• 2. Risk is higher with multiple
usage of such medications
• 3. Sedatives (excluding ICU
One of the medication 2
patients that are sedated and
paralyzed).

None of the medication 1

 RANGE OF SCORES

1. Low Fall Risk 2. High Fall Risk

(Total of 7 to 11 marks) (Total of 12 and above marks)

PAEDIATRIC FALLS SCALE
RISK AND ACTION PLAN
MINISTRY OF HEALTH
MALAYSIA
 Ensure steps to mitigate the risk and hazards of falls are undertaken (e.g., safety
Primary Prevention (General Prevention)
of the environment/ward)
Implement primary prevention strategies (low-risk standard protocol)
Provide falls prevention information (e.g., brochures, leaflets) for patients and
their families.

Orientate and educate the child and their family regarding the falls prevention
Paediatric Patient Admitted
programme. Use audio-visual aids if available.

Child is high-risk group? Age ≤ 36mth

NO

Falls risk assessment Use the Paediatric Falls Risk Assessment Scale (PFRA).

YES Continue implementing primary prevention strategies (low-risk standard

Low-Risk Score <12 protocol)

Repeat fall risk assessment if

significant change of status or fall
Implement high-risk standard protocol.
Communicate high falls risk assessment at each shift change or transfer of
care to other healthcare providers.
High-Risk Score ≥12
 RISK ACTION

Low risk standard 1. Identify patient using a wrist band and sticker, signage at cot/ bed and in patient chart.
protocol 2. Orientate the caregiver and/or patient to the ward and cubicle
(score 7-11) 3. Educate the caregiver and/or patient on falls and falls prevention protocols
4. Place the bed in a low position with the brakes on
5. Raise the side rails especially if the child is left alone on the cot
6. Assess large gaps that would allow an extremity of the patient to slip through or become
entrapped as this may necessitate the use of additional safety measures
7. Ensure that the call bell is within reach and educate the caregiver and/or patient on its
function.
8. Clear the environment of unused equipment. Other non-medical equipment should be
hazard-free.
9. Assess for adequate lighting. A night light should be left on at night
10. Preferably use non-skid footwear for ambulating children. Use appropriate-sized clothing
to prevent tripping
11. Ensure that caregivers supervise their children at all times. Caregivers must inform the
nurse on duty if he or she is leaving the patient alone, even if it is for a few minutes.
12. Document falls prevention education and include in the nursing plan
High risk standard 1. Identify patient with an ID band on the patient (sticker) and signage on the bed and in
protocol patient chart
(score ≥12) 2. Educate the caregiver and/or patient on falls and falls prevention protocols
3. Monitor the high-risk patient closely
4. Place the patient in a developmentally-appropriate bed
5. Consider moving the patient closer to the nurses’ station
6. Keep the bed in the lowest position with the brakes on, unless patient is directly attended
7. Raise the side rails at all times
8. Make sure that protective barriers are available to close off spaces and gaps in bed and
railings.
9. Remove all unused equipment around the patient's bed.
10. Always keep the door open unless there is a specific isolation precaution in place
11. Ensure that the patient is accompanied during ambulation
12. Ensure that caregivers supervise their children at all times. Caregivers must inform the
nurse on duty if he or she is leaving the patient alone, even if it is for a few minutes.
13. Review the medication administration schedule
14. Document in nursing plan
Unit Pembangunan Piawaian Kualiti Kejururawatan,
BKJ
23.04.2024