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Addendum: Care of the Hospitalized Pediatric Patient

Addendum: Care of the Hospitalized Pediatric Patient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related


Fall Prevention Nursing Practice Guideline Addendum:
Care of the Hospitalized Pediatric Patient


The purpose of this addendum is to provide nursing staff with interventions to prevent falls in
pediatric patients. The adopted UWHC adopted guideline, Health Care Protocol: Prevention of
Falls (Acute Care) (ICSI, 2010), does not provide guidance for nurses specifically caring for
pediatric patients. Little research has been conducted regarding fall prevention interventions in
pediatrics; however, the literature does propose that nursing care regarding fall prevention in the
pediatric population should be approached differently than adults (Kingston, Bryant & Speer,
2010). The following recommendations are based on expert opinion.

Intended Users

Nursing staff caring for pediatric in-patients at American Family Children’s Hospital (AFCH)

Target Population

Pediatric in-patients



1. Assess effects of patient’s medications especially those having hypotensive, tranquilizing
or sedative effects. (Category II)

2. Assess patient’s coordination and balance before assisting with transfer and mobility
activities. (Category II)

3. Assess parent’s ability to set appropriate behavioral/activity limits for child during day
and evening hours with frequent room checks. (Category II)

4. Assess patient and/or family’s ability to participate in plan of care development and
implementation. (Category IB)

5. Utilize a pediatric specific fall assessment tool to identify fall risk. GRAF-PIF scale will
be used at AFCH. (Category IB)


Based on nursing assessment, identify patient’s level of fall risk (standard or high fall
risk). (Category II)

Outcomes Identification

Identify individualized patient outcomes targeted at fall risk prevention as evidenced by
an absence of falls. (Category II)


1. Develop individualized plan of care which specify strategies to prevent falls. (Category

2. Identify appropriate situations when modifications are needed, including consideration of
moving patient closer to the nurses’ station or use of Patient Safety Attendant. (Category


1. Indicate fall risk using visual cues. At AFCH place a yellow star on the door and a yellow
high fall risk sticker on the front of the patient medical chart. The child should wear the
yellow high fall risk wristband when possible (due to size of child and wristband). When
child is leaving unit for any purpose, notify transporting staff of fall risk and point out
fall precaution sticker. (Category IB)

2. Ensure child is in an age-appropriate bed. (Category IB)

3. Reinforce any activity limitation with child and parent(s). (Category IB)

4. Assure patient is wearing proper footwear to avoid falls. (Category IB)

5. Assure that the environment is uncluttered and clear of obstacles through room checks
every 2-3 hours. (Category IB)

6. Maintaining an unobstructed pathway to bathroom and doorway. (Category IB)

7. Provide adequate lighting in patient care area during day and night. (Category IB)

8. Offer patient assistance to the bathroom every 2-3 hours while awake, monitor every 4
hours at night and document. Remain with patient in the bathroom as warranted by
patient’s physical/psychological status. (Category II)

9. Instruct parent(s) to inform the nurse and/or physician if the child seems to be less
coordinated than usual, or complains of dizziness or feeling weak. (Category IB)

10. Reinforce and review education with the patient and family related to fall risk factors and
plan of care to decrease within the hospital. (Category IB)

11. Teach the patient and family specific instructions related to level of assistance needed for
both ambulation and transfers to maintain safety. (Category IB)


Every nurse should evaluate the effectiveness of fall prevention strategies and modify the
plan as needed. (Category II)

Child Health Cooperation of America Nursing Falls Study Task Force. (2009). Pediatric falls:

state of the science. Pediatric Nursing, 35(4), 227-231.

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.

Graf, E. (2004). Identifying Predictor Variables Associated with Pediatric In-patient Fall Risk,
Children’s Memorial Medical Center, Chicago, IL.
Graf, E. (2004). General risk assessment for pediatric in-patient falls scale (GRAF-PIF). Fall
Risk Assessment Tool, Children’s Memorial Medical Center. Federal Copyright received
Graf, E. (2005, November). Pediatric Hospital Falls: Development of a Predictor Model to Guide
Pediatric Clinical Practice. 38th Biennial STT International Conference, Indianapolis,
Harvey, K., Kramlich, D., Chapman, J., Parker, J., & Blades, E. (2010). Exploring and

evaluating five paediatric falls assessment instruments and injury risk indicators: an

ambispective study in a tertiary care setting. Journal of Nursing Management, 18,

Institute for Clinical Systems Improvement (ICSI). (2010). Health care protocol: Prevention of
falls (acute care). Bloomington, MN: Institute for Clinical Systems Improvement.
Kingston, K., Bryant, T. & Speer, K. (2010). Pediatric falls benchmarking collaborative. Journal

Of Nursing Administration, 40(6), 287-292

Morse, J.M. (1996). Preventing Patient Falls. Thousand Oaks, CA: Sage Publications.
Razmus, I., Wilson, D., Smith, R. & Newman, E. (2006). Falls in hospitalized children. Pediatric

Nursing, 32(6), 568-572


Levels of Evidence
Rating Scheme For The Strength Of The Evidence

Strongest (I) – Weakest (VII) as follows:

I: A systematic review of meta-analysis of all relevant Randomized Clinical
Trials (RCT) or Evidence Based Practice (EBP) Clinical Guidelines on
systematic reviews of RCTs
II: At least one properly designed RCT of appropriate size
III: Well designed trials without randomization
IV: Well designed single group pre-post cohort, time series, or matched case-
control studies
V: Systematic review of well-designed descriptive and qualitative studies
VI: Single experimental, quasi-experimental, nonexperimental (descriptive or
qualitative) study
VII: Opinion of respected authorities, based on clinical evidence, descriptive
studies or reports of expert committees.

Rating Scheme for the Strength of the Recommendations

Category IA: A strong recommendation supported by high to moderate
quality evidence suggesting net clinical benefits or harms.
Category IB: A strong recommendation supported by low quality evidence
suggesting net clinical benefits or harms, or an accepted
practice (e.g., aseptic technique) supported by low to very low
quality evidence.
Category IC: A strong recommendation required by state or federal
Category II: A weak recommendation supported by any quality evidence
suggesting a trade off between clinical benefits and harms.
No recommendation: An unresolved issue for which there is low to very low quality
evidence with uncertain trade offs between benefits and harms.