1. NSW Paediatric Fall Risk Assessment CLINICAL EXCELLENCE COMMISSION November 2014 Developed by NSW Paediatric Falls Resources Committee

2. Paediatric Fall Resource for NSW The CEC in collaboration with NSW Kids and Families have purchased a state-wide license to use the Miami Children’s Hospital Humpty Dumpty Falls Assessment Tools ™ The Humpty Dumpty Falls Assessment Tools have been localised to NSW and will now be known in NSW as the NSW Paediatric Fall Risk Assessment Tool

3. Fall Risk Screening Falls are a leading cause of injury for children Falls are one of the major preventable risks factors for in increased length of stay for paediatric patients in NSW hospitals National Safety and Quality Health Service Standards - Standard 10: Preventing Falls and Harm from Falls Patient safety initiative

4. Falls Definition Miami Children’s Hospital defines a fall as: An unintended event resulting in a person coming to rest on the ground/floor or other lower level (witnessed) or reported to have landed on the floor (unwitnessed) -This can be from standing, bed, cot or chair (World Health Organisation)

5. Incidence - Paediatric Falls in the hospital Add local LHD data here

6. Environmental Causes - Paediatric Falls in the hospital Result of improper use of cot (crib) side rails either partially raised or incorrectly secured (Levene and Bonfield, 1991) Children less than one year old tended to fall out of bed while adolescents tended to fall while ambulating to or in the bathroom. Other factors included slipping on a wet surface or tripping over an object. Parents were in attendance most of the time (Cooper and Nolt, 2007) Majority of falls in children younger than 10 are related to crib, rails, playrooms and well-intended parents who may forget and leave the child unattended with the side rail down (Hendrich 2007)

7. Who is at risk of a fall? Preschoolers Children under 10 years Children with disabilities and minimal mobility Children with neurological diagnosis Children with challenging and/or impulsive behaviours Children in wheelchairs, regardless of cognitive ability

8. Paediatric fall risk factors History of previous falls related to illness Cognitive impairment from sedation, anaesthesia, disorientation, developmental delay Impaired mobility/inadequate muscle tone Central nervous system disorders Sensory impairment e.g. poor vision Needs to go to the toilet frequently or has diarrhoea Post operative restrictions such as pain, casts/splints, mobility aids etc Takes medications associated with increased risk of falls e.g. psychoactive, anticonvulsants

9. Consequences of Falls Minor to serious injury Increased stay in hospital Impact on family/carer Potential change in independence on discharge Increase in patient/family/carer costs (Death – rarely)

10. NSW Fall Risk Assessment Tool Parameters Age Gender Diagnosis Cognitive impairments Environmental Factors Response to Surgery / Sedation / Anesthesia Medication usage Falls Assessment Tool score At risk for falls if 12 or above Maximum Score 23 Minimum Score 7

11. Look at the whole picture of the patient. 2 1 2 2 3 2 3 15

12. When to do a Fall Risk Assessment Emergency Department Within 24 hours of admission When there is a major change in patient risk status Inpatient Upon admission When there is a major change in patient status Every 3 days or after a fall Outpatient Settings Upon initial visit to the outpatient setting With each age change When there is a major change in patient status since last visit

13. Where do I document my Fall Risk Assessment results? Add local process here e.g. NSW Paediatric Fall Risk Assessment Tool can be accessed through PowerChart; Adhoc charting Assessment is to be completed within the first 6 hours of admission to ward Re-assessment every 3 days or when the child's condition changes, including after a fall.

14. Children at a LOW risk of a fall Children at LOW RISK (score 7-11) must be: – Reassessed at appropriate intervals during their stay to check if risk level has changed – Orientated to their room and any potential fall risks – Provided with the available Parent/carer Information Sheets – Localise to LHD/hospital process

15. Children at a HIGH risk of a fall Children at HIGH RISK (score 12 or above) must be: – Identified at general “Handover” – Identified on the Handover sheet – Identified during bedside handover discussion – Have a fall risk management plan devised, documented and communicated to staff, treating team and family/carer (and patient where appropriate) – Localise to LHD/hospital process

16. Parent/Carer Information Parent/carer information sheet should be distributed to all parents/carers on admission A copy of the information sheet can be found on the CEC website OR (LHD to insert local location) Parents/Carers (and the child where appropriate) must be informed of risk of falls and involved in falls prevention management planning.

17. Fall Prevention Management Planning Children identified at risk of a fall must have a documented prevention management plan. This includes relevant referrals and further assessments This must be developed in conjunction with parent/carer (and child where appropriate). Must be re-evaluated when the child's condition changes, including after a fall.

18. What is a Fall Prevention Management Plan? LHD to insert local details

19. Post Fall Care Actions Note: Any Fall must be seen as a clinical priority All falls must be recorded in IIMS and in Patient medical records 1.Ensure patient is safe 2.Nursing assessment (including observations as per age appropriate SPOC) 3.Medical review 4.Implement strategies to reduce risk of another fall 5.Document and communicate 6.Re screen and redo falls prevention management plan.

20. Local Health District Falls Coordinator OR Local Health District Paediatric CNC OR Clinical Excellence Commission Who do I ask for more information?

21. Discharge Planning Communicate fall risk status and ongoing recommendations/referrals to patient, family/ carers and relevant service providers – General Practitioners – Community Health Services – Community Service Providers

22. Summary of Falls Prevention Initiatives Identify and assess all patients ED, admission to ward or Outpatients using NSW Paediatric Fall Risk Assessment Tool Provide information to parent/carer Information sheet Risk assessment and management Implement and document falls risk management plan for high risk children Change in condition (or fall) Reassess and reconsider management plan. Follow local post fall care actions Reporting and monitoring IIMS plus inform senior clinicians involved in child’s care Discharge planningCommunicate risk and plan for follow-up at home

23. Acknowledgements Miami Children’s Hospital (Humpty Dumpty Falls Assessment Program™) NSW Kids and Families Paediatric Falls Resources Committee Sydney Children’s Hospital Network NSLHD + CCLHD Paediatric Services John Hunter Children’s Hospital NSW Paediatric CNC Group

24. Thank you For further information: falls@cec.health.nsw.gov.au www.cec.health.nsw.gov.au