Hourly Patient Rounding

Effective programs decrease call bells and falls, and increase patient and staff satisfaction.

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Learning Scope #339
1 contact hour
Expires Oct. 4, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this CE article is to provide nurses with information about hourly rounding. After reading this article, you will be able to:

1. Summarize how hourly rounding benefits patients, staff and the facility.
2. Describe different components and elements to hourly rounding programs.
3. Identify the barriers and difficulties of initiating an hourly rounding program.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

WALKING down the hall back to the nurses' station in the hopes of finishing some documentation, Emma hears that all too familiar "beep-beep-beep." She looks around and sees the call bell from Room 237 is going off again. She feels like she just left that room 5 seconds ago.

"What does she need?" Emma thinks to herself. She just was in there to help get that patient back into bed. She turns around and heads back into 237. She enters the room with a forced smile and says, "Yes, Mrs. P, what can I do for you?" Mrs. P responds, "Could I please have my cough medicine now?" Emma says, "Of course you can." However, she is thinking to herself, "Now, why didn't she ask me that when I was in here?"

Many nurses can relate to this situation. That persistent ringing of the call bell can become very frustrating, especially when the floor or unit is already short-staffed and each nurse has been assigned an overwhelming patient load. Call bells end up inflicting more strain for nurses in an already stress-filled environment, which can lead to a decrease in staff retention. And, most importantly, if that call bell is not answered in a timely fashion for the patient, patient safety is put in jeopardy, along with patient satisfaction.

It is imperative to find an approach to combat this common issue, which brings with it many serious implications to the inpatient acute care setting. Facilities from the small community hospital to the large city medical center have found the strategy to employ is hourly patient rounding. Research has shown hourly patient rounding (which will be referred to as rounding for the rest of the article) decreases call-bell usage, increases patient safety by decreasing patient falls, and increases both patient and staff satisfaction.

Rounding's Beginning
The concept of rounding is not new. In the late 1980s, a medical center in Birmingham, AL, introduced the role of the unit hostess after receiving an increase in complaints from patients and physicians about the lack of attention to amenities and response to call lights.

The unit hostess was responsible to round 4 times a shift on every patient while also answering call lights within 5 minutes. The hostess would attend to all requests that did not require licensed personnel, such as water, juice, pillows or temperature adjustments. If a request needed licensed personnel, the hostess informed the nurse.

Within a 2-week period, there was a dramatic decline in complaints from both patients and physicians, as well as many positive comments from the nursing staff. Many nurses felt relieved knowing the call bell would be answered. Management felt that with this program, patients' total needs were being met while they received high-quality nursing care.1 The current rounding programs share some of the basic elements that were included in this model.

Rounding programs in facilities throughout the nation vary in multiple areas, including how often rounding occurs, who does it and what those staff members ask patients.

The most common model is to utilize hourly rounding. In this model, rounding occurs every hour during day and evening shift, but every 2 hours during the night shift hours. Some facilities have developed their program to have rounding occur every 2 hours around the clock; however, the literature states the most significant results occur with the hourly rounding model.2 An important consideration to these programs is that patients should not be wakened during either day or evening hours unless treatment is necessary. Some facilities have eliminated rounding every hour in maternity units because new mothers have complained they do not want staff in the room that often. In these cases, the program should be modified to every 2 hours.

Study Results
Woodard's research study focused in on the charge nurse performing the rounding every 2 hours on a 28-bed med/surg unit.3 The investigator felt an experienced registered nurse, like those in the charge nurse role, would be best suited for this responsibility, as this person would be able to quickly and efficiently assess the anticipated needs, as well as the needs of the patient. Especially with the continued increase in patient acuity, the primary nurse juggles maintaining safe, quality care while addressing other issues and concerns.

The results of the study showed a decrease in call-light use and falls, as well as an increase in patient satisfaction. A medical center in California uses managers and other senior nursing staff to utilize the rounding protocol. The facility's patient satisfaction has been in the top 1 percent, according to Press Ganey reports.3

The Four P's
Gone are the days of the nurse entering the room, asking the patient how he is doing, if there is anything he needs and then leaving to go check in on another patient. Staff members entering the room need to introduce themselves and tell the patient they are there to do rounds.

All rounding programs have either a script or specific tactics the staff needs to perform when they round. This helps to foster relationships, meet patients' needs and provide consistent care.2 Universal inquiries involve pain, comfortable position, toileting and making sure frequently used items are within reach, otherwise known as the four P's: pain, positioning, personal needs (utilizing the restroom) and placement.8 Specific actions included in placement are making sure the call light, telephone, television, bed light, bedside table, tissue box, water, garbage can or any other possessions are within the patient's reach.8 Call-light usage decreases because once patients understand the nurse or other staff member will be consistently available to address these specific issues, they will stop using the call light.4

Patients use call bells to notify nurses of many different needs, from the truly life-threatening to the mundane. Major reasons why patients use the call bell are bathroom assistance, IV problems/alarms, pain medication, repositioning, mobility assistance and room amenities.2 Many patients in the hospital need help with their activities of daily living such as ambulating, eating, bathing and dressing. And they communicate these needs primarily through the call bell.

Rounding shows the nursing staff is being proactive in caring for the needs of the patient and patients perceive they are receiving a higher quality of care. Patients' perceptions of quality nursing care relate more to concrete nursing actions such as meeting physical needs or timely medication administration.2 Plus, rounding helps return the call bell to lifeline, instead of the frustrating annoyance.

A universal premise of rounding is prior to leaving the room, staff needs to ask the patient, "Do you need anything else while I am here?" This is followed by telling the patient the next time someone will round.

In many programs, licensed and unlicensed personnel share the responsibility of rounding.   These programs rely on good communication and teamwork between staff members to be successful.  If not, treatment or care could be delayed, which would negatively affect the desired outcomes of rounding.

Some programs include writing the name of the staff member who is scheduled to round next for this patient on the whiteboard by the patient's bed. A rounding program at a hospital in Wisconsin included having the staff write during the admission process on the white board what "very good care" meant to that particular patient as well as the personal care concerns, such as feeling hot or wanting to receive test results right away. Caregivers would then refer to the white board during rounds to make sure these areas were addressed.5 For example, if a patient's care concern was feeling cold, any caregiver who entered the room would inquire about the temperature or offer an extra blanket. This allows patients to take part in their care while staff members show respect for their perspectives and choices.

Rounding & Falls
Patient falls are costly in a number of different ways -- to nursing quality, to the hospital, to society and most importantly to the patient. Tzeng and Yin estimated "the projected cost per fall with injury to hospitals in 2007 would be at least $6,437 and the average cost per fall would be $425."6

The Joint Commission examined fall events from 1995 to 2004 and found the top five reasons fatal falls occur, as reported by healthcare organizations, are due to inadequate staff communication, incomplete orientation and training, incomplete patient assessment and reassessment, environmental issues, and incomplete care planning and provision.6 These all are considered extrinsic risk factors for inpatient falls.

The specific actions included in the script or checklist of rounding programs can counteract some of the environmental risk factors, such as making sure glasses, hearing aids, telephone, garbage can, tissue box and television are all within reach. An action to improve caregiver communication is using the whiteboard as a tool to write a patient's personal care concern. Rounding has become an integral part of many institution's fall awareness programs, as technology should never replace the human element of visualizing the patient.

Initiating a Program
There are some barriers associated with initiating a rounding program. Typical barriers include the education of all staff members about the program and gaining their buy-in; staff keeping up with workload, consistency of staff in performing checks, staffing and acuity levels.7

Initiating a hospital-wide hourly program is not an easy process because of the need to educate a high number of staff members. There needs to be careful planning, communication, evaluation and consideration of needs of the personnel who will be utilizing this new process to make the implementation as successful as possible.10 The best way to get started is to have a pilot unit because when staff from the other units notices the positive outcomes, they will start buying into the process.7

Many staff members may be resistant to this program initially because they fear they will have an increase in workload. However, they will learn to value rounding when they realize the decrease in interruptions from call lights caused an increase in the efficiency of their daily routines.5 This will help staff stay on top of their other duties. Having a pilot unit also is beneficial when the need exists to educate the large number of staff members. The staff members of the pilot unit can be considered the "experts" in this area. These staff can join the education team and help educate the rest of the staff on the other nursing units as the program goes facility-wide.

At times, scripting might become a barrier as it could come off too rehearsed and seem unnatural for the staff. Best judgment needs to be used to help the staff make it their own as they participate in the rounding process while not allowing a deviation from the protocol so the desired outcomes are still achieved. Nurses also need to make sure that scripting does not get in the way of their critical thinking and prioritizing patient care.9

The unit managers need to buy into the process as well and be willing to coach their staff if need be. Meade, Bursell and Ketelsen noted "a key factor to successful implementation of an intervention on a nursing unit is hospital leadership, especially that of nurse managers."2 Nursing leadership should also focus on "enlisting staff champions to ensure rounding behaviors are performed consistently on all shifts."11

In some facilities, managers have taken on the responsibility of performing daily rounding on the staff to ensure compliance with the rounding program. This can be done through interviewing the patient and checking to see whether the staff is using the message board if that is a part of the program. When the manager finds a staff member consistently performs rounding, the manager will thank this staff member in a staff meeting or on the spot in front of other staff members. This public recognition can help motivate other staff members to follow the program.

However, if the manager finds a staff member is not participating in the program, then the staff member will be privately confronted. Expectations will be reviewed, as will the importance of following program. The manager then has an opportunity to suggest different ways to help with compliance. If the staff member consistently fails to follow the program, the manager should consider disciplinary action.

Even with the barriers, many institutions have successfully adopted rounding programs because of the immense benefits. Additionally, it is thought that rounding can decrease pressure ulcers, but further research needs to be done to verify this. And remember, no two rounding programs are the same. Each program shares the basic concepts, but every facility adopts certain elements to meet their specific needs. There are even differences within specialty units such as maternity. However, the goals are always the same: to increase patient safety, satisfaction and staff retention, as well as maintain a quieter environment.

References
1. Sheedy, S. (1989). Responding to patients: The unit hostess. Journal of Nursing Administration, 19(4), 31-33.

2. Meade, C., Bursell, A., & Ketelsen, L. (2006). Effects of nursing rounds on patients' call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70.

3. Woodward, J.L. (2009). Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clinical Nurse Specialist, 23(4), 200-206.

4. HCPro (2007, 26 April). Hourly rounding improves patient safety. Staff Development Weekly: Insight on Evidence-Based Practice in Education. Retrieved Oct. 4, 2012, from the World Wide Web: http://www.hcpro.com/print/NRS-69788-975/Hourly-rounding-improves-patient-safety.html

5. Advisory Board Company (2006, June 2). Hourly rounding decreases call light frequency, may ultimately improve care quality. Nurse Executive Watch.

6. Tzeng, H., & Yin, C. (2008). Nurses' solutions to prevent inpatient falls in hospital patient rooms. Nursing Economics, 26(3), 179-187.

7. Orr, N., Tranum, K., & Kupperschmidt, B. (2007). Hourly rounding for positive patient and staff outcomes: Fairy tale or success story? Oklahoma Nurse, 51(4), 11.

8. Ford, B. (2010). Hourly rounding: A strategy to improve patient satisfaction scores. Medsurg Nursing, 19(3), 188-191.

9. Ulianmo, V., & Ligotti, N. (2011). Patient satisfaction and patient safety: Outcomes of purposeful rounding. Topics in Patient Safety, 11(4), 1,4.

10. Deitrick, L., Baker, K., Paxton, H., Flores, M., & Swavely, D. (2012). Hourly rounding: Challenges with implementation of an evidence-base process. Journal of Nursing Quality, 27(1), 13-19.

11. Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. MedSurg Nursing, 21(1), 23-26, 36.

Kristin E. Davies is a clinical educator at Grand View Hospital, Sellersville, PA.




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