Can Rounding Reduce Patient Falls in Acute Care? An Integrative Literature Review

Background: Falls are a persistent problem in all healthcare settings, with rates in acute care hospitals ranging from 1.iii to 8.9 falls per ane,000 inpatient days, about 30% resulting in serious injury. Methods: A 30-day prospective pilot report was conducted on ii units with pre- and postimplementation evaluation to determine the impact of patient-centered proactive hourly rounding on patient falls every bit part of a Lean 6 Sigma process improvement project. Nurse leaders and a staff champion from Unit one were involved in the process from the start of the implementation period, while Unit 2 was introduced to the project for training shortly before the intervention began. Results: On Unit 1, where staff and leadership were engaged in the project from the showtime, the 1-year baseline hateful fall rate was 3.9 falls/one,000 patient days. The pilot catamenia fall rate of ane.3 falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). On Unit two, where there was no run-in menstruum, the one-year baseline hateful fall rate was 2.vi falls/i,000 patient days, which fell, but not significantly, to 2.5 falls/ane,000 patient days during the pilot catamenia (P = 0.799). Give-and-take: Engaging an interdisciplinary team, including leadership and unit champions, to complete a Lean Vi Sigma procedure comeback projection and implement a patient-centered proactive hourly rounding program was associated with a meaning reduction in the autumn rate in Unit 1. Implementation of the same plan in Unit of measurement 2 without engaging leadership or front-line staff in program pattern did non impact its fall rate. Conclusions: The active interest of leadership and front-line staff in programme design and as unit of measurement champions during the projection run-in menstruation was critical to significantly reducing inpatient autumn rates and call bell employ in an developed medical unit.

Background

Falls are a pervasive and persistent problem in all healthcare settings, with adverse clinical, social, and economic outcomes for patients, staff, and institutions involved. Reported rates range from ane.3 to 8.nine falls per ane,000 inpatient days in astute care hospitals,¹ with an estimated 30% of these resulting in serious injury.² The Centers for Medicare and Medicaid Services have transferred the financial burden of inpatient fall prevention to hospitals, and reporting of patient falls now impacts both ranking and payment systems for hospitals and other healthcare organizations. Yet no clinical data support the value of evidence-based guidelines for preventing falls.ⁱⁱⁱ

The difficulty of preventing falls is exacerbated by shortened astute care lengths of stay, requiring that autumn prevention interventions make an touch within short periods. To address these challenges, experts are recommending the use of multifactorial fall prevention programs.^iv,v Successful programs typically include combinations of strong leadership and back up, a culture of safety, front-line staff who are engaged in programme design, a multidisciplinary team that guides the prevention program, staff pedagogy and training, and changes in pessimistic attitudes toward autumn prevention.^{5,half dozen}

While preliminary evidence for multifactorial fall prevention programs is promising, and consistent themes are associated with successful implementation, the bear upon of individual components remains unclear. It has not however been established whether effectiveness is primarily a role of successful implementation as opposed to characteristics of the components selected.

This commodity describes the development, implementation, and evaluation of patient-centered hourly rounding, a program congenital around a conceptual framework nosotros proposed in "Patient Falls: Searching for the Elusive 'Silver Bullet'" (Nursing, July 2014).^seven We hypothesized that this process would lend itself to successful and sustainable implementation, reduced patient falls and, based on previous evidence, decreased call bell usage.^viii

Methods

Study overview and setting. Nosotros conducted a 30-day prospective airplane pilot study with pre- and postimplementation evaluation to make up one's mind the touch of patient-centered proactive hourly rounding on patient falls. (See Glossary of research terms.) The intervention was implemented from September 23 to Oct 20, 2013, in 2 medical units at Christiana Hospital, a 907-bed infirmary in Newark, Del. It is part of Christiana Care Health System, a not-for-profit, nonsectarian, independent academic medical center. The study units comprised a 35-bed developed medical stroke unit (Unit 1) and a twoscore-bed inpatient hematology/oncology unit (Unit 2).

Intervention design and implementation. The patient-centered hourly rounding intervention was designed collaboratively by clinical nurses, a pharmacist, a physician, a physical therapist, a process comeback expert, a researcher, and nurse leaders. It was designed around 3 core principles:

• avoiding redundancy with existing strategies
• engaging patients as active partners in fall prevention where possible
• establishing a culture of accountability to the strategy and staff buy-in.

The design was a result of a half dozen-month Lean Six Sigma process improvement projection based effectually the DMAIC principles: Define, Measure, Analyze, Improve, and Command. Lean Half-dozen Sigma methodology consists of tools and techniques used to sympathize and standardize process variation and to identify and eliminate waste product. The goal of a Lean Six Sigma projection is to accomplish a quantum in functioning, resulting in a sustained improved outcomes.

Nurse leaders and a staff champion from Unit of measurement one were involved in the process from the outset of the implementation period, while Unit two was introduced to the projection for preparation soon before the intervention began.

Patient-centered proactive hourly rounding. This was conducted every hour between 0600 and 2200 hours and every ii hours between 2200 and 0600 hours. Rounding was performed past nurses and patient care technicians (PCTs) (Unit 1) or nurses only (Unit 2) based on differences in RN staffing betwixt the two units. (Meet Defining a patient-centered proactive hourly round.)

Program implementation. The 2 objectives that we defined as critical for communicating to staff during grooming were that:

• unit staff empathize what patient-centered hourly rounding is, recognize its value, and receive the training and time required to consummate patient-centered hourly rounding.
• patient-centered hourly rounding occurs, as defined, each hour from 0600 to 2200 and once every 2 hours from 2200 to 0600, for each patient on the units during the airplane pilot menstruum.

Mandatory instruction and grooming for all staff on both units began 2 weeks earlier implementation of the pilot. Staff development specialists and nurse managers did the preparation at regularly scheduled staff meetings and value comeback team meetings in the ii weeks preceding implementation and supplemented it 2 weeks into the implementation menses to refocus staff on the intervention'south disquisitional components. The unit of measurement-based value comeback team is charged with driving improvements in quality, safety, and patient-centered intendance. The slides adult as part of this process and used during training sessions are available from the corresponding author on asking.

Evaluation of rounding and time periods. For Unit 1, the baseline flow was divers as January to Dec, 2012. The project period was divers as Jan to September, 2013, during which time the Lean 6 Sigma Define, Measure, Analyze, and Improve phases of the DMAIC procedure were completed. This involved the multidisciplinary team, nurse leaders, and clinical nurses and champions from Unit 1. For Unit ii, the baseline period was defined as January to September, 2013.

The airplane pilot period for both units was the 30 days from September 23 to Oct 20, 2013. Rounding was performed past nurses and PCTs (Unit 1) or nurses only (Unit 2).

Study outcomes. The fall charge per unit both earlier and during the pilot was measured every bit number of falls per i,000 patient days. Compliance with the patient-centered proactive hourly rounding process was monitored using three different tools. Outset, the nurse director on each unit randomly selected a patient menses sheet each day during the pilot and reviewed the recorded times of the rounding for the prior 24 hours. The boilerplate and median time between rounds was calculated for each unit. 2d, the nurse director on each unit randomly selected lx unique patient-centered proactive rounds on his or her unit to notice during the pilot. Last, two researchers selected ane staff fellow member from each shift on each unit of measurement during the pilot to survey about the terminal round he or she completed. Researchers used convenience sampling, surveying the beginning staff fellow member they encountered on the unit who was not engaged with a patient.

Staff perceptions virtually the airplane pilot, specially the burden on nursing time, the efficacy of the strategy, and its potential as a sustainable, successful fall prevention measure were assessed using an anonymous survey administered i week after the airplane pilot period ended. Staff were sent an viii-item survey by east-mail to consummate using an bearding web-based interface (SurveyMonkey), and were given 10 days to reply, with ane reminder e-mail.

Statistical analysis. The Isle of man-Whitney test was used to compare baseline fall rates with project period fall rates for Unit 1. The one-sample Wilcoxon-signed rank test was used to compare Unit 1's airplane pilot and baseline period autumn rates, Unit 1'south project and pilot menses autumn rates, and Unit 2'south airplane pilot and projection menstruum fall rates. The ane-sample Wilcoxon-signed rank test was used to allow comparing between a single fall rate measure for both units' pilot periods and the fall rates from the other study periods. Robust regression analysis was used to assess whether median intervals between rounds increased, which would betoken decreasing compliance with hourly rounding as prescribed. Robust regression analysis also was used to examine whether circular completion percentages and staff study of completion percentages increased. Similarly, this would indicate deteriorating compliance with the program. P < 0.05 was considered statistically significant. All analyses were conducted using Stata v. 12 (Stata Corp., College Station, Tex.).

Results

Fall charge per unit data. In Unit of measurement 1, the 1-year baseline mean fall rate was 3.nine falls/1,000 patient days, significantly above the National Database of Nursing Quality Indicators benchmark. A marginally significant drib occurred during the project period to 2.v falls/i,000 patient days (P = 0.059). The pilot period fall rate of ane.three falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). The project and airplane pilot period autumn rates did non differ significantly (P = 0.202). In Unit two, the 1-year baseline hateful fall charge per unit was 2.6 falls/1,000 patient days, which fell, only not significantly, to 2.5 falls/ane,000 patient days during the pilot period (P = 0.799).

Process compliance data. Fifty-six patient menstruation sheets were selected randomly for review during the pilot, 27 from Unit 1 and 29 from Unit 2. The times that rounding was recorded were then examined to determine if intervals between rounds increased during the airplane pilot catamenia for each unit. The overall time between rounds was very close to i hour for the period from 0600 to 2200 hours, every bit prescribed, but also close to 1 hour between 2200 and 0600 hours when rounds were required but every 2 hours. During the pilot, the mean fourth dimension between rounds did not increase significantly on either Unit of measurement one (P = 0.133) or Unit two (P = 0.712).

Besides the documentation review, 108 rounds were observed, with 88% of the prescribed steps being completed on boilerplate. Attention to patients' comfort needs (which occurred in 98% of rounds) and access to the call bell (which occurred in 97% of rounds) were the most-oftentimes performed tasks in the patient-centered round, only communication of when the next circular would occur took identify in only 67% of rounds completed. For both units combined, the midnight shift showed the greatest compliance with an average extent of completion of 97% (N = 12). (Encounter Observed compliance with patient-centered hourly rounding.) The extent to which each circular was completed did not fall significantly over fourth dimension for either Unit of measurement 1 (P = 0.704) or Unit of measurement 2 (P = 0.713).

Researchers surveyed 108 staff members who reported completing an boilerplate of 87% of the requirements of each round. Staff reported asking patients if they could do annihilation else for them most frequently (occurred in 96% of completed rounds), but reported addressing positioning with patients in simply 73% of the rounds in which this would have been appropriate. (Run across Self-reported compliance with patient-centered hourly rounding.) The extent to which staff reported that each round was completed did not autumn significantly over time for either Unit ane (P = 0.827) or Unit 2 (P = 0.194).

Tabular array:

Observed compliance with patient-centered hourly rounding*

Staff survey data. Ninety-4 per centum of staff on Unit ane (17/eighteen) reported that they believed patient-centered hourly rounding had either a positive or strong positive bear on on patient care overall, and 89% (16/18) believed that patient-centered hourly rounding is an constructive autumn prevention strategy. Thirty-9 percent of staff on Unit of measurement 1 (7/18) perceived their overall workload to have been reduced following the introduction of patient-centered hourly rounding, and 83% (15/18) reported a reduction in call bong employ by patients. Lxxx-nine percent of staff surveyed on Unit ane (16/18) would recommend that other units adopt patient-centered hourly rounding. (See Staff survey data.)

Past dissimilarity, only 25% of staff on Unit of measurement 2 (5/xx) reported that they believed patient-centered hourly rounding had a positive impact on patient care overall and only l% (x/20) believed that patient-centered hourly rounding is an constructive fall prevention strategy. No staff on Unit of measurement 2 perceived their overall workload to accept been reduced following the introduction of patient-centered hourly rounding and only 10% (2/20) reported a reduction in call bell use by patients. Only 25% of staff surveyed on Unit of measurement 2 (five/20) would recommend that other units adopt patient-centered hourly rounding.

Discussion

We establish that engaging an interdisciplinary team, including leadership and unit of measurement champions, to complete a Lean Six Sigma procedure improvement project and implement a patient-centered proactive hourly rounding program was associated with a significant reduction in the fall rate. Implementation of the same patient-centered proactive hourly rounding programme in the absence of engaging leadership or front end-line staff in plan design did not bear upon the fall charge per unit.

This discrepancy cannot exist deemed for equally a office of successful implementation considering both units showed excellent compliance with the process. Since this compliance did not turn down during the pilot, our data suggest that patient-centered hourly rounding is likely a sustainable strategy. Notwithstanding, the success of the plan is associated with staff perceptions of the intervention. On Unit 1, where leadership and front-line staff were actively involved in program design and unit champions were designated during the project run-in period, staff perception about the programme and its impact on their own workload and patients was highly positive. On Unit 2, simply a minority of staff were positive about the touch on of the program.

Our findings strongly endorse the inclusion of leadership support and engagement of front-line staff in successful fall prevention programme design. As our data prove, these features are not impacting process implementation. Rather, we believe, based on anecdotal bear witness we observed during the pilots, that they may be impacting the patient centeredness of the rounds. This would be consistent with observations that systems that foster staff accountability may contribute to success in autumn prevention.^ix,10 The discrepancies in the staff survey data also suggest that staff buy-in to the fall prevention program and its goals may be limited in the absence of leadership support, engagement of front-line staff in program design, and a clinical nurse champion. Staff buy-in is a critical component of any process improvement project,¹¹ and leadership including staff in the development process has been shown to nurture a sense of ownership of the outcome.¹²

Tabular array:

Self-reported compliance with patient-centered hourly rounding*

On Unit 2, where hourly rounding did not touch the fall rate, staff were asked to recognize the value of patient-centered hourly rounding through one-way learning, where information passes from decision makers to those in practice roles. On Unit of measurement 1, where hourly rounding combined with a project run-in menstruum did touch the fall rate, two-manner learning occurred through staff engagement in program evolution. This learning is typically much deeper and acknowledges that staff tin can add to the knowledge base during program design.

Much of the reduction in fall rate observed on Unit 1 occurred during the transition from the baseline period to the project run-in menstruum. This was the time when leadership and staff were working closely together with the goals of reducing falls through establishing a culture of accountability for autumn prevention and developing staff purchase-in to the goals. While the pregnant reduction in fall rates was not observed until the cumulative stages of project development and programme implementation had occurred, these data signal that engaging an interdisciplinary squad and including leadership and unit of measurement champions in fall prevention program development may be critical components of any fall prevention effort.

The primary limitation of our study was the brusk pilot menstruum of just thirty days. The consistency of the process data suggests that patient-centered hourly rounding is a sustainable intervention, just further investigation of the impact over a longer period is needed. Much of the literature about falls has only limited data, just based on the success of the airplane pilot, nosotros accept the support of our institution to implement patient-centered hourly rounding for a longer period. During this longer report, the issue of staff noncompliance, although low, must be addressed. The engagement of unit staff and leadership in programme blueprint on Unit 1 may actually have resulted in the event on fall rates being observed prior to the start of the pilot.

Incorporating hourly rounding into an already-established fall prevention program has been shown to strengthen the program and decrease autumn rates.¹³ Hourly rounding besides has been shown to reduce call bell usage; call-bell usage is associated with patient falls.^8,14 Nevertheless, prove regarding hourly rounding equally a primary strategy to reduce patient falls is inconclusive.¹⁵ Further investigation into whether hourly rounding is a robust stand-alone fall prevention strategy is required. Similarly, future studies should consider whether any fall prevention programme that is suitable for the patient population may be effective if implemented through a process characterized by leadership back up that engages forepart-line staff in plan design.

Despite limitations, our findings provide compelling evidence that the implementation of a patient-centered hourly rounding program post-obit specific design with leadership support and engagement of front-line staff is an constructive autumn prevention strategy. Staff purchase-in and accountability should exist fostered through the design and implementation processes and two-manner learning should be used in staff training where possible.

Determination

We plant that a patient-centered proactive hourly rounding programme, where leadership and forepart-line staff were actively involved in program design and unit champions were designated during the project run-in flow, significantly reduced inpatient fall rates in an adult medical unit and reduced call bell utilise. In the absence of leadership engagement, plan development with front-line staff, and unit champions, patient-centered hourly rounding does not appear to exist an constructive fall prevention strategy.

Tabular array:

Staff survey data*

Glossary of enquiry terms

• Convenience sampling. Obtaining a sample by using the participants who are easiest to access; no effort is made to ensure that the sample is truly representative of the target population.¹⁶
• Mann-Whitney test. A test that compares differences between two groups.¹⁶ Information technology is used for comparing nonparametric, continuous data between 2 groups.
• Due north. Sample size.¹⁶
• P. Statistic indicating significance. P < 0.05 means the results are pregnant; the smaller the number, the less likely that the results are due to hazard.¹⁶
• Robust regression analysis. This determines the human relationship between an contained variable and a dependent variable when the data being examined comprise outliers, or farthermost values, that should not be excluded.
• Wilcoxon-signed rank exam. A statistical exam to compare the average values of the same measurements made under two different atmospheric condition. Used when the information are not normally distributed, this test compares median values.

Defining a patient-centered proactive hourly round

1. Hello, I'1000 your nurse_______________. I'm hither to do rounds.
2. Assess patient's hurting levels using appropriate assessment scale. If Percent is rounding, ask the patient if he or she is in hurting, and contact nurse immediately. Provide pain medication as appropriate.
3. Offer toileting assistance (urinal, bedside commode, bathroom).
4. Assess the patient'south position, and reposition if necessary.
5. Put the phone call bell within reach, and have patient perform teach-back.
6. Put phone, Tv, bedside table, tissues, and personal items within patient'south reach.
7. Place trash can side by side to the bed, straighten up room, and put whatever trash in the can.
8. What else I can do for you before I leave? I take time.
9. I, or another member of the healthcare squad, volition be dorsum in the room at <state fourth dimension>. Until and so, delight do not get up without notifying united states of america. Please use your call bell.

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