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J Nurs Care Qual Vol. 30, No. 2, pp. 153–159 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Effectiveness of Structured Hourly Nurse Rounding on Patient Satisfaction and Clinical Outcomes Lisa A. Brosey, DNP, RN, CPHQ; Karen S. March, PhD, RN, ACNS-BC Structured hourly nurse rounding is an effective method to improve patient satisfaction and clinical outcomes. This program evaluation describes outcomes related to the implementation of hourly nurse rounding in one medical-surgical unit in a large community hospital. Overall Hospital Consumer Assessment of Healthcare Providers and Systems domain scores increased with the exception of responsiveness of staff. Patient falls and hospital-acquired pressure ulcers decreased during the project period. Key words: accidental falls, evidence-based nursing/standards, hourly rounding, PARiHS framework, patient satisfaction, pressure ulcer/prevention and control
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CUTE CARE FACILITIES continue to evaluate cost-effectiveness methods to enhance patient satisfaction and improve patient safety. A growing body of evidence describing the positive effects of structured nurse rounding on patient satisfaction and clinical outcomes has emerged within the past few years.1−25 On the basis of this emerging evidence and the positive effects demonstrated, many organizations in the United States and
Author Affiliations: Lancaster General Health, Lancaster, Pennsylvania (Dr Brosey), and The Stabler Department of Nursing, York College of Pennsylvania, York (Dr March). No funding was received for this work. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Lisa A. Brosey, DNP, RN, CPHQ, Lancaster General Health, Lancaster, PA 17604 ([email protected]).
the United Kingdom have instituted hourly nurse rounding as a standard component of nursing practice in an attempt to improve patient satisfaction and reduce patient harm.* Hourly nurse rounding entails assessment of 3 to 12 elements on each patient every hour between 6 AM to 10 PM and then every 2 hours from 10 PM to 6 AM.1,6,9 Rounds are reduced to every 2 hours during the night so that sleep patterns are less disturbed and patients are not awakened unnecessarily. The most noted elements assessed during hourly nurse rounding include pain level, need for toileting or elimination, assessment of the environment including room temperature, proximity of personal items, safety hazards, and positioning of the patient or need to change the patient’s position.1,2,4,6,7,9,11−21,23−25 Studies on hourly nurse rounding reveal that patients report higher patient satisfaction, fewer patient falls and hospital-acquired pressure ulcers (HAPUs), and decreased call bell activation.1−22,24,25 Evidence further suggests
Accepted for publication: July 19, 2014 Published online before print: September 18, 2014 DOI: 10.1097/NCQ.0000000000000086
*References 1,
3, 6, 7, 10-13, 16, 17, 20 -22 .
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that nursing care strongly contributes to patients’ perceptions of overall satisfaction and likelihood to recommend a facility to others.26−30 Supplemental Digital Content, Table (available at: http://links.lww.com/ JNCQ/A126), provides a summary of studies on the effects of structured nurse rounding on patient satisfaction, patient falls, HAPU, and call light usage. LOCAL PROBLEM The project facility adopted structured hourly nurse rounding as a standard of nursing care in 2008; however, there was little structure to and accountability for implementation of this practice. As a result, past efforts with hourly nurse rounding were inconsistent and ineffective. Discussions with the nursing staff and observation of practice revealed minimal compliance with hourly nurse rounding process or the intent to assess pain, elimination, environment, and position (PEEP) proactively in the current day. Therefore, the project leader met with nursing leadership to present current evidence and benefits associated with this intervention and to garner support for implementation on one pilot unit. The project unit was a 24-bed medicalsurgical nursing unit with private and semiprivate rooms. This unit was selected on the basis of its need for improvement in patient satisfaction scores (lowest rating of medical-surgical units in facility) as well as its higher incidence of patient falls (2 times the national mean) and HAPUs (higher than facility mean). Intended improvement/study question The purpose of this project was to implement a standardized structured hourly nurse rounding process and to monitor the outcomes of patient satisfaction, patient falls, and HAPUs over a 3-month time period. METHODS Setting Promoting Action on Research Implementation in Health Services (PARiHS) framework was the translation model used for the
project.31 This framework is based on the premise that successful implementation of evidence into practice is dependent on 3 factors: evidence, context or environment, and facilitation. Each factor has equal importance in the implementation process and is interrelated with other factors. For example, if the evidence is strong and the environment is accessible to change, then the facilitation of the change process will be less rigorous and demanding. In contrast, if the evidence is not strong and the environment is not adaptive to change, the facilitation process may require a higher level of support and change management skills for successful implementation to occur. The framework requires evaluation and presentation of the supporting evidence, evaluation and analysis of the context or environment (including support from management and the culture for change of the environment), and the use of facilitating techniques that are fluid and adaptive to the changing environment. For this project, the level of evidence was rated low (most of the evidence on hourly nurse rounding included quality improvement program evaluations) whereas context or environment was rated high (demonstrated by the expressed attitudes and beliefs of the majority of staff members and leadership about the value of improving the care provided to patients and the desire to reduce harm). Since the evidence component was low and the context component was high, the facilitation method suggested by the PARiHS framework was to enable and empower the staff to take control of their learning and change process needs through mentoring and support of staff decisions.31 Discussions regarding current best practices and the positive effects of structured hourly nurse rounding practices were key elements in supporting the staff to be active in the decision to move forward with implementation. Institutional review board–exempt approval was obtained for this evidence-based practice project. Planning the intervention A literature search was conducted using CINAHL, PubMed, Cochrane Database of
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Effectiveness of Structured Hourly Nurse Rounding Systematic Reviews, and Nursing & Allied Health Collection. The search was limited to published literature between 2008 and 2014. Key search words used were patient satisfaction, patient fall prevention, pressure ulcer prevention, and call light. Additional search words of hospital and rounds were added to the key word of patient satisfaction, and the search word hospital was added to the key words patient fall prevention and pressure ulcer prevention. Peer-reviewed articles were evaluated. Evaluation of titles and abstracts was performed with the following inclusion criteria: inpatients in an acute care facility, an intervention consisting of structured nurse rounding, and written in the English language. Studies that included every hour or every 2 hours’ structured nurse rounding and reported outcomes were analyzed for strength and quality of evidence based on the Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines32 (see Supplemental Digital Content, Table, available at: http:// links.lww.com/JNCQ/A126). Evidence was classified into 1 of 5 (levels 1-5) hierarchical levels dependent on the study design and then a rating of quality (a, b, c) was assigned on the basis of the overall study characteristics. The process of implementation included development of a structured approach to staff education, historical data analysis, observations of staff workflow, evaluation of the current state of hourly nurse rounding, and development of guidelines for structured hourly nurse rounding on the unit. First, a meeting with the 8-member unit-based nursing governance council resulted in unanimous approval for implementation of structured hourly nurse rounding. A 20-minute education session that included a review of evidence, working definition of structured hourly nurse rounding, review of historical performance indicators, and goals for improvement in the fiscal year were provided to every staff member on the unit through group staff meetings or one-onone sessions. A fact sheet was presented to the staff for their reference. Observations and shadowing of the staff on all 3 shifts, on weekdays and weekends,
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were performed for several weeks. These observations yielded information on workflow patterns, usage and timeliness of response to call lights, and length of time needed to complete a structured round with and without need for toileting. Baseline data were collected on compliance with performing hourly nurse rounding, patient satisfaction, fall rates, and HAPU rates. Key stakeholders included the nurse manager, registered nurses, patient care assistants, and unit secretaries, who were instrumental in developing the timeline for implementation and were empowered to make decisions throughout the project, and the patients. Guidelines and principles outlining the accountabilities for performing the nurse rounding were developed on the basis of the published evidence, the observed time needed for conducting nurse rounding, and the workflow patterns of the staff. Methods of evaluation Baseline patient satisfaction scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys and inpatient fall rates and HAPU rates through the event report process were collected, analyzed, and presented prior to implementation of structured nurse rounding. Structured hourly nurse rounding compliance was also determined during a 7-day period of time just prior to implementation. Monthly data collection and outcome reporting were provided on the performance indicators. Monitoring of 7-consecutive-day rounding compliance was assessed each month during the project implementation period. Continuous monitoring of compliance of structured hourly rounds was not performed since manual collection of the data was perceived by the staff as adding burden to their other duties. Results were discussed monthly at staff meetings and were graphically displayed in the staff lounge. Analysis Descriptive statistics were used to trend, organize, and describe the characteristics of the data collected on hourly nurse rounding compliance, inpatient fall rates, and HAPU rates.
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A Cox-Stuart trend analysis was performed on the historical inpatient fall data to effectively illustrate that fall rates declined more consistently postimplementation. Frequency distribution analysis of the HCAHPS responses was performed. Data were compared with appropriate benchmarks for patient satisfaction, inpatient fall, and HAPU rates. RESULTS Outcomes An overall goal of more than 80% hourly nurse rounding compliance was set after the baseline assessment and prior to the implementation of hourly nurse rounding. Preintervention baseline hourly nurse rounding compliance was 48.4%. Additional monthly compliance reviews were performed for 7-consecutive-day periods revealing compliance rates of 69.4%, 44.3%, and 59.2%. Overall compliance was calculated by the total number of rounds completed divided by the total number of possible events. Hourly nurse rounding was considered to have been performed when a staff member entered the patient’s room, evaluated the patient for PEEP, and documented the activity on designated flow sheets.
The project unit discharged 582 eligible patients during the project period. Eighty-one HCAHPS surveys were returned. Percentage of “always” declined slightly in the HCAHPS composite domain score of responsiveness of staff to 48.6% (n = 81) from patients discharged postimplementation as compared with a result of 49.3% (n = 35) preimplementation. However, the other domain responses all increased 6.1% to 30.9% postintervention when compared with preintervention. The Table displays the comparisons. A patient fall was counted anytime a patient descended to the floor with or without assistance from the hospital staff. A patient fall rate was calculated by the total number of falls reported divided by the total number of patient-days multiplied by 1000. A rate of 7.02 patient falls per 1000 patient-days was noted in the prior year (November 2011 to February 2012) and a rate of 3.18 resulted following implementation (November 15, 2012, to February 14, 2013). This reflected a 57.7% reduction from the previous year during similar time periods. Patient fall rates had decreased on the project unit prior to implementation of structured hourly nurse rounding. A CoxStuart trend analysis was performed on data from the preceding 12 months prior to
Table. Percentage of “Always,” “Yes,” and “9 or 10” Reponses in each HCAHPS Domain Composite Results Pre- and Postimplementation of Hourly Nurse Rounding
HCAHPS Domain Overall satisfaction Communication with nurses Responsiveness of hospital staff Communication with doctors Hospital environment Pain management Communication about medicines Discharge information Likelihood to recommend
Pre % (n = 35)
Post % (n = 81)
1 y After Project Implementation (n = 472)
48.6 70.5 49.3 69.2 49.1 58.3 50.8 72.7 60.0
72.3 76.6 48.6 76.7 61.8 69.8 81.7 86.3 74.7
72.2 78.8 57.6 75.7 59.8 70.1 59.1 85.8 76.6
Abbreviation: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.
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Effectiveness of Structured Hourly Nurse Rounding implementation. This analysis revealed a statistically significant (P = .015) reduction in the rate of falls in the preceding 12 months. Therefore, the likelihood that the downward trend continued because of random chance was only 1.5%. A Cox-Stuart trend analysis was also performed on data from 3 additional years, which did not demonstrate any similar downward trend during the corresponding data periods. In addition, data patterns revealed that the October to December quarter historically had the highest rate in the preceding 3 years. That pattern was not seen following the project implementation. The unit’s improved patient fall rate of 3.18 falls per 1000 patient-days remained higher than database comparisons but demonstrated a major improvement in reduction of patient harm (Figure). Lower patient fall rates were sustained as demonstrated by a 2.19 patient fall rate per 1000 patient-days 1 year postimplementation. A HAPU rate was calculated by the total number of HAPUs divided by the total number of patient-days multiplied by 1000. Available information demonstrated that 4 HAPUs were reported preimplementation compared with zero during the project implementation
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period, and only 1 HAPU was reported in the 12 months postimplementation. The ultimate goal of zero HAPU continues to be a focus for the facility and is in alignment with national benchmarks. DISCUSSION Summary The initial increase in compliance with hourly nurse rounding to 69.4% in December from baseline was not sustained in subsequent months. The goal of compliance (>80%) was not met in any of the implementation phase monitoring periods. When asked, the staff reported that they believed they were conducting the hourly PEEP rounds but thought they were not always documenting the events. Some suggest that manual monitoring of this indicator may be ineffective due to the reliance on humans to remember to record their actions, which is often not completed.27 Incorporating hourly nurse rounding into the normal workflow for staff lessens the perception that an additional task was being requested. For the HCAHPS domain of responsiveness of staff, the percentage of “always” responses
Figure. Project unit inpatient fall incidence: Rate per 1000 patient-days.
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was the only domain in which the score was lower postimplementation than preimplementation. The other domain percentages all increased. All but one HCAHPS domain demonstrated increases in the percentage of “always, “yes,” and “9 and 10” responses during the project period, which was consistent with the evidence. The rate of patient falls on the project unit decreased prior to implementation of structured hourly nurse rounding possibly due to a reemphasis on the Fall Prevention Program in the nursing department. When comparing falls rates from similar time periods, it appeared there was a decline in fall rates, although the trend began to decline prior to project implementation. Historically, fall rates had been highest in the October to December time period. That usual pattern did not recur during the project implementation (Figure). A reduction of 11 fall incidences between the pre- and postimplementation period reflected a cost avoidance of $46 563 ($4322 × 11) for the project implementation period.33 The reduction in the rate of patient falls, when comparing analogous yearly time periods, was similar to reports from other projects and studies documented in the literature. While the decline in fall rates during implementation was modest compared with preceding quarters, it was clinically significant for the winter quarter especially considering historic data and case-mix indices. Both Bourgault et al13 and Krepper et al16 noted no effect in patient falls with implementation of rounding following preexisting robust fall prevention programs and low rates of patient falls prior to implementation. HAPU rates per 1000 patient-days had also declined in the 6 months prior to implementation on the project unit. However, a reduction of 4 HAPUs comparing pre- and postimplementation resulted in a cost avoidance of
$172 720 ($43 180 × 4).33 This reduction in HAPU rate was similar to results reported by Ellis,14 Sherrod et al,18 and the Studer Group.2 Limitations This project was implemented on 1 medical-surgical unit in 1 hospital. In addition, 3 months is a short period of time to evaluate a change in nursing workflow or cultural adoption of this intervention for sustainability. CONCLUSIONS Change management strategies were used to influence the culture of nursing practice, so changes were not be perceived as simply additional tasks to complete. Recommendations for project sustainability include incorporating unit-based rounding champions to continue to stimulate enthusiasm and prioritize discussions so that the initial improvement changes do not drift. Periodic monitoring and public display of the data stimulate continual focus on the results of this intervention. Evidence indicates that structured hourly nurse rounds are safe, efficient, and useful in today’s practice. Performing hourly nurse rounding may be cost-effective as an intervention because it promotes cost avoidance by reducing injuries related to patient falls and pressure ulcer formation, both of which may extend hospital length of stays. The corpus of evidence suggested that structured nurse rounding demonstrated favorable trends in improving patient satisfaction and reducing patient falls, HAPUs, and call light usage. This project demonstrated overall improvement in patient satisfaction indicators and decreased patient harm through lower patient fall and HAPU rates. Reduced patient harm contributed more than $200 000 in cost avoidance of care that is not reimbursed to organizations.
REFERENCES 1. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, sat-
isfaction, and safety. Am J Nurs. 2006;106(9): 58-70.
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Effectiveness of Structured Hourly Nurse Rounding 2. Studer Group. Hourly rounding supplement. Best Practice ed. http://www.studergroup.com/flash hourlyrounding. Published 2007. Accessed November 15, 2012. 3. Culley T. Reduce call light frequency with hourly rounds. Nurs Manag. 2008;39(3):50-52. 4. Murphy TH, Labonte P, Houser L. Falls prevention for elders in acute care. An evidence-based nursing practice initiative. Crit Care Nurs Q. 2008;31(1):3339. 5. Sobaski T, Abraham M, Fillmore R, McFall DE, Davidhizar R. The effect of routine rounding by nursing staff on patient satisfaction on a cardiac telemetry unit. Health Care Manag. 2008;27(4):332-337. 6. Tea C, Ellison M, Feghali F. Proactive patient rounding to increase customer service and satisfaction on an orthopaedic unit. Orthop Nurs. 2008;27(4):233-240. 7. Weisgram B, Raymond S. Using evidence-based nursing rounds to improve patient outcomes. Medsurg Nurs. 2008;17(6):429-430. 8. Stefancyk AL. Safe and reliable care. Am J Nurs. 2009;109(7):70-71. 9. Ford BM. Hourly rounding: a strategy to improve patient satisfaction scores. Medsurg Nurs. 2010;19(3):188-191. 10. Berg K, Sailors C, Reimer R, O’Brien Y, Ward-Smith P. Hourly rounding with a purpose. Iowa Nurs Rep. 2011;3:12-14. 11. Blakley D, Kroth M, Gregson J. The impact of nurse rounding on patient satisfaction in a medical-surgical hospital unit. Medsurg Nurs. 2011;20(6):327-332. 12. Bonuel N, Manjos A, Lockett L, Gray-Becknell T. Best practice fall prevention strategies. Crit Care Nurs Q. 2011;34(2):154-158. 13. Bourgault AM, King MM, Hart P, Campbell MK, Swartz S, Lou M. Does regular rounding by nursing associates boost patient satisfaction? Nurs Manag. 2008;39(11):18-24. 14. Ellis E. Hourly nurse rounds help to reduce falls, pressure ulcers, and call light use, and contribute to rise in patient satisfaction. http://www.innovations.ahrq .gov/content.aspx?id=3204. Published 2012. Accessed November 24, 2012. 15. Kessler B, Claude-Gutekunst M, Donchez AM, Dries RF, Snyder MM. The merry-go-round of patient rounding: assure your patients get the brass ring. Medsurg Nurs. 2012;21(4):240-245. 16. Krepper R, Vallejo B, Smith C, et al. Evaluation of a standardized hourly rounding process (SHaRP). J Healthc Q. 2014;36(2):62-69. 17. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study. Medsurg Nurs. 2012;21(1):23-26. 18. Sherrod BC, Brown R, Vroom J, Sullivan DT. Round with purpose. Nurs Manag. 2012;43(1):33-38.
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19. Tucker SJ, Bieber PL, Attlesey-Pries JM, Olson ME, Dierkhising RA. Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews Evid Based Nurs. 2012;9(1): 18-29. 20. Hutchings M, Ward P, Bloodworth K. “Caring around the clock”: a new approach to intentional rounding. Nurs Manag. 2013;20(5):24-30. 21. Dix G, Phillips J, Braide M. Engaging staff with intentional rounding. Nurs Times. 2012;108(3):14-16. 22. Braide M. The effect of intentional rounding on essential care. Nurs Times. 2013;109(20):16-18. 23. Gardner G, Woollett K, Daly N, Richardson B. Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: a pilot study. Int J Nurs Pract. 2009;15(4):287-293. 24. Woodard JL. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurs Spec. 2009;23:201-206. 25. Petras DM, Dudjak LA, Bender CM. Piloting patient rounding as a quality improvement initiative. Nurs Manag. 2013;44(7):19-23. 26. Shattell M, Hogen B, Thomas S. “It’s the people that make the environment good or bad.” The patient’s experience of the acute care hospital environment. AACN Clin Issues. 2005;16(2):159-169. 27. Wagner D, Bear M. Patient satisfaction with nursing care: a concept analysis within a nursing framework. J Adv Nurs. 2008;65(3):692-701. 28. Otani K, Herrmann PA, Kurz RS. Improving patient evaluation of hospital care and increasing their intention to recommend: are they the same or different constructs? Health Serv Manag Res. 2010;23(2):6065. 29. Kennedy B, Craig JB, Wetsel M, Reimels E, Wright J. Three nursing interventions’ impact on HCAHPS scores. J Nurs Care Qual. 2013;28(4):327-334. 30. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201-203. 31. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges [debate]. Implement Sci. 2008;3:1. doi:10.1186/17485908-3-1. 32. Dearholt SL, Dang D. Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. 2nd ed. Indianapolis, IN: Sigma Theta Tau International; 2012. 33. Schifalacqua MM, Mamula J, Mason AR. Return on investment imperative. The cost of care calculator for an evidence-based practice program. Nurs Adm Q. 2011;35(1):15-20.
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J Nurs Care Qual Vol. 30, No. 2, pp. 153–159 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Effectiveness of Structured Hourly Nurse Rounding on Patient Satisfaction and Clinical Outcomes Lisa A. Brosey, DNP, RN, CPHQ; Karen S. March, PhD, RN, ACNS-BC Structured hourly nurse rounding is an effective method to improve patient satisfaction and clinical outcomes. This program evaluation describes outcomes related to the implementation of hourly nurse rounding in one medical-surgical unit in a large community hospital. Overall Hospital Consumer Assessment of Healthcare Providers and Systems domain scores increased with the exception of responsiveness of staff. Patient falls and hospital-acquired pressure ulcers decreased during the project period. Key words: accidental falls, evidence-based nursing/standards, hourly rounding, PARiHS framework, patient satisfaction, pressure ulcer/prevention and control
A
CUTE CARE FACILITIES continue to evaluate cost-effectiveness methods to enhance patient satisfaction and improve patient safety. A growing body of evidence describing the positive effects of structured nurse rounding on patient satisfaction and clinical outcomes has emerged within the past few years.1−25 On the basis of this emerging evidence and the positive effects demonstrated, many organizations in the United States and
Author Affiliations: Lancaster General Health, Lancaster, Pennsylvania (Dr Brosey), and The Stabler Department of Nursing, York College of Pennsylvania, York (Dr March). No funding was received for this work. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Lisa A. Brosey, DNP, RN, CPHQ, Lancaster General Health, Lancaster, PA 17604 ([email protected]).
the United Kingdom have instituted hourly nurse rounding as a standard component of nursing practice in an attempt to improve patient satisfaction and reduce patient harm.* Hourly nurse rounding entails assessment of 3 to 12 elements on each patient every hour between 6 AM to 10 PM and then every 2 hours from 10 PM to 6 AM.1,6,9 Rounds are reduced to every 2 hours during the night so that sleep patterns are less disturbed and patients are not awakened unnecessarily. The most noted elements assessed during hourly nurse rounding include pain level, need for toileting or elimination, assessment of the environment including room temperature, proximity of personal items, safety hazards, and positioning of the patient or need to change the patient’s position.1,2,4,6,7,9,11−21,23−25 Studies on hourly nurse rounding reveal that patients report higher patient satisfaction, fewer patient falls and hospital-acquired pressure ulcers (HAPUs), and decreased call bell activation.1−22,24,25 Evidence further suggests
Accepted for publication: July 19, 2014 Published online before print: September 18, 2014 DOI: 10.1097/NCQ.0000000000000086
*References 1,
3, 6, 7, 10-13, 16, 17, 20 -22 .
153
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that nursing care strongly contributes to patients’ perceptions of overall satisfaction and likelihood to recommend a facility to others.26−30 Supplemental Digital Content, Table (available at: http://links.lww.com/ JNCQ/A126), provides a summary of studies on the effects of structured nurse rounding on patient satisfaction, patient falls, HAPU, and call light usage. LOCAL PROBLEM The project facility adopted structured hourly nurse rounding as a standard of nursing care in 2008; however, there was little structure to and accountability for implementation of this practice. As a result, past efforts with hourly nurse rounding were inconsistent and ineffective. Discussions with the nursing staff and observation of practice revealed minimal compliance with hourly nurse rounding process or the intent to assess pain, elimination, environment, and position (PEEP) proactively in the current day. Therefore, the project leader met with nursing leadership to present current evidence and benefits associated with this intervention and to garner support for implementation on one pilot unit. The project unit was a 24-bed medicalsurgical nursing unit with private and semiprivate rooms. This unit was selected on the basis of its need for improvement in patient satisfaction scores (lowest rating of medical-surgical units in facility) as well as its higher incidence of patient falls (2 times the national mean) and HAPUs (higher than facility mean). Intended improvement/study question The purpose of this project was to implement a standardized structured hourly nurse rounding process and to monitor the outcomes of patient satisfaction, patient falls, and HAPUs over a 3-month time period. METHODS Setting Promoting Action on Research Implementation in Health Services (PARiHS) framework was the translation model used for the
project.31 This framework is based on the premise that successful implementation of evidence into practice is dependent on 3 factors: evidence, context or environment, and facilitation. Each factor has equal importance in the implementation process and is interrelated with other factors. For example, if the evidence is strong and the environment is accessible to change, then the facilitation of the change process will be less rigorous and demanding. In contrast, if the evidence is not strong and the environment is not adaptive to change, the facilitation process may require a higher level of support and change management skills for successful implementation to occur. The framework requires evaluation and presentation of the supporting evidence, evaluation and analysis of the context or environment (including support from management and the culture for change of the environment), and the use of facilitating techniques that are fluid and adaptive to the changing environment. For this project, the level of evidence was rated low (most of the evidence on hourly nurse rounding included quality improvement program evaluations) whereas context or environment was rated high (demonstrated by the expressed attitudes and beliefs of the majority of staff members and leadership about the value of improving the care provided to patients and the desire to reduce harm). Since the evidence component was low and the context component was high, the facilitation method suggested by the PARiHS framework was to enable and empower the staff to take control of their learning and change process needs through mentoring and support of staff decisions.31 Discussions regarding current best practices and the positive effects of structured hourly nurse rounding practices were key elements in supporting the staff to be active in the decision to move forward with implementation. Institutional review board–exempt approval was obtained for this evidence-based practice project. Planning the intervention A literature search was conducted using CINAHL, PubMed, Cochrane Database of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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Effectiveness of Structured Hourly Nurse Rounding Systematic Reviews, and Nursing & Allied Health Collection. The search was limited to published literature between 2008 and 2014. Key search words used were patient satisfaction, patient fall prevention, pressure ulcer prevention, and call light. Additional search words of hospital and rounds were added to the key word of patient satisfaction, and the search word hospital was added to the key words patient fall prevention and pressure ulcer prevention. Peer-reviewed articles were evaluated. Evaluation of titles and abstracts was performed with the following inclusion criteria: inpatients in an acute care facility, an intervention consisting of structured nurse rounding, and written in the English language. Studies that included every hour or every 2 hours’ structured nurse rounding and reported outcomes were analyzed for strength and quality of evidence based on the Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines32 (see Supplemental Digital Content, Table, available at: http:// links.lww.com/JNCQ/A126). Evidence was classified into 1 of 5 (levels 1-5) hierarchical levels dependent on the study design and then a rating of quality (a, b, c) was assigned on the basis of the overall study characteristics. The process of implementation included development of a structured approach to staff education, historical data analysis, observations of staff workflow, evaluation of the current state of hourly nurse rounding, and development of guidelines for structured hourly nurse rounding on the unit. First, a meeting with the 8-member unit-based nursing governance council resulted in unanimous approval for implementation of structured hourly nurse rounding. A 20-minute education session that included a review of evidence, working definition of structured hourly nurse rounding, review of historical performance indicators, and goals for improvement in the fiscal year were provided to every staff member on the unit through group staff meetings or one-onone sessions. A fact sheet was presented to the staff for their reference. Observations and shadowing of the staff on all 3 shifts, on weekdays and weekends,
155
were performed for several weeks. These observations yielded information on workflow patterns, usage and timeliness of response to call lights, and length of time needed to complete a structured round with and without need for toileting. Baseline data were collected on compliance with performing hourly nurse rounding, patient satisfaction, fall rates, and HAPU rates. Key stakeholders included the nurse manager, registered nurses, patient care assistants, and unit secretaries, who were instrumental in developing the timeline for implementation and were empowered to make decisions throughout the project, and the patients. Guidelines and principles outlining the accountabilities for performing the nurse rounding were developed on the basis of the published evidence, the observed time needed for conducting nurse rounding, and the workflow patterns of the staff. Methods of evaluation Baseline patient satisfaction scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys and inpatient fall rates and HAPU rates through the event report process were collected, analyzed, and presented prior to implementation of structured nurse rounding. Structured hourly nurse rounding compliance was also determined during a 7-day period of time just prior to implementation. Monthly data collection and outcome reporting were provided on the performance indicators. Monitoring of 7-consecutive-day rounding compliance was assessed each month during the project implementation period. Continuous monitoring of compliance of structured hourly rounds was not performed since manual collection of the data was perceived by the staff as adding burden to their other duties. Results were discussed monthly at staff meetings and were graphically displayed in the staff lounge. Analysis Descriptive statistics were used to trend, organize, and describe the characteristics of the data collected on hourly nurse rounding compliance, inpatient fall rates, and HAPU rates.
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A Cox-Stuart trend analysis was performed on the historical inpatient fall data to effectively illustrate that fall rates declined more consistently postimplementation. Frequency distribution analysis of the HCAHPS responses was performed. Data were compared with appropriate benchmarks for patient satisfaction, inpatient fall, and HAPU rates. RESULTS Outcomes An overall goal of more than 80% hourly nurse rounding compliance was set after the baseline assessment and prior to the implementation of hourly nurse rounding. Preintervention baseline hourly nurse rounding compliance was 48.4%. Additional monthly compliance reviews were performed for 7-consecutive-day periods revealing compliance rates of 69.4%, 44.3%, and 59.2%. Overall compliance was calculated by the total number of rounds completed divided by the total number of possible events. Hourly nurse rounding was considered to have been performed when a staff member entered the patient’s room, evaluated the patient for PEEP, and documented the activity on designated flow sheets.
The project unit discharged 582 eligible patients during the project period. Eighty-one HCAHPS surveys were returned. Percentage of “always” declined slightly in the HCAHPS composite domain score of responsiveness of staff to 48.6% (n = 81) from patients discharged postimplementation as compared with a result of 49.3% (n = 35) preimplementation. However, the other domain responses all increased 6.1% to 30.9% postintervention when compared with preintervention. The Table displays the comparisons. A patient fall was counted anytime a patient descended to the floor with or without assistance from the hospital staff. A patient fall rate was calculated by the total number of falls reported divided by the total number of patient-days multiplied by 1000. A rate of 7.02 patient falls per 1000 patient-days was noted in the prior year (November 2011 to February 2012) and a rate of 3.18 resulted following implementation (November 15, 2012, to February 14, 2013). This reflected a 57.7% reduction from the previous year during similar time periods. Patient fall rates had decreased on the project unit prior to implementation of structured hourly nurse rounding. A CoxStuart trend analysis was performed on data from the preceding 12 months prior to
Table. Percentage of “Always,” “Yes,” and “9 or 10” Reponses in each HCAHPS Domain Composite Results Pre- and Postimplementation of Hourly Nurse Rounding
HCAHPS Domain Overall satisfaction Communication with nurses Responsiveness of hospital staff Communication with doctors Hospital environment Pain management Communication about medicines Discharge information Likelihood to recommend
Pre % (n = 35)
Post % (n = 81)
1 y After Project Implementation (n = 472)
48.6 70.5 49.3 69.2 49.1 58.3 50.8 72.7 60.0
72.3 76.6 48.6 76.7 61.8 69.8 81.7 86.3 74.7
72.2 78.8 57.6 75.7 59.8 70.1 59.1 85.8 76.6
Abbreviation: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.
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Effectiveness of Structured Hourly Nurse Rounding implementation. This analysis revealed a statistically significant (P = .015) reduction in the rate of falls in the preceding 12 months. Therefore, the likelihood that the downward trend continued because of random chance was only 1.5%. A Cox-Stuart trend analysis was also performed on data from 3 additional years, which did not demonstrate any similar downward trend during the corresponding data periods. In addition, data patterns revealed that the October to December quarter historically had the highest rate in the preceding 3 years. That pattern was not seen following the project implementation. The unit’s improved patient fall rate of 3.18 falls per 1000 patient-days remained higher than database comparisons but demonstrated a major improvement in reduction of patient harm (Figure). Lower patient fall rates were sustained as demonstrated by a 2.19 patient fall rate per 1000 patient-days 1 year postimplementation. A HAPU rate was calculated by the total number of HAPUs divided by the total number of patient-days multiplied by 1000. Available information demonstrated that 4 HAPUs were reported preimplementation compared with zero during the project implementation
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period, and only 1 HAPU was reported in the 12 months postimplementation. The ultimate goal of zero HAPU continues to be a focus for the facility and is in alignment with national benchmarks. DISCUSSION Summary The initial increase in compliance with hourly nurse rounding to 69.4% in December from baseline was not sustained in subsequent months. The goal of compliance (>80%) was not met in any of the implementation phase monitoring periods. When asked, the staff reported that they believed they were conducting the hourly PEEP rounds but thought they were not always documenting the events. Some suggest that manual monitoring of this indicator may be ineffective due to the reliance on humans to remember to record their actions, which is often not completed.27 Incorporating hourly nurse rounding into the normal workflow for staff lessens the perception that an additional task was being requested. For the HCAHPS domain of responsiveness of staff, the percentage of “always” responses
Figure. Project unit inpatient fall incidence: Rate per 1000 patient-days.
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was the only domain in which the score was lower postimplementation than preimplementation. The other domain percentages all increased. All but one HCAHPS domain demonstrated increases in the percentage of “always, “yes,” and “9 and 10” responses during the project period, which was consistent with the evidence. The rate of patient falls on the project unit decreased prior to implementation of structured hourly nurse rounding possibly due to a reemphasis on the Fall Prevention Program in the nursing department. When comparing falls rates from similar time periods, it appeared there was a decline in fall rates, although the trend began to decline prior to project implementation. Historically, fall rates had been highest in the October to December time period. That usual pattern did not recur during the project implementation (Figure). A reduction of 11 fall incidences between the pre- and postimplementation period reflected a cost avoidance of $46 563 ($4322 × 11) for the project implementation period.33 The reduction in the rate of patient falls, when comparing analogous yearly time periods, was similar to reports from other projects and studies documented in the literature. While the decline in fall rates during implementation was modest compared with preceding quarters, it was clinically significant for the winter quarter especially considering historic data and case-mix indices. Both Bourgault et al13 and Krepper et al16 noted no effect in patient falls with implementation of rounding following preexisting robust fall prevention programs and low rates of patient falls prior to implementation. HAPU rates per 1000 patient-days had also declined in the 6 months prior to implementation on the project unit. However, a reduction of 4 HAPUs comparing pre- and postimplementation resulted in a cost avoidance of
$172 720 ($43 180 × 4).33 This reduction in HAPU rate was similar to results reported by Ellis,14 Sherrod et al,18 and the Studer Group.2 Limitations This project was implemented on 1 medical-surgical unit in 1 hospital. In addition, 3 months is a short period of time to evaluate a change in nursing workflow or cultural adoption of this intervention for sustainability. CONCLUSIONS Change management strategies were used to influence the culture of nursing practice, so changes were not be perceived as simply additional tasks to complete. Recommendations for project sustainability include incorporating unit-based rounding champions to continue to stimulate enthusiasm and prioritize discussions so that the initial improvement changes do not drift. Periodic monitoring and public display of the data stimulate continual focus on the results of this intervention. Evidence indicates that structured hourly nurse rounds are safe, efficient, and useful in today’s practice. Performing hourly nurse rounding may be cost-effective as an intervention because it promotes cost avoidance by reducing injuries related to patient falls and pressure ulcer formation, both of which may extend hospital length of stays. The corpus of evidence suggested that structured nurse rounding demonstrated favorable trends in improving patient satisfaction and reducing patient falls, HAPUs, and call light usage. This project demonstrated overall improvement in patient satisfaction indicators and decreased patient harm through lower patient fall and HAPU rates. Reduced patient harm contributed more than $200 000 in cost avoidance of care that is not reimbursed to organizations.
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