RISK FACTORS FOR PREDICTING FALLS IN HOSPITALIZED PEDIATRIC PATIENTS: A SCOPING REVIEWABSTRACT
Objective: to map scientific evidence regarding risk factors for predicting fall-related injuries in pediatric hospital settings.
Method: a scoping review was conducted according to the Joanna Briggs Institute methodology and reported in compliance with the PRISMA-ScR Checklist to answer the following research question: What are the risk factors for predicting fall-related injuries in hospitalized pediatric patients? Data collection took place from May to June 2024 across the following databases: Cochrane Library, CINAHL, Embase, LILACS, MEDLINE/PubMed, SciELO, SCOPUS, and Web of Science; Google Scholar and the CAPES Catalog of Theses & Dissertations were also used, with no time restrictions. Selection was performed by two reviewers, with a third reviewer resolving any disagreements. The protocol is registered on the Open Science Framework: osf.io/vqm39.
Results: a total of 1,036 documents were identified during the study period. The final sample consisted of 24 studies. The identified risk factors included: parental presence; environmental factors; length of hospital stay; low healthcare staffing levels; age; sex; history of falls; medication use; ambulation; use of biomedical devices; elimination needs; and physical status/medical diagnosis.
Conclusion: predictive factors for falls in hospitalized children include aspects controllable by the nursing team, such as the environment and parental presence, as well as individual child characteristics, such as age and health conditions. There is an urgent need for further studies and validated tools to better understand these risks and ensure the safety of pediatric patients in Brazil.
DESCRIPTORS:
Accidental falls; Hospital; Risk factors; Risk assessment; Hospitalized child; Patient safety
RESUMO
Objetivo: mapear as evidências científicas sobre os fatores de risco para predição de lesões decorrentes de quedas na pediatria em ambiente hospitalar.
Método: revisão de escopo de acordo com a metodologia Joanna Briggs Institute e relatada, conforme Checklist PRISMA-ScR, para responder à questão de pesquisa: Quais são os fatores de risco para predição das lesões decorrentes de quedas nos pacientes pediátricos hospitalizados? A coleta de dados foi realizada de maio a junho de 2024 nas bases: Cochrane Library, CINAHL, Embase, LILACS, MEDLINE/PubMed, SciELO, SCOPUS, Web of Science, sendo também utilizado o Google Scholar e o Catálogo de Teses & Dissertações/CAPES, sem filtro temporal. A seleção foi realizada por dois revisores, sendo as divergências apreciadas por um terceiro. O protocolo registrado no Open Science Framework: osf.io/vqm39.
Resultados: foram mapeados 1.036 documentos no período do estudo. A amostra final foi constituída de 24 estudos. Os fatores de risco identificados foram: presença dos pais; fatores ambientais; tempo de internação; baixo quantitativo de profissionais de saúde; idade; sexo; queda prévia; uso de medicamentos; deambulação; uso de dispositivos biomédicos; eliminações; e estado físico/diagnóstico médico.
Conclusão: os fatores de predição para quedas em crianças hospitalizadas incluem aspectos controláveis pela equipe de enfermagem, como o ambiente e a presença dos pais, além de características individuais das crianças, como idade e condições de saúde. Há uma necessidade urgente de estudos adicionais e ferramentas validadas que ajudem a entender melhor esses riscos e a garantir a segurança dos pacientes pediátricos no Brasil.
DESCRITORES:
Acidente por queda; Hospital; Fatores de risco; Avaliação de risco; Criança hospitalizada; Segurança do paciente
RESUMEN
Objetivo: mapear la evidencia científica sobre los factores de riesgo para predecir lesiones relacionadas con caídas en entornos hospitalarios pediátricos.
Método: se realizó una revisión exploratoria según la metodología del Joanna Briggs Institute y se informó de acuerdo con la Checklist PRISMA-ScR para responder a la pregunta de investigación: ¿Cuáles son los factores de riesgo para predecir lesiones relacionadas con caídas en pacientes pediátricos hospitalizados? La recopilación de datos se llevó a cabo de mayo a junio de 2024 en las siguientes bases de datos: Cochrane Library, CINAHL, Embase, LILACS, MEDLINE/PubMed, SciELO, SCOPUS, Web of Science, y también utilizando Google Scholar y el Catálogo de Tesis y Disertaciones/CAPES, sin filtrado temporal. La selección fue realizada por dos revisores, y las discrepancias fueron evaluadas por un tercero. El protocolo está registrado en Open Science Framework: osf.io/vqm39.
Resultados: se mapearon 1036 documentos durante el período de estudio. La muestra final consistió en 24 estudios. Los factores de riesgo identificados fueron: presencia de los padres; factores ambientales; duración de la estancia; escaso número de profesionales sanitarios; edad; sexo; antecedentes de caídas; uso de medicamentos; deambulación; uso de dispositivos biomédicos; eliminación; y estado físico/diagnóstico médico.
Conclusión: los factores predictivos de caídas en niños hospitalizados incluyen aspectos controlables por el personal de enfermería, como el entorno y la presencia de los padres, así como características individuales de los niños, como la edad y el estado de salud. Existe una necesidad urgente de realizar estudios adicionales y desarrollar herramientas validadas para comprender mejor estos riesgos y garantizar la seguridad de los pacientes pediátricos en Brasil.
DESCRIPTORES:
Caída; Hospital; Factores de riesgo; Evaluación de riesgos; Niño hospitalizado; Seguridad del paciente
INTRODUCTION
In the pursuit of improved care processes and quality of care, a growing effort has become evident within the health and education sectors to promote safe patient care1. This topic gained significant prominence in the 1990s following publication of the U.S. report “To Err Is Human: Building a Safer Health System”, which sparked widespread global debate regarding patient safety2.
In an effort to implement measures aimed at ensuring safe care, the World Health Organization (WHO), in partnership with Joint Commission International (JCI), a leading healthcare accreditation agency, issued six international patient safety goals in 2006, with the reduction in the risk of fall-related injuries among them3. The Ministry of Health (Ministério da Saúde - MS) in Brazil established the National Patient Safety Program (Programa Nacional de Segurança do Paciente - PNSP) in 2013 via Ordinance No. 529. The program’s primary action involves implementing preventive interventions to reduce fall risks and manage incidents, while also emphasizing the importance of incident reporting4.
Given the frequency of non-fatal falls, the associated healthcare costs, and the high risk of death, the WHO asserts that preventing fall-related injuries has become a priority in safety promotion. While there are numerous definitions for a “fall”, the WHO defines it as an event that “results in a patient inadvertently coming to rest on the ground or another lower level, excluding intentional changes in position made to lean against furniture, walls, or other objects”5.
Falls represent a significant public health issue and are the second leading cause of unintentional injury-related deaths worldwide. It is estimated that 684,000 people die annually as a result of such accidents, with over 80% of these deaths occurring in low- and middle-income countries. Furthermore, approximately 37.3 million falls each year are severe enough to require medical attention. Within this global context, children constitute a particularly vulnerable group5.
Falls among children and adolescents are often linked to their developmental stage and influenced by the maturation of motor skills, as well as the risks to which they are exposed at each stage. According to WHO definitions, a “child” is a person aged zero to 9 years, and an “adolescent” is aged 10 to 19 years5. However, this population must be considered a high-risk group in a hospital setting6. Numerous specific factors in the hospital environment influence the safety of the process, such as the child’s level of understanding, the diversity of care procedures, the family member’s willingness to participate in care, and the importance of effective, assertive communication among all parties involved to ensure the ongoing safety of the pediatric patient1.
Falls are a type of safety incident which can cause unnecessary harm to a patient’s health and well-being. Factors influencing falls in children can be intrinsic, such as: male gender, age under 3 years, level of consciousness, history of previous falls, health conditions, and the use of certain medications; or extrinsic, such as parental involvement in establishing a safety culture and environmental conditions (i.e. furniture unsuitable for the child’s age, failure to use raised bed rails, wet floors, among others)6-7.
Although falls are widely recognized as a significant patient safety issue, data regarding the pediatric population remain limited. Available estimates indicate that the fall rate among children is lower than that observed in adults, ranging from 0.6 to 1.7 per 1,000 patient-days. Despite the scarcity of specific information, this type of incident is consistently identified as one of the leading preventable adverse events in hospital settings8.
Approaches to prevention must be broad and diverse, focusing on education, training, and safe care promotion. Thus, it is essential to prioritize both research on falls and the formulation of effective policies to mitigate risks6-9. An appropriate intervention grounded in best practices requires the use of tools to assess fall risk across the pediatric population in order to identify the level of risk, act upon that assessment, and prevent potential falls, thereby enhancing safety10.
Quantifying the factors that cause falls can enable a re-evaluation of healthcare delivery, fostering strategies which ensure safer hospital care. Given this issue, the following research question arises: What are the risk factors for predicting fall-related injuries in hospitalized pediatric patients? Therefore, the aim of this study was to map the scientific evidence regarding risk factors for predicting fall-related injuries in pediatric hospital settings.
METHOD
This is a scoping review in accordance with the Joanna Briggs Institute (JBI) methodology11. The presentation and structure followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist to ensure methodological quality in the presentation of all stages12. The research project for this review was registered in the Open Science Framework (OSF) under protocol number osf.io/vqm39, available for public and open consultation at: https://doi.org/10.17605/OSF.IO/FH67T.
This review was conducted between May and June 2024, and went through the five stages established according to the JBI protocol: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies and data extraction; 4) data mapping and analysis; and 5) publication of results.
The research question was outlined using the acronym PCC for guidance and development, being: P - Population (children), C - Concept (risk factors for injuries resulting from falls) and C - Context (hospital environment), contributing to identify the research question: What are the risk factors for predicting injuries resulting from falls in hospitalized pediatric patients?
The following databases were searched to collect information in order to identify studies relevant to this review: Cochrane Library, Cumulative Index of Nursing and Allied Heath Literature (CINAHL - EBSCO), Embase, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature and Retrieval System online (MEDLINE/PubMed) via National Center for Biotechnology Information (NCBI/PubMed), Scientific Electronic Library Online (SciELO), SciVerse Scopus (SCOPUS) and Web of Science (WoS). No filters regarding publication date were applied as this was a scoping review, and all types of published materials, including grey literature, were accepted, provided they addressed the study’s guiding question.
Google Scholar was used as a search tool to locate works not indexed in any scientific database. The search was conducted exclusively in Portuguese to capture the most significant journals and works in that language that were not otherwise available in databases. In addition to Google Scholar, the Theses and Dissertations Catalog of the Coordination for the Improvement of Higher Education Personnel (CAPES) was searched to ensure the study incorporated the widest possible range of digitally available academic information.
Health Sciences Descriptors (DeCS) and MeSH terms were used to assist in the selection of studies, alongside search expressions designed to broaden the scope of the study. A senior librarian was consulted to help structure the search and achieve the desired results. Consequently, search strategies for each database were defined using combinations of Boolean operators AND and OR, namely: pediatric falls AND falls prevention AND hospitalized children, pediatric patient AND accidental falls AND hospitalized children, “hospitalized child*” AND falls, "Pediatric Fall*" AND "Assessment Tools" AND (risk OR prevention), Pediatric Fall Risk Assessment Tool, fall prevention program for pediatric Inpatient.
Original studies and gray literature comprising various types of investigations addressing the research question regarding risk factors for predicting fall-related injuries in hospitalized pediatric patients were included, with no time or language restrictions. Exclusion criteria eliminated editorials, conference proceedings, theoretical essays, single-case studies, opinion pieces, letters, and studies that did not address the review question.
The results were imported into EndNote Web to check for duplicate bibliographic references13. Rayyan software (Qatar Computing Research Institute, Doha, Qatar)14 was used to analyze and determine the eligibility of the studies. Studies identified in the initial search were imported into EndNote Web, a bibliographic management software, to assist in organizing references, identifying duplicates, and excluding articles unrelated to the topic. Publication selection followed PRISMA-ScR recommendations12. The titles and abstracts were initially read. The publications were subsequently read in full based on the established eligibility criteria.
Materials were gathered from the selected databases and either included in or excluded from the sample after the title and abstract were read. The selection and extraction process was performed by two reviewers, both nursing graduates with practical pediatric experience and currently pursuing a Master’s degree in Nursing Care for Women, Children, Adolescents, and Families (focusing on patient safety), who read the materials. The two reviewers were blinded during the selection process and worked using independent spreadsheets; these were compared at the end of the reading phase to verify agreement. Studies with consensus were included in the final selection, while those without consensus were evaluated by a third reviewer. This third reviewer, a professor holding a doctorate and possessing experience in pediatrics and patient safety, made the final decision regarding the selection of the final studies to be included in this scoping review.
Data extracted from the studies were recorded using a data collection tool based on the model found in the JBI manual11; this tool was set up in Microsoft Office Excel 365/2022 and organized as a summary table. The variables included authors, year of publication, journal, country, objective, study design, level of evidence, and risk factors.
The data were analyzed and categorized descriptively. The results of this scoping review are presented both descriptively and in a table summarizing key information from the selected studies. As this scoping review involved publicly available data, ethics committee approval was not required.
RESULTS
A total of 1,036 publications were initially identified, with 78 in CINAHL, 254 in MEDLINE/PubMed, 92 in Embase, six in SciELO, 179 in WoS, 29 in LILACS, 10 in Cochrane, 264 in SCOPUS, nine in the CAPES Theses & Dissertations Catalog, and 115 in Google Scholar. After excluding duplicates and applying eligibility criteria, 24 studies comprised the final sample (Figure 1).
Flowchart of the selection process for scoping review articles. Porto Alegre, RS, Brazil, 2024.
Of the 24 studies, 21 (87.5%) were original articles and three (12.5%) belonged to the gray literature. Among the original articles, five (23.80%) were published in the Journal of Pediatric Nursing, concentrating the largest number of articles on the topic, followed by the journal Child Health Nursing with three (14.2%) publications. Another 13 journals published one study (Chart 1).
The oldest study within the final sample dated back to 2006, while the period from 2013 to 2021 saw the highest number of publications, totaling 21 (87.5%) studies. The Americas accounted for the majority of publications with 11 (45.83%), notably the United States with seven (29.16%), Brazil with three (12.5%), and Mexico with one (4.16%). There were seven (29.16%) publications from Asia; of these, five (20.83%) were from South Korea, one (4.16%) from Saudi Arabia, and one (4.16%) from Turkey. Additionally, there were five (20.83%) European publications: two (8.34%) from Portugal, two (8.34%) from Italy, and one (4.16%) from the Czech Republic. Only one (4.16%) publication was found from Oceania (Australia).
Regarding study design, there was a predominance of cross-sectional studies (11; 45.83%) with level IV evidence according to Melnik’s classification, followed by case-control studies (6; 25%) with level III evidence, reviews (3; 12.5%) with level V evidence, a methodological study (1; 4.16%) with level IV evidence, a cohort study (1; 4.16%) with level III evidence, a qualitative study (1; 4.16%) with level V evidence, and a systematic review (1; 4.16%) with level of evidence I.
Notable examples regarding fall prediction factors include age, medication use, history of falls, use of medical devices, parental presence, mobility, physical status/diagnosis, and length of hospital stay; these factors were the most frequently reported, discussed, and tested across various pediatric populations14-30,33-37. Two studies did not clearly present their risk factors, as they utilized the “Risk for Falls” nursing diagnosis within electronic health records; however, they were included in the review because they addressed the topic under analysis31-32. Only one study proposed a hypothesis regarding the child-family dyad to be tested in future research, aiming to validate findings from its small-sample study18.
DISCUSSION
The hospital is considered an environment which can be favorable to the risk of falls, being a suitable space for implementing interventions aimed at promoting health and patient safety. In this context, it is essential to evaluate the main factors predicting falls, especially in the pediatric population9-10. Based on the results obtained and the analysis of fall prevention strategies in a hospital environment as reported in the literature and practiced by nurses, it is possible to state that identifying children at risk should be a priority in initiatives involving safety.
Authors of previous studies had already compiled the main factors predicting falls in the most used scales, summarizing the following factors: weakness, disability/physical capacity, risk of seizure, respiratory and gastrointestinal disease, age, mental change/confusion, previous fall, use of equipment, emptying/elimination pattern, age under 3 and over 13 years old, sex, diagnosis (presence of one or more), developmental delay, mobility, gait, physiotherapy, ability to activity, environmental factors, venous access, caregiver involvement, length of hospital stay and selected/dangerous medications, with no agreement on the type of medication15,20,24.
After identifying factors predicting falls, a study was conducted in South Korea in which a new fall prediction scale was constructed and tested15. To this end, risk factors were selected and extracted from the main fall scales used today, such as HDFS, GRAF-PIF and SNUFS (Seoul National University Hospital Pediatric Fallrisk Scale), with the latter in turn being developed in the same country in 2014. The items which compose this new Newfs-PI scale are: age (with the score given being equivalent to the age group), activity (varying scores for children free of biomedical artifacts and undergoing rehabilitation), prescription (different score for the number of medications), history of falls and length of stay (increasing score according to the number of days of hospitalization). These factors combined achieved more adequate specificity and sensitivity, with sensitivity being the biggest gain compared to other existing scales.
Some falls in the pediatric population are attributed to the natural process of child development and often go unreported because they do not result in serious injuries. This contributes to underreporting, making it difficult to obtain accurate data on the true incidence of falls among children. Consequently, there is significant variability in the information collected on this topic22-24,26. Given the high prevalence of falls during child development, they require distinct analysis, as it is the responsibility of healthcare professionals to promote safer environments and reduce the risk of falls of any nature23.
Age-related risk factors have been widely discussed and analyzed by various authors. The risk of falls has generally been observed to be higher in children under two years of age, as indicated in some studies23. Other authors have found a statistically significant association for children under three years of age22,24,27,33,35. It has also been suggested that the risk of falling extends to children aged one to five26. Another study observed fall risks in children under nine, although the analysis was descriptive and did not yield statistical significance17. One study presented contrasting findings, indicating a higher risk of falls among children aged five or older30. Finally, more recent studies have not identified significant distinctions based on age group19. However, a more refined analysis using a more sensitive scale revealed distinct scores for each age group16.
The child’s sex variable as a predictive risk factor for falls has been widely described, yet findings remain highly inconsistent. Some authors found no statistical association between the patient’s sex and fall risk18,21-22,29-30,34,37. However, other authors identify male sex as a potential risk factor, noting a higher frequency of falls among males17-19,21-22,29-30,34,37. It is worth adding that although males experience more falls, girls tend to sustain more severe injuries when they do fall26.
A history of previous falls was identified by some authors as a statistically significant predictor, suggesting that patients who have fallen once are prone to experiencing subsequent falls17-18,29-30,37. This factor was deemed important enough to warrant implementing computerized alerts or visual indicators to ensure healthcare professionals pay closer attention to these patients18,23,30.
Parental presence did not prevent childhood falls18,19,23,26,29,33-35,37; however, parental absence in the hospital environment increased the risk factor for falls19. Studies have shown that parents use anxiolytics, antihypertensives, and hypoglycemic agents, constituting a factor which may be relevant to the parent-child dyad31-32. Falls occurring in the presence of parents may also be associated with their inability to properly use the safety equipment available in the hospital environment, as suggested by previous research18,29. Continuing education for family members is highlighted in many research findings; such education not only reduces fall incidence, but also supports higher-quality, safer nursing care20,23,29,35.
The use of medications, sedation, and anesthesia appeared in many studies, however there was little consensus (as with other risk factors). A statistical association was found regarding medication use; while the significance was lower for sedatives, hypnotics, barbiturates, phenothiazines, antidepressants, laxatives/diuretics, and narcotics, it was higher for anesthesia and sedation22. Concomitant use of medications, including sedatives, antidepressants, neurotransmitters, anxiolytics, hypnotics, hypoglycemic agents, and diuretics, proved to be a risk factor when three or more medications were used24,30,32,34.
Regarding ambulation, the majority of falls occurred while patients were walking or running; it is suggested that biomechanical characteristics, such as the patient’s mobility, be included in new assessment scales25. Fall risk is linked to a child’s mobility, and weakness is correlated with the occurrence of falls17,34. Fall risk may stem from weakness or a loss of balance28,30, which aligns with findings regarding motor issues and impaired gait, where studies showed significant differences in fall risk for children with such difficulties21,37.
Patients who fell did not have gait limitations but were in motion26. A similar pattern was observed in a study of obese children, where falls occurred while patients were moving or performing exercises37. This risk associated with movement was noted in children over the age of 10 who fell during therapy, while walking to the bathroom, or during other transfers23. Another study stated that children with independent mobility are more prone to falling29.
Regarding the concept of mobility, it is worth noting that more active children tend to fall more frequently, as do children described by their mothers as having behavioral issues27; such children often fail to grasp the risks involved and expose themselves to danger more often29. This type of behavior or temperament, including defiant actions like climbing bed rails, has also been documented36. Hyperactive children are considered at risk of falling due to their restlessness and difficulty controlling their impulses or following instructions from the multidisciplinary team8,34.
The use of biomedical devices was not a widely discussed risk factor, yet it emerged as a common occurrence during children’s hospitalizations. This risk factor was highlighted due to its role in hindering the children’s ability to walk26. It was also noted in the context of allowing children greater freedom of movement, thereby making them more active and prone to falls, as previously discussed17. Another less clear and under-researched point concerns the use of intravenous lines; it remains unclear whether the correlation stems from the devices themselves or from the medications administered through them34-35.
Environmental factors are correlated with the risk of falls. This risk is linked to factors such as appropriate footwear, environmental cleanliness, the removal of unnecessary equipment, and ensuring the call bell is within the child’s reach22. These examples would show a stronger association if integrated into a prevention protocol, as demonstrated in other studies8,20,23. An additional environmental factor involves the improper use of beds and cribs, as well as the incorrect use of their side rails23.
Some authors have correlated the length of hospital stay with falls, noting that falls occurred within the first five days of admission, while others observed them after approximately eight days26,36. Following this line of reasoning, the risk of falls increases with a prolonged pediatric hospital stay; consequently, the Newfs-PI scale assigns a higher score based on the number of days hospitalized7. Conversely, one study found the highest number of falls on the first day of admission, with a subsequent rise after the third day8. However, other authors found no statistically significant difference regarding the length of hospital stay30,37.
The elimination factor was shown in a meta-analysis to correlate with fall risk, although it was minimally explored in the study24. In a case-control study comparing patients who fell with those who did not using the Little Schmidy Hospital Fall Risk scale (an unvalidated tool), the scale’s items were tested and correlated and one of these items addresses the elimination factor. The analysis revealed a correlation between elimination events and the adverse event itself (the fall). However, it remained unclear whether the elimination factor was directly linked to an urgent need to eliminate or to the act of moving to the bathroom, indicating a need for further investigation into this factor30. In turn, enuresis was cited as having a statistically significant association21 in an effort to fully characterize this risk factor.
The risk factor regarding physical status, pre-existing conditions, or diagnosis showed varied findings and discussions across the studies selected for this review. While patients requiring care for bleeding, blood products, or hematological disorders might be expected to have a higher risk of falling, the child’s diagnosis was not found to be statistically significant in this regard36. One study used patients with onco-hematological and gastrointestinal/digestive conditions as its reference group, as this group experienced the highest number of falls; when compared to other diagnoses, patients with cutaneous, musculoskeletal, or orthopedic conditions showed a lower risk of falling than those with neurological/central nervous system or cardiac diagnoses18. A link between falls and onco-hematological diagnoses was also observed in another study26; similarly, another study found statistical significance, albeit with a weak correlation, regarding the same medical diagnosis8.
Neurological diagnoses and their variations were highlighted across several analysis lines. Mental status alterations were identified as risk factors, as were neurological disorders, such as seizures or dizziness, which were associated with falls28,30. A neurological diagnosis alone also pointed to an increased risk21. One study linked the issue to cerebral palsy or cognitive impairments22, while an earlier study identified altered mental status and episodes of disorientation as risk factors37. Associations were also found involving at least one developmental delay; furthermore, neurological diagnoses, specifically epilepsy, were highlighted as significant factors35.
Research comparing children with typical neurodevelopment to those with neurological impairments indicated that children with preserved neurodevelopment actually had higher fall rates than the group with neurological limitations. However, a higher prevalence of falls was observed within the group with neurological impairments among children with attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, or overall developmental delay27. A study focusing exclusively on patients with cerebral palsy concluded that seizures increased the likelihood of falls; it further noted that children with better mobility and standing ability faced a higher risk of falling compared to those without these characteristics29.
Regarding the risk factor of “medical diagnosis”, respiratory diseases were cited to a lesser extent, with the highest number of falls occurring among children experiencing fluctuating oxygenation levels22. The risk factor of “low staffing levels” was notable for only appearing in a Brazilian study, prompting a reflection on the work processes to which nursing teams are subjected in this context8.
The combination of the seven HDFS items (gender, cognitive impairment, age, environmental factors, drug use, diagnosis, and response to surgery/sedation/anesthesia) with varying scoring ranges led to an overestimation of children classified as high-risk19. This overestimation of patients at high risk for falls increases the workload for nursing professionals, as they tend to implement more actions and interventions to prevent the adverse event21. The tendency of these scales to overestimate risk was highlighted by a high rate of false positives, indicating low sensitivity and specificity. Consequently, this necessitates a higher level of vigilance from the nursing team and adherence to implemented prevention measures30.
Findings from meta-analyses and scoping reviews confirmed that currently available pediatric fall risk scales exhibit high sensitivity and low specificity; they also suggest a need to develop new scales featuring a greater number of categories or variables and excluding items that rely on the nurse’s subjective judgment20, 24. Furthermore, computerizing the assessment process was identified as a key factor for optimizing the use of risk scales and facilitating future research, while also easing the nursing workload by reducing redundant tasks and generating alerts for patients at high risk of falling24,30,35.
The studies have various limitations that prevent generalizing data regarding falls in the pediatric population. Many fall-prediction factors are derived from limited populations and single institutions over short periods; furthermore, the studies involve diverse age groups and specific patient populations from specialized centers focused on single diagnoses21,26,30. The fact that nurses may already be implementing some form of fall-prevention protocol could introduce bias regarding the number of falls at the institution21-22.
Knowledge of fall risk factors and the use of fall-prevention scales have not proven effective without prior staff training, the continuity of fall-prevention programs, and the ongoing professional development of multidisciplinary teams8,20,23-24.
Limitations of this study include cultural differences among the countries with the highest research output, as well as the diversity of the studies presented; consequently, it is not possible to clearly determine whether the identified risk factors can effectively measure fall risk when grouped together. Another aspect to consider regarding the study’s limitations is the scarcity of data and the limited number of studies demonstrating high methodological quality. While levels of evidence aided in data interpretation, they were not used as inclusion criteria for selecting studies for this scoping review in an effort to avoid further limitations and capture the widest possible range of risk factors.
CONCLUSION
Inconsistency and enormous diversity in the results of the different studies were found when mapping the fall prediction factors, suggesting the need for additional and complementary studies for the pediatric population. Thus, a greater number of statistically significant associations of the risk factors listed in this scoping review will be necessary to determine an adequate panel of factors for predicting falls in hospitalized children. The global cultural difference must be viewed with care, as there are different ways of caring and views in each place and this must be taken into account. There is an urgent need for a validated tool with greater specificity and sensitivity which helps Brazilian nurses to better conduct and manage patient safety at risk of falling in their pediatric units.
The widely treated fall prediction factors were primarily those involving the place where the child is hospitalized and what the nursing team can control, such as the pediatric hospitalization unit, the presence of parents and their knowledge, environmental factors, length of stay and the low number of professionals. Other factors are characterized by the peculiarities of each child, and these items are those which need to be better correlated to understand the risk of falling, such as age, sex, previous fall, use of medication, walking, use of biomedical devices, eliminations and physical status/diagnosis.
The factors predicting falls are different in different age groups, such as learning to walk, or even running in hospital corridors, going to the bathroom with urinary urgency or using diapers, bathing alone or in a bathtub, all of which must be examined, and thereafter extract the factors with the highest correlation with the adverse event.
The need for a multicenter study in Brazil is latent, and it is recommended to expand the analysis of data from different populations, as well as the different diagnoses treated. Pediatric patients who are hospitalized in this country need to be better understood and supported by tools which are better associated with their demographic-epidemiological profile, which directly implies patient safety.
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