Hourly Rounding
Hourly Rounding for Falls Prevention in the Emergency Department
Sandra Patchel, RN, CEN
Chamberlain College of Nursing
NR451
Professor Anderson
February 01, 2013
Hourly Rounding for Falls Prevention in the Emergency Department
Introduction
Patient falls are one of the most frequently reported adverse events in the Emergency Department (ED), and can lead to serious injuries, such as head injuries or fractures, or can result in death. Falls can lead to an increased length of stay for the patient, increased utilization of resources, cost for the hospital and patient, chance of falling again, and chance of unplanned discharge to a rehabilitation facility or nursing home, as well as a poor quality of life. York Hospital considers all falls to be preventable, yet the number of falls in the …show more content…
ED has increased over the last year from less than 1 per 1000 patient days, to 4 per 1000 patient days despite measures such as bedside sitters, falls armbands and color coded socks. The Clinical Leaders of the ED need to educate the RN and Emergency Nursing Assistant (ENA) staff on the importance of hourly rounding on all patients to decrease the number of falls.
Contributions to the Future of Health Care
People are living longer lives than ever before. In 1970, the projected life expectancy was 70.8 years; in 2020 it is projected to be 79.5 years (United States Census Bureau, n.d.). One of the most prominent risks for falling is advanced age (Saleh, Nusair, Zubadi, Shloul, & Saleh, 2011). As the population ages and the risk for falls increases, it is important to put into practice a method to protect patients from the injuries that can result from falling. As the process of hourly rounding becomes integrated into the workflow of the staff of the ED and becomes a standard of care for the future, there will be a decrease in the injuries to patients, a decrease in the workload of the staff, and a decrease in costs for the hospitals.
Step 1: Assess the Need for Change in Practice
One of the Blue Book initiatives for all units in York Hospital is to reduce patient falls to less than 2 per 1000 patient days. Every patient is assessed for fall risk using the SCHMID tool during triage, whether they arrived by private vehicle through the waiting room or by ambulance. Any patient receiving a score of 3 or greater is determined to be at risk for a fall and given a special armband. Yellow socks are placed on the patient to alert all staff of the fall risk. Patients that are altered, either because of disease or chemicals, are provided with a bedside sitter. This sitter is a hospital employee who is on “light duty” due to an injury, and can have no direct contact with the patient other than adjusting the bed linens. They are responsible for alerting a staff member when the patient begins to climb out of bed, or becomes increasingly more agitated. It has been shown that a bedside sitter with no patient contact is ineffective in preventing falls, but frequent rounding by an RN or nursing assistant has an increase effect in reducing the number of falls (Olrich & Kalman, 2012). There are currently no guidelines or recommendations for staff as to how often to check in on patients who are at risk for falls, so the question is: Does hourly rounding decrease the number of patient falls in the Emergency Department to less than 2 per 1000 patient days?
Step 2: Link the Problem, Interventions, and Outcomes
As previously stated, the number of patient falls has been steadily increasing in the Emergency Department, despite measures already in place to prevent such falls. In the study by Saleh, Nusair, Zubadi, Shloul, & Saleh (2011), the authors found that educating the nursing staff about the importance of hourly rounding on all patients, providing them with a specific set of questions to ask, and instructing them on what behaviors and changes to observe led to a decrease in falls from 25 to 4 over an 8 week period. A similar study conducted over a period of 6 months found that the use of hourly rounding with a scripted response yielded a reduction in falls to less than 1 percent (Kessler, Claude-Gutekunst, Donchez, Dries, & Snyder, 2012). These authors noted the importance of involving the unit’s Practice Council to develop the specific scripts helped the staff feel involved in the change, and thus increased the success of the initiative.
Step 3: Synthesize the Best Evidence
Decreasing patient falls is an important issue in all areas of health care, but is more pronounced in the acute care settings. There have been many studies conducted to attempt to determine the best practice for the prevention of falls, and many utilized hourly rounding to meet this goal. Six peer reviewed articles were used to assist with this project, covering many different types of units, but all within a hospital setting. “Hourly Rounding: A Replication Study” by Olrich, Kalman, and Nigolian details a study conducted on two medical-surgical units regarding the impact hourly rounding has on patient falls, as well as patient satisfaction and call light usage. Data was collected for 6 months prior to the implementation of hourly rounding, and for 6 months during the practice. Leadership rounds were completed to ensure that staff members were practicing hourly rounding. The study found that hourly rounding by nursing had positive effects on all 3 variables studied (Olrich & Kalman, 2012). The second article reviewed is titled “Hourly Rounding in a High Dependency Unit”, authored by Lowe and Hodgson. Over a two week period, nurses in a High Dependency Unit (Critical Care Unit), were told to fill out a log that addressed the four P’s- Pain, Potty, Position, and Possessions. These logs were to be placed on the patient’s chart and completed every hour. Only 25 out of 44 patients had the log completed every hour. There were no patient falls during this two week period (Lowe & Hodgson, 2012). The third article used for this project was authored by Kessler, Claude-Gutekunst, Donches, Dries, and Snyder, and is titled “The Merry-Go-Round of Patient Rounding: Assure Your Patients Get the Brass Ring. In this study, the leadership of a 30 bed medical-surgical unit conducted research to find ways to improve patient satisfaction and safety. They determined hourly rounding to be the best intervention, and tasked the unit’s Practice Council to develop a plan for rounding. The staff was educated on the policy, and either the RN or the Nursing Assistant conducted hourly rounding, with attention to the four P’s, and left with a scripted response. Data was initially compiled by NRC Picker scores after 2 months, in addition to staff impression of the rounding. The study includes data for the past 6 years showing marked improvement in staff and patient satisfaction, patient safety as evidenced by decreased falls, and an increase in the amount of nursing awards given to the staff of this unit (Kessler et al., 2012).
The fourth article used for this project is titled “Measuring the Effect of Patient Comfort Rounds on Practice Environment and Patient Satisfaction: a Pilot Study” by Gardner, Woollett, Daly, and Richardson. The study was conducted using 2 parallel surgical units, with 61 patients and 23 nurses in the intervention unit, and 68 patients and 16 nurses in the control unit. The nurses and nursing assistants were given a specific set of questions to ask, and behaviors and changes to observe and chart, intervening as needed. At the end of 8 weeks, data on patient and nurse satisfaction, as well as on patient falls, pressure ulcers, and urinary tract infections were obtained. Satisfaction was increased, while patient safety improved in the interventions unit (Gardner, Wollett, Daly, & Richardson, 2009). The fifth article reviewed was authored by Saleh, Nusair, Zubadi, Shloul, and Saleh and is titled “The Nursing Rounds System: Effect of Patient’s Call Light Use, Bed Sores, Falls, and Satisfaction Level”. This study was conducted on the stroke unit of a large rehabilitation hospital. It included 104 patients over 8 weeks. Data was gathered for 8 weeks prior to the implementation of the study, including number of call light activated, number of falls, and number of bed sores. For the next 8 weeks, the nursing staff was given a specific set of questions to ask and documentation to complete during hourly rounding. The data was gathered on the same variables during this 8 week period. Falls improved from 25 to 4, bed sores decreased by 50%, and call bell decreased from 98.8 to 29.3 during rounding (Saleh et al., 2011). The sixth and final article used for this study is titled “Improving Care on Mental Health Wards with Hourly Nurse Rounds”, by Moran, Harris, Ward-Miller, Radosta, Dorfman, and Espinosa. In 4 psychiatric sites of a hospital system, including a 260 bed freestanding psychiatric hospital, hourly rounding was studied to improve patient safety, measured by number of falls, and improve patient satisfaction. 502 patients were included in the study. For a week prior to the study, information was gathered regarding amount of visits to the nurse’s station, number of complaints made by patients on the unit to patient services, number of patient injuries, including falls. For two months, staff, including nurses, psychiatric technicians, and mental health workers conducted rounds each hour with a flow sheet that contained questions to ask and an area to document the rounding. During these two months, data was again collected on the 3 variables and compared to the initial data. Data was again collected after 10 months, and showed a reduction in injuries by 75%, and a reduction in visits to the nurse’s station by 50% (Moran et al., 2011).
Step 4: Design Practice Change
As demonstrated in the previously discussed articles, hourly rounding is an important tool for decreasing patient falls, and would be an invaluable program in the ED. In order to reflect the shared-decision making philosophy at York Hospital, the Policy and Practice Council of the ED, several Clinical Leaders, and the Educator will draft a policy for hourly rounding. This policy will include a script for the RN or ENA to ask each patient while rounding and a standardized method for charting. Once the method for charting is determined, the Information Services Department will adjust the appropriate form in eCare as necessary.
Upon the completion of the policy, all RN and ENA staff will be educated on each step of hourly rounding, the scripts, and the charting. All staff will be required to attend an education session scheduled at various times during a two week period in order to accommodate all shifts. Any staff on leave during these two weeks will be individually educated. The new policy will take effect at 7am on the Monday following the two week education period. The physicians will also receive an abbreviated education, as they will not be required to chart as the RNs will but should be informed about the rounding so that they can communicate more effectively with the RN and ENA staff regarding fall risks and observations. The Patient Representatives will also receive a customized education so that they may include fall assessment in their customer service rounds. By including the RNs, ENAs, Physicians, and Patient Representatives, the patients will have contact with multiple staff members involved in their care that will be able to assess the risk for a fall and intervene before a fall occurs.
Step 5: Implement and Evaluate the Change in Practice
For successful implementation of hourly rounding, all staff must be aware that participation is mandatory. The Clinical Leaders, Educator, and Nurse Manager will communicate with patients and family members on a regular basis throughout every shift to ensure staff are conducting rounds as per the policy. If a staff member is found to be deficient in rounding, they will be re-educated on the policy and given a verbal warning consistent with the disciplinary policy of the hospital.
To evaluate the effectiveness of the proposed change plan, data on several key factors will need to be gathered and assessed 3 months after the initiation of hourly rounding, then every month thereafter. First, the Clinical Information Specialist (CIS) will generate a report from Powerchart of every patient that was assessed as a fall risk of 3 or greater on the SCHMID tool during the initial time period of the practice change. Every fall that occurs requires the primary RN to enter a report in the Safety Reporting System (SRS). A report will be generated by the CIS from the SRS listing all patients that had a reported fall, and compared with the list of fall risks from Powerchart. The number of falls per 1000 patient days will be calculated, and compared to the 3 months prior to the initiation of hourly rounding. A decrease in the number of falls to less than 2 per 1000 patient days will be a measure of success. In addition, the chart of any patient that was evaluated to be a fall risk yet suffered a fall will be reviewed to find the possible system failure and places for improvement.
Step 6: Integrate and Maintain the Change in Practice
To integrate and maintain the change in practice to hourly rounding, the staff will attend a brief education session as part of the yearly ED competencies. This will offer the opportunity to answer any questions, provide any new education or policies, and present data on the decreased fall rate so that the employees can see the positive results of their diligence. All new employees must view a presentation similar to that given to the staff at the initiation of the new policy, and will be trained on the scripting and charting by their preceptor. Staff will be encouraged to offer constructive suggestions on changes to the policy, and those suggestions will be reviewed by the Policy and Practice Council for possible amendments to the practice. In addition, any increase in the fall rate to over 2 per 1000 patient days will be monitored and evaluated for the need to amend the practice. Given the severity of risks patient falls poses on patient recovery, health care costs, and length of hospital stay, hourly rounding must become a priority to every staff member (Gardner et al., 2009).
Implement and Evaluate Plan The Clinical Educator, in conjunction with the Policy and Practice committee, will develop a script for the RN and ENA staff to follow while conducting hourly rounding. The script will include addressing pain, position, and personal needs, as well as ensuring that stretcher side rails are up, and the call bell is in reach and in working order. For two weeks, all ED RN’s will be inserviced at the beginning of each shift on the use of the Schmid tool in the triage note, criteria for falls precautions, procedures for placing falls identification on patients, in their room, and on the chart, and the process of hourly rounding. The Clinical Educator, Clinical Leader, and the Clinical Nurse Specialist will assist with the inservice. Beginning on Monday of week 3, all RNs will complete the fall risk assessment with the triage note. All patients admitted for detoxification, dementia, or uncontrolled seizures will automatically be placed on falls precautions. Any patient that receives a score of 3 or greater on the Schmid tool; any patient over 85 years old or over 80 yrs old with a history of falls, with impaired mental status, with gait deficit, with special toileting needs, visual deficit, fluid/ electrolyte imbalance, dizziness/ lightheadedness/ fatigue, multiple medications and orthostatic hypotension, bleeding disorders, orthopedic conditions, or taking tranquilizers will be placed on falls precautions. If placed on falls precautions, the following will occur: Placement of a yellow band on patient; falls precaution sign placed on room entrance and in patient room on white board; flag patient 's chart and fire an icon on the eCare board; use of yellow slipper socks; document of plan of care, outcomes and interventions appropriate to patient. All amputees and patients with ambulatory dysfunction should be transported via stretcher, not wheelchair, and a sitter will be placed at bedside if patient is climbing out of bed. Every RN and ENA will round with each of their patients every hour, following the script and addressing any concerns as immediately as possible. Charting will be completed each hour in the progress note, stating the condition of the patient and any interventions needed.
Steps to Maintain Change After three months, the fall rates as charted in the Safety Reporting System will be reviewed by the Performance Improvement Committee, and compared with the rates in the 6 months prior to the interventions. The Information Services Coordinator will compile this report. The Policy and Practice committee and the Clinical Educator will review the findings and make any changes to policy as warranted. This report will be reviewed every 3 months subsequently to ensure a fall rate of less than 2 per 1000 patient days. Any increase in falls will be noted, and the process further investigated for any breakdown in the system and need to amend the policy.
The Education committee will develop a competency for hourly rounding, including a review of the script, Schmid tool, and risk factors for falls. This will be included in the department’s yearly competencies in October. The committee will also develop a module on the Learning Management System (LMS) for every new employee to complete as part of their orientation. This module will be specific to jobs, for instance RN, ENA, MD, ancillary staff, etc. During all RN yearly evaluations, random charts are reviewed for compliance in different areas. The Nurse Manager will add reviewing progress notes for charting on hourly rounding as part of the required compliance, and their evaluation will reflect this compliance. The Nurse Manager, Assistant Nurse Manager, and Clinical Leader on duty will conduct rounds through the department, speaking with patients and families to determine if rounds are being conducted.
Finally, any time a fall occurs, a post fall huddle will be conducted including any staff involved, any staff witnesses, and the Clinical Leader. The procedure will be evaluated, and any deviation from the policy will be noted. Any recommendations for improvement gathered from this huddle will be brought to the Policy and Practice committee for evaluation.
Summary
Patient safety is a top priority to all members of the health care team, and one of the foremost concerns is the risk of patient falls. Nurses and nursing assistants are on the front lines of patient care, and provide the greatest opportunity to prevent patient falls. One of the most important ways to prevent such falls is the completion of hourly rounds. Staff members must be educated on the importance of addressing the patient’s needs, provided a script to ensure adequate communication, and provided with a method to electronically chart the process of rounding. The rate of falls should be evaluated monthly in order to properly identify the need for change in the process. By using hourly rounding with attention to patient fall interventions, nurses have the power to dramatically change patient care outcomes and potentially eliminate the costs incurred by hospitals due to these accidents.
References
Gardner, G., Wollett, K., Daly, N., & Richardson, B.
(2009). Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: a pilot study. International Journal of Nursing Practice, 15(4), 287-293. http://dx.doi.org/10.1111/j.1440-172X.20090175.3x
Kessler, B., Claude-Gutekunst, M., Donchez, A. M., Dries, R. F., & Snyder, M. M. (2012). The Merry-Go-Round of Patient Rounding: Assure Your Patients Get the Brass Ring. MEDSURG Nursing, 21(4), 240-245.
Lowe, L., & Hodgson, G. (2012). Hourly Rounding in a High Dependency Unit. Nursing Standard, 27(8), 35-40.
Moran, J., Harris, B., Ward-Miller, S., Radosta, M., Dorfman, L., & Espinosa, L. (2011). Improving care on mental health wards with hourly nurse rounds. Nursing Management- UK, 18(1), 22-26.
Olrich, T., & Kalman, M. (2012). Hourly Rounding: A Replication Study. MEDSURG Nursing, 21(1), 23-36.
Saleh, B., Nusair, H., Zubadi, A. L., Shloul, A., & Saleh, U. (2011). The nursing rounds system: Effect of patient’s call light use, bed sores, fall and satisfaction level. International Journal of Nursing Practice, 17(3), 209-303.
United States Census Bureau. (n.d.).
http://www.census.gov
Sandra Patchel, RN, CEN
Chamberlain College of Nursing
NR451
Professor Anderson
February 01, 2013
Hourly Rounding for Falls Prevention in the Emergency Department
Introduction
Patient falls are one of the most frequently reported adverse events in the Emergency Department (ED), and can lead to serious injuries, such as head injuries or fractures, or can result in death. Falls can lead to an increased length of stay for the patient, increased utilization of resources, cost for the hospital and patient, chance of falling again, and chance of unplanned discharge to a rehabilitation facility or nursing home, as well as a poor quality of life. York Hospital considers all falls to be preventable, yet the number of falls in the …show more content…
ED has increased over the last year from less than 1 per 1000 patient days, to 4 per 1000 patient days despite measures such as bedside sitters, falls armbands and color coded socks. The Clinical Leaders of the ED need to educate the RN and Emergency Nursing Assistant (ENA) staff on the importance of hourly rounding on all patients to decrease the number of falls.
Contributions to the Future of Health Care
People are living longer lives than ever before. In 1970, the projected life expectancy was 70.8 years; in 2020 it is projected to be 79.5 years (United States Census Bureau, n.d.). One of the most prominent risks for falling is advanced age (Saleh, Nusair, Zubadi, Shloul, & Saleh, 2011). As the population ages and the risk for falls increases, it is important to put into practice a method to protect patients from the injuries that can result from falling. As the process of hourly rounding becomes integrated into the workflow of the staff of the ED and becomes a standard of care for the future, there will be a decrease in the injuries to patients, a decrease in the workload of the staff, and a decrease in costs for the hospitals.
Step 1: Assess the Need for Change in Practice
One of the Blue Book initiatives for all units in York Hospital is to reduce patient falls to less than 2 per 1000 patient days. Every patient is assessed for fall risk using the SCHMID tool during triage, whether they arrived by private vehicle through the waiting room or by ambulance. Any patient receiving a score of 3 or greater is determined to be at risk for a fall and given a special armband. Yellow socks are placed on the patient to alert all staff of the fall risk. Patients that are altered, either because of disease or chemicals, are provided with a bedside sitter. This sitter is a hospital employee who is on “light duty” due to an injury, and can have no direct contact with the patient other than adjusting the bed linens. They are responsible for alerting a staff member when the patient begins to climb out of bed, or becomes increasingly more agitated. It has been shown that a bedside sitter with no patient contact is ineffective in preventing falls, but frequent rounding by an RN or nursing assistant has an increase effect in reducing the number of falls (Olrich & Kalman, 2012). There are currently no guidelines or recommendations for staff as to how often to check in on patients who are at risk for falls, so the question is: Does hourly rounding decrease the number of patient falls in the Emergency Department to less than 2 per 1000 patient days?
Step 2: Link the Problem, Interventions, and Outcomes
As previously stated, the number of patient falls has been steadily increasing in the Emergency Department, despite measures already in place to prevent such falls. In the study by Saleh, Nusair, Zubadi, Shloul, & Saleh (2011), the authors found that educating the nursing staff about the importance of hourly rounding on all patients, providing them with a specific set of questions to ask, and instructing them on what behaviors and changes to observe led to a decrease in falls from 25 to 4 over an 8 week period. A similar study conducted over a period of 6 months found that the use of hourly rounding with a scripted response yielded a reduction in falls to less than 1 percent (Kessler, Claude-Gutekunst, Donchez, Dries, & Snyder, 2012). These authors noted the importance of involving the unit’s Practice Council to develop the specific scripts helped the staff feel involved in the change, and thus increased the success of the initiative.
Step 3: Synthesize the Best Evidence
Decreasing patient falls is an important issue in all areas of health care, but is more pronounced in the acute care settings. There have been many studies conducted to attempt to determine the best practice for the prevention of falls, and many utilized hourly rounding to meet this goal. Six peer reviewed articles were used to assist with this project, covering many different types of units, but all within a hospital setting. “Hourly Rounding: A Replication Study” by Olrich, Kalman, and Nigolian details a study conducted on two medical-surgical units regarding the impact hourly rounding has on patient falls, as well as patient satisfaction and call light usage. Data was collected for 6 months prior to the implementation of hourly rounding, and for 6 months during the practice. Leadership rounds were completed to ensure that staff members were practicing hourly rounding. The study found that hourly rounding by nursing had positive effects on all 3 variables studied (Olrich & Kalman, 2012). The second article reviewed is titled “Hourly Rounding in a High Dependency Unit”, authored by Lowe and Hodgson. Over a two week period, nurses in a High Dependency Unit (Critical Care Unit), were told to fill out a log that addressed the four P’s- Pain, Potty, Position, and Possessions. These logs were to be placed on the patient’s chart and completed every hour. Only 25 out of 44 patients had the log completed every hour. There were no patient falls during this two week period (Lowe & Hodgson, 2012). The third article used for this project was authored by Kessler, Claude-Gutekunst, Donches, Dries, and Snyder, and is titled “The Merry-Go-Round of Patient Rounding: Assure Your Patients Get the Brass Ring. In this study, the leadership of a 30 bed medical-surgical unit conducted research to find ways to improve patient satisfaction and safety. They determined hourly rounding to be the best intervention, and tasked the unit’s Practice Council to develop a plan for rounding. The staff was educated on the policy, and either the RN or the Nursing Assistant conducted hourly rounding, with attention to the four P’s, and left with a scripted response. Data was initially compiled by NRC Picker scores after 2 months, in addition to staff impression of the rounding. The study includes data for the past 6 years showing marked improvement in staff and patient satisfaction, patient safety as evidenced by decreased falls, and an increase in the amount of nursing awards given to the staff of this unit (Kessler et al., 2012).
The fourth article used for this project is titled “Measuring the Effect of Patient Comfort Rounds on Practice Environment and Patient Satisfaction: a Pilot Study” by Gardner, Woollett, Daly, and Richardson. The study was conducted using 2 parallel surgical units, with 61 patients and 23 nurses in the intervention unit, and 68 patients and 16 nurses in the control unit. The nurses and nursing assistants were given a specific set of questions to ask, and behaviors and changes to observe and chart, intervening as needed. At the end of 8 weeks, data on patient and nurse satisfaction, as well as on patient falls, pressure ulcers, and urinary tract infections were obtained. Satisfaction was increased, while patient safety improved in the interventions unit (Gardner, Wollett, Daly, & Richardson, 2009). The fifth article reviewed was authored by Saleh, Nusair, Zubadi, Shloul, and Saleh and is titled “The Nursing Rounds System: Effect of Patient’s Call Light Use, Bed Sores, Falls, and Satisfaction Level”. This study was conducted on the stroke unit of a large rehabilitation hospital. It included 104 patients over 8 weeks. Data was gathered for 8 weeks prior to the implementation of the study, including number of call light activated, number of falls, and number of bed sores. For the next 8 weeks, the nursing staff was given a specific set of questions to ask and documentation to complete during hourly rounding. The data was gathered on the same variables during this 8 week period. Falls improved from 25 to 4, bed sores decreased by 50%, and call bell decreased from 98.8 to 29.3 during rounding (Saleh et al., 2011). The sixth and final article used for this study is titled “Improving Care on Mental Health Wards with Hourly Nurse Rounds”, by Moran, Harris, Ward-Miller, Radosta, Dorfman, and Espinosa. In 4 psychiatric sites of a hospital system, including a 260 bed freestanding psychiatric hospital, hourly rounding was studied to improve patient safety, measured by number of falls, and improve patient satisfaction. 502 patients were included in the study. For a week prior to the study, information was gathered regarding amount of visits to the nurse’s station, number of complaints made by patients on the unit to patient services, number of patient injuries, including falls. For two months, staff, including nurses, psychiatric technicians, and mental health workers conducted rounds each hour with a flow sheet that contained questions to ask and an area to document the rounding. During these two months, data was again collected on the 3 variables and compared to the initial data. Data was again collected after 10 months, and showed a reduction in injuries by 75%, and a reduction in visits to the nurse’s station by 50% (Moran et al., 2011).
Step 4: Design Practice Change
As demonstrated in the previously discussed articles, hourly rounding is an important tool for decreasing patient falls, and would be an invaluable program in the ED. In order to reflect the shared-decision making philosophy at York Hospital, the Policy and Practice Council of the ED, several Clinical Leaders, and the Educator will draft a policy for hourly rounding. This policy will include a script for the RN or ENA to ask each patient while rounding and a standardized method for charting. Once the method for charting is determined, the Information Services Department will adjust the appropriate form in eCare as necessary.
Upon the completion of the policy, all RN and ENA staff will be educated on each step of hourly rounding, the scripts, and the charting. All staff will be required to attend an education session scheduled at various times during a two week period in order to accommodate all shifts. Any staff on leave during these two weeks will be individually educated. The new policy will take effect at 7am on the Monday following the two week education period. The physicians will also receive an abbreviated education, as they will not be required to chart as the RNs will but should be informed about the rounding so that they can communicate more effectively with the RN and ENA staff regarding fall risks and observations. The Patient Representatives will also receive a customized education so that they may include fall assessment in their customer service rounds. By including the RNs, ENAs, Physicians, and Patient Representatives, the patients will have contact with multiple staff members involved in their care that will be able to assess the risk for a fall and intervene before a fall occurs.
Step 5: Implement and Evaluate the Change in Practice
For successful implementation of hourly rounding, all staff must be aware that participation is mandatory. The Clinical Leaders, Educator, and Nurse Manager will communicate with patients and family members on a regular basis throughout every shift to ensure staff are conducting rounds as per the policy. If a staff member is found to be deficient in rounding, they will be re-educated on the policy and given a verbal warning consistent with the disciplinary policy of the hospital.
To evaluate the effectiveness of the proposed change plan, data on several key factors will need to be gathered and assessed 3 months after the initiation of hourly rounding, then every month thereafter. First, the Clinical Information Specialist (CIS) will generate a report from Powerchart of every patient that was assessed as a fall risk of 3 or greater on the SCHMID tool during the initial time period of the practice change. Every fall that occurs requires the primary RN to enter a report in the Safety Reporting System (SRS). A report will be generated by the CIS from the SRS listing all patients that had a reported fall, and compared with the list of fall risks from Powerchart. The number of falls per 1000 patient days will be calculated, and compared to the 3 months prior to the initiation of hourly rounding. A decrease in the number of falls to less than 2 per 1000 patient days will be a measure of success. In addition, the chart of any patient that was evaluated to be a fall risk yet suffered a fall will be reviewed to find the possible system failure and places for improvement.
Step 6: Integrate and Maintain the Change in Practice
To integrate and maintain the change in practice to hourly rounding, the staff will attend a brief education session as part of the yearly ED competencies. This will offer the opportunity to answer any questions, provide any new education or policies, and present data on the decreased fall rate so that the employees can see the positive results of their diligence. All new employees must view a presentation similar to that given to the staff at the initiation of the new policy, and will be trained on the scripting and charting by their preceptor. Staff will be encouraged to offer constructive suggestions on changes to the policy, and those suggestions will be reviewed by the Policy and Practice Council for possible amendments to the practice. In addition, any increase in the fall rate to over 2 per 1000 patient days will be monitored and evaluated for the need to amend the practice. Given the severity of risks patient falls poses on patient recovery, health care costs, and length of hospital stay, hourly rounding must become a priority to every staff member (Gardner et al., 2009).
Implement and Evaluate Plan The Clinical Educator, in conjunction with the Policy and Practice committee, will develop a script for the RN and ENA staff to follow while conducting hourly rounding. The script will include addressing pain, position, and personal needs, as well as ensuring that stretcher side rails are up, and the call bell is in reach and in working order. For two weeks, all ED RN’s will be inserviced at the beginning of each shift on the use of the Schmid tool in the triage note, criteria for falls precautions, procedures for placing falls identification on patients, in their room, and on the chart, and the process of hourly rounding. The Clinical Educator, Clinical Leader, and the Clinical Nurse Specialist will assist with the inservice. Beginning on Monday of week 3, all RNs will complete the fall risk assessment with the triage note. All patients admitted for detoxification, dementia, or uncontrolled seizures will automatically be placed on falls precautions. Any patient that receives a score of 3 or greater on the Schmid tool; any patient over 85 years old or over 80 yrs old with a history of falls, with impaired mental status, with gait deficit, with special toileting needs, visual deficit, fluid/ electrolyte imbalance, dizziness/ lightheadedness/ fatigue, multiple medications and orthostatic hypotension, bleeding disorders, orthopedic conditions, or taking tranquilizers will be placed on falls precautions. If placed on falls precautions, the following will occur: Placement of a yellow band on patient; falls precaution sign placed on room entrance and in patient room on white board; flag patient 's chart and fire an icon on the eCare board; use of yellow slipper socks; document of plan of care, outcomes and interventions appropriate to patient. All amputees and patients with ambulatory dysfunction should be transported via stretcher, not wheelchair, and a sitter will be placed at bedside if patient is climbing out of bed. Every RN and ENA will round with each of their patients every hour, following the script and addressing any concerns as immediately as possible. Charting will be completed each hour in the progress note, stating the condition of the patient and any interventions needed.
Steps to Maintain Change After three months, the fall rates as charted in the Safety Reporting System will be reviewed by the Performance Improvement Committee, and compared with the rates in the 6 months prior to the interventions. The Information Services Coordinator will compile this report. The Policy and Practice committee and the Clinical Educator will review the findings and make any changes to policy as warranted. This report will be reviewed every 3 months subsequently to ensure a fall rate of less than 2 per 1000 patient days. Any increase in falls will be noted, and the process further investigated for any breakdown in the system and need to amend the policy.
The Education committee will develop a competency for hourly rounding, including a review of the script, Schmid tool, and risk factors for falls. This will be included in the department’s yearly competencies in October. The committee will also develop a module on the Learning Management System (LMS) for every new employee to complete as part of their orientation. This module will be specific to jobs, for instance RN, ENA, MD, ancillary staff, etc. During all RN yearly evaluations, random charts are reviewed for compliance in different areas. The Nurse Manager will add reviewing progress notes for charting on hourly rounding as part of the required compliance, and their evaluation will reflect this compliance. The Nurse Manager, Assistant Nurse Manager, and Clinical Leader on duty will conduct rounds through the department, speaking with patients and families to determine if rounds are being conducted.
Finally, any time a fall occurs, a post fall huddle will be conducted including any staff involved, any staff witnesses, and the Clinical Leader. The procedure will be evaluated, and any deviation from the policy will be noted. Any recommendations for improvement gathered from this huddle will be brought to the Policy and Practice committee for evaluation.
Summary
Patient safety is a top priority to all members of the health care team, and one of the foremost concerns is the risk of patient falls. Nurses and nursing assistants are on the front lines of patient care, and provide the greatest opportunity to prevent patient falls. One of the most important ways to prevent such falls is the completion of hourly rounds. Staff members must be educated on the importance of addressing the patient’s needs, provided a script to ensure adequate communication, and provided with a method to electronically chart the process of rounding. The rate of falls should be evaluated monthly in order to properly identify the need for change in the process. By using hourly rounding with attention to patient fall interventions, nurses have the power to dramatically change patient care outcomes and potentially eliminate the costs incurred by hospitals due to these accidents.
References
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United States Census Bureau. (n.d.).
http://www.census.gov