Effect of Hourly Nursing Rounds on Call Light Use, Patient Falls, and Patient Satisfaction

1. Effect of Hourly Nursing Rounds on Call Light Use, Patient Falls, and Patient Satisfaction  Stephanie R. Bruce, BS, RNUniversity of Wisconsin-Milwaukee, School of Nursing I�d like to start with an anonymous quote: �The high road to service is traveled with integrity, compassion and understanding�People don�t care how much you know until they know how much you care.� I�d like to start with an anonymous quote: �The high road to service is traveled with integrity, compassion and understanding�People don�t care how much you know until they know how much you care.�

2. Acknowledgments Mary Beth Trentadue, Preceptor Julie Darmody, Faculty Supervisor

3. Introduction Problem: Data publicly reported Medicare Ruling Limited research Purpose: To evaluate the effect of hourly nursing rounds on patient call light use, patient falls, and patient satisfaction. Problem: Customer service, patient satisfaction and preventable incidents, such as falls, have become more important as hospital data has become public. In addition, the Center of Medicare and Medicaid services made a ruling, effective October of this year, that injuries from falls will no longer bump up the payment (DRG). Hourly nursing rounds is a strategy to address these issues. Hourly nursing rounds is the process of nursing staff routinely checking on patients to meet and anticipate the needs of the patient and family. There is limited research on the effect of hourly nursing rounding on patient call light use, patient falls, and patient satisfaction. Purpose: The purpose of this study was to evaluate the effect of hourly nursing rounds on patient call light use, patient falls, and patient satisfaction. Problem: Customer service, patient satisfaction and preventable incidents, such as falls, have become more important as hospital data has become public. In addition, the Center of Medicare and Medicaid services made a ruling, effective October of this year, that injuries from falls will no longer bump up the payment (DRG). Hourly nursing rounds is a strategy to address these issues. Hourly nursing rounds is the process of nursing staff routinely checking on patients to meet and anticipate the needs of the patient and family. There is limited research on the effect of hourly nursing rounding on patient call light use, patient falls, and patient satisfaction. Purpose: The purpose of this study was to evaluate the effect of hourly nursing rounds on patient call light use, patient falls, and patient satisfaction.

4. Background Fall Rate 3.3-7.0 falls/1000 patient days 30-48% result in injury (Kalman, 2008) Cost of Injury: $15-30,000/fall $1.08 billion/year (Landro, 2005) Correlation between staff responsiveness and overall satisfaction (OR 4.1) (Tea, Ellison & Feghali, 2008) Most calls occur at medication and meals times (Meade, Bursell & Ketelsen, 2006) According to Kalman, in the United States the national fall rate is between 3.3 to 7 falls per 1000 patient days in the hospital setting. Of these, 30 to 48 % result in injury at a cost of $15-30,000 per fall. This is an annual cost of over 1 billion dollars. Tea, Ellison and Feghali found a strong correlation (odds ratio of 4.1) between staff responsiveness� effect on overall satisfaction scores. Lastly, call light use is highest when staff is busiest (i.e. medication administration and meal times).According to Kalman, in the United States the national fall rate is between 3.3 to 7 falls per 1000 patient days in the hospital setting. Of these, 30 to 48 % result in injury at a cost of $15-30,000 per fall. This is an annual cost of over 1 billion dollars. Tea, Ellison and Feghali found a strong correlation (odds ratio of 4.1) between staff responsiveness� effect on overall satisfaction scores. Lastly, call light use is highest when staff is busiest (i.e. medication administration and meal times).

5. Literature Review Search terms: Nursing Hourly Rounding Databases used: CINAHL 11 of 28,289?69(added call light use) PubMED 3 of 3 plus 6 related articles MEDLINE 1 of 1051?1(added call light use) Cochrane 0 of 15 ClinicalTrials.gov 1 of 1 I did a review of the literature on nursing hourly rounding through CINAHL, PubMED, MEDLINE and Cochrane. In addition, there is one federally funded study currently taking place.I did a review of the literature on nursing hourly rounding through CINAHL, PubMED, MEDLINE and Cochrane. In addition, there is one federally funded study currently taking place.

6. Literature Review Call light use reduced 37.8% Patient falls decreased 50% Patient satisfaction score increased a mean of 8.9 points (on 100-point scale) -Meade, Bursell & Ketelsen, 2006 Nurse called 12-15 times/day for non-urgent requests Each response takes a minimum of 4 minutes Hourly rounding estimated to save 166 hours/month -Studer Group, 2006 Meade et al�s study was conducted on 63 units in 22 hospitals. They studied the effects of nursing rounding at one hour, two hour and standard care. They found that nursing rounding at either interval improved outcomes. The most dramatic effects were seen with hourly rounding. Call light use decreased by 38%, patient falls by 50% and patient satisfaction increased by 8.9 points. The Studer group states that the nurse is called to each patient�s room an average of 12-15 times a day for non-urgent matters. Each response takes a minimum of 4 minutes of a nurse�s time. It is therefore estimated that hourly rounding can save 166 hours a month in staff time. Meade et al�s study was conducted on 63 units in 22 hospitals. They studied the effects of nursing rounding at one hour, two hour and standard care. They found that nursing rounding at either interval improved outcomes. The most dramatic effects were seen with hourly rounding. Call light use decreased by 38%, patient falls by 50% and patient satisfaction increased by 8.9 points. The Studer group states that the nurse is called to each patient�s room an average of 12-15 times a day for non-urgent matters. Each response takes a minimum of 4 minutes of a nurse�s time. It is therefore estimated that hourly rounding can save 166 hours a month in staff time.

7. Framework PDSA (Plan Do Study Act) (Institute for Healthcare Improvement, 2004) �Behavioral shaping� (Kazin, 1989)

8. Methods Setting 45-bed medical-surgical unit in community hospital 14-week study 4-week pre-implementation phase Baseline data 6-week implementation phase Staff education Coaching 4-week post-implementation phase Follow-up data Data collected pre- and post-implementation Call light use and reason Patient falls Patient satisfaction Data were collected using the same tool, days of the week, and time. Approval was obtained from both the facility and UWM�s IRB.Data were collected using the same tool, days of the week, and time. Approval was obtained from both the facility and UWM�s IRB.

9. Intervention Each hour the nursing staff will round on all the patients in the unit. Nurse (RN) rounds odd hours Patient care associate (PCA) even hours Round on the hour 6am-10pm, then every 2 hours Upon entering the room, introduce yourself and tell the patient you are there to do your rounds.

10. Intervention Hourly Rounding Goals Improve patient safety and satisfaction Give patients a heightened sense of security Decrease the number of call lights for non-emergency concerns Reduce staff stress levels

11. The following items will be checked and performed for each patient: Assess the patient pain Offer toileting assistance. Change the patient�s position to promote comfort. Make sure the call light (and soft call light when appropriate) is within the patient�s reach. Put the telephone within the patient�s reach. Put the bedside table next to the bed. Put the Kleenex box within the patient�s reach.

12. The following items will be checked and performed for each patient: Offer sip of fluid to patient and put within patient reach Make sure the garbage bag is on the side of bedside table and empty as needed. Prior to leaving the room, ask, �Is there anything I can do for you before I leave? I have time while I am here in the room.� Tell the patient that a member of the nursing staff (use names on white board) will be back in an hour to round again.

13. Results Pre-Implementation: Call Lights 4.2 calls per patient Falls One Patient Satisfaction Promptness response to call (n=42) Mean 79.2 Overall rate of care given (n=41) Mean 87.8 Promptness in response to call light was below all press ganey database (84.8 rank 10), 150-299 bed group (83.6 rank 13), and WI peer group (87.4 rank 1)!Promptness in response to call light was below all press ganey database (84.8 rank 10), 150-299 bed group (83.6 rank 13), and WI peer group (87.4 rank 1)!

14. Results Post-Implementation: Call Lights 2.7 calls per patient Falls Zero Patient Satisfaction Promptness response to call (n=12) Mean 85.4 Overall rate of care given (n=16) Mean 92.2 Promptness in response to call light compared to all respondents improved in all three groups. all press ganey database (84.8 rank 54), 150-299 bed group (83.5 rank 65), and WI peer group (87.3 rank 30)! Promptness in response to call light compared to all respondents improved in all three groups. all press ganey database (84.8 rank 54), 150-299 bed group (83.5 rank 65), and WI peer group (87.3 rank 30)!

22. Results 36% Reduction in call light use Reason for call light use did not vary 100% Decrease in falls* Satisfaction increased 6.2 points (on 100-point scale) Patient call light use decreased from 4.2 calls per patient before implementation to 2.7 calls per patient after implementation of hourly nursing rounds, for a 36 percent reduction in call light use. Reasons for call light use did not vary between pre- and post-implementation. Since there was only one fall in the pre-implementation period, statistical significance was not reached. As seen in the previous slide, satisfaction scores increased 6.2 points. According to the literature, each call takes at least four minutes of staff time. 1.5 calls less/patient 1 call costs 4 minutes 6 minutes less/patient average census 28 Therefore, hourly rounding had a time savings of 168 minutes Patient call light use decreased from 4.2 calls per patient before implementation to 2.7 calls per patient after implementation of hourly nursing rounds, for a 36 percent reduction in call light use. Reasons for call light use did not vary between pre- and post-implementation. Since there was only one fall in the pre-implementation period, statistical significance was not reached. As seen in the previous slide, satisfaction scores increased 6.2 points. According to the literature, each call takes at least four minutes of staff time. 1.5 calls less/patient 1 call costs 4 minutes 6 minutes less/patient average census 28 Therefore, hourly rounding had a time savings of 168 minutes

23. Discussion of Barriers Gaining �buy-in� from staff Staff completion of accountability tool �dissatisfaction/non-compliance with rounding logs Consistency in staff using protocol Staffing, acuity, admits and discharges

24. Limitations Conclusions about influence on falls cannot be determined due to small sample Satisfaction data is still coming in

25. Implications Rounding was shown to be an effective intervention to Decrease call light use Increase patient satisfaction Based on these results, hospital-wide adaptation of this protocol is recommended.

26. Recommendations: Future Study Training Create unit leaders/Rounding champions Follow each staff member as they round Use pre- and post-tests with staff education Need for: Randomized control study Cost benefit analysis Use of call light system that can collect data Call light system that collects data 24/7, more data Call light system that collects data 24/7, more data

27. References Kalman, M. (2008). Getting back to basics: hourly rounds to decrease patient falls and call light usage and increase patient satisfaction. Retrieved on April 14, 2008 from http://stti.confex.xom/stti/congrs08/techprogram/paper_37872.htm Kazin, A. (1989). Behavioral modification in applied settings. 4th ed. Pacific Grove, CA: Brooks Cole. Landro L. (2005). The informed patient: hospitals aim to curb injuries from falling. Wall Street Journal, D1. Institute for Healthcare Improvement. (2004). Project planning form. Boston: Institute for Healthcare Improvement, 1-9. Meade, C.M., Bursell, A.L. & Ketelsen, L. (2006). Effects of nursing rounds on patients� call light use, satisfaction, and safety. AJN, 106, 58-70. Studer Group (2006). AHC Research Call Light Study. Retrieved on March 35, 2008 from www.studergroup.com Tea, C., Ellison, M. & Feghali, F. (2008). Proactive patient rounding to increase customer service and satisfaction on an orthopaedic unit. Orthopaedic Nursing, 27, 233-40.

28. Questions/Comments Thank you.