Using Purposeful Hourly Rounding

Using Purposeful Hourly Rounding with Fall Alarm to Reduce Patients' falls in An Acute Care Unit Background and Significance Background Hospital stays subject patients, their loved ones, and families to considerable stress. As they face complex medical conditions that require constant testing, monitoring, and attention from physicians and nurses, they are placed in dependent situations which make them emotionally and socially vulnerable. They are compelled to seek assistance with rudimentary needs such as eating, positioning, and elimination. They need high-quality, equitable, and efficient patient-centered care. Without patient safety, however, positive outcomes in an acute care setting remain a far stretch from reality. Unfortunately, it is now common for the unexpected to occur and cause harm to patients while in the hospital. Often, such harm is considered an identifiable, preventable and critical problem in the safety of hospitals and other healthcare facilities. One such unexpected events are “falls,” which refers to an unplanned to the floor with or without injury to the patient. Falls and injuries related to falls rank as some of the most commonplace and costly happenings in the acute care setting. A patient fall has devastating impacts on the patient, the medical facility, and the healthcare system. Patients are subjected to additional diagnostic tests and interventions thereby substantially delaying their plan of care. Such delays increase their length of hospital stay, leading to overcrowding in the acute care environment. Hospital falls may also result in life-threatening injuries and extreme cases, death. Sadly, falls continue to occur even when patients are under the watchful eyes of nurses and other clinical officers. Purposeful hourly rounding is one of the most proactive ways for nurses and clinical workers to discern patient needs and establish positive fall prevention outcomes. This capstone project examines a process improvement undertaking of an acute care unit that had experienced a rise in the rate of patient falls over a period of three months. The purpose of the project is to assess whether staff education and the implementation of an evidence-based purposeful hourly rounding program would help reduce the number of patient falls. Significance of the Study/Relevance to Nursing Practice Nursing staff in acute care units face the arduous task of keeping their patients safe from falls and any fall-related injuries on a day-to-day basis. Quigley (2015) reminds nurses that the American Nurses Association has designated patient falls as a nursing-sensitive indicator. As such, nurses play a critical role in preventing patient falls in the acute care setting and maintaining the safety of each patient’s environment. Nurses are in a position where they can determine the value of an evidence-based fall prevention program such as purposeful hourly rounding to achieve positive outcomes. Such outcomes may include a reduction in the rate of patient falls and injuries related to falls, increased patient satisfaction, and saving on costs. The outcomes are essential to the leadership of medical facilities and healthcare organizations since they demonstrate a commitment to the culture of quality and safety. The Agency of Healthcare Research and Quality (AHRQ) (2013) outlines the essence of educating all members of a healthcare team and integrating hourly rounding protocol into the day-to-day nursing staff activities as one of the best fall-prevention strategies. Purpose Statement The purpose of this capstone project is to evaluate the impact of the use (staff education and implementation) of an evidence-based purposeful hourly rounding program on the patient fall rate of an acute care unit. Upon completion, the project seeks to evaluate the compliance of nursing staff members to the requirements of the program over a 3-month period and to achieve a 25 percent reduction in falls. The overall goal is to reduce the fall rate by 50 percent within six months. Clinical reasoning strategies will be applied with a view to developing optional strategies to evaluate the project’s alternative outcomes. Alternative outcomes considerations help in planning for potential alterations that could lead to a different outcome to the one intended by the project. Clinical reasoning is a complicated process that makes use of both formal and informal thinking methods to collect and assess patient information and determine the need for alternative actions. Clinical reasoning skills such as informal thinking, the things that could affect the project’s outcome include staff training time and documentation compliance, as well as existing generalizations with regards to tools for application by nursing staff. The project applies the Shewhart cycle- plan, do, check, act (PDCA). PDCA is a continuous improvement model that hospitals can use to ensure nurses and other staff practice interventions to meet the intended outcome measures. Plan Do Check Act Identification of problem and planning changes Implementation of the change program. Data collection, analysis of results, and identification of differences. Implement the necessary changes and continue to evaluate effectiveness. Fig. 1. Table showing Shewart’s PDCA cycle Increased rate of patient falls in acute care unit Educate staff on purposeful hourly rounding and conduct trials. Monthly data is collected on number of falls and rounding of components. Implementation of the changes identified from data evaluation. Purposeful hourly rounding enables nurses and relevant clinical staff to spend more time at patients’ bedside and attend to their direct needs. Therefore, it enables them to communicate to hospital leaders, patients’ families, and other stakeholders that quality of care and patient safety are the priorities for patient-centered care. As such, the capstone project is in line with maintaining a culture of safety in medical facilities and improving the quality of care. Literature Review The literature review section uses carefully selected evidence-based and peer-reviewed journals. The review focuses on the academic evidence to find correlating studies to examine and incorporate in the research. The sources used for the search include the University’s Library and electronic databases such as MedLine, Science Direct, JSTOR, CINAHL, Google Scholar, and PubMed. The Boolean terms used for the search include purposeful hourly rounding, patients falls, falls in an acute care setting, fall prevention strategies, nurse, doctor of nursing practice, effectiveness, and program. The literature search aims to determine existing knowledge of the importance and effectiveness of purposeful hourly rounding programs. Nurses spend most of their time providing direct care to patients. Ensuring the safety of patients and protecting them from fall-related injuries is a critical aspect of nursing and it is important to medical organizations, patients, and their families. As such, nurses must have the requisite knowledge to protect patients from falls and fall-related injuries if they are to promote a culture of safety and improve the quality of care provided to patients. Medical organizations also have a responsibility to ensure their patients’ safety. Falls are often a burden to patients, nurses, patients’ families and hospitals. The pain, immobility, injuries and reduced functionality that falls cause affects the physical and psychological health of victims. Fall-related complications often lead to lengthened hospital stays, patients losing their independence, and a substantial cost burden. Additional Hospital Stay and Cost caused by Patient Falls Zecevic, Chesworth, Zaric, Huang, Salmon, McAuslan, Welch, & Brunton (2012) sought to find the cost of patient falls in an acute care setting. In their findings, the hospital cost for patients who experienced fall-related injuries and complications was $30,696 more than the cost for patients who did not fall (Zecevic, Chesworth, Zaric, Huang, Salmon, McAuslan, Welch, & Brunton, 2012). Further, the average hospital stay for fall victims was 34 days longer than that of patients who did not fall. Falls are a systemic issue, and institutional fall and fall-related injuries prevention strategies are needed from a patient safety and risk management viewpoint (Zecevic, Chesworth, Zaric, Huang, Salmon, McAuslan, Welch, & Brunton, 2012). The goals of such programs are to make fall prevention a required standard of practice and fall reduction a strategic priority in acute care settings. Patient Perceptions of Falls Patient falls are a commonplace occurrence in acute care settings. These falls often lead to injuries hence increases the affected patients’ length of stay at a hospital. A multitude of interventions have been applied universally as a preventative strategy to address patient falls in acute care settings, but their effectiveness in reducing patient falls is inconclusive. Shuman, Liu, Montie, Galinato, Todd, Hegstad &Titler (2016) carried out a study aimed at describing the perceptions of hospitalized older adults aged over 60 years about their fall risks, the interventions received to prevent falls, and the fall prevention instructions received on discharge. The researchers used qualitative methods to come up with a prospective, exploratory study. Eight principal themes and several supporting minor themes emerged. These are overall perspectives on falls, perceptions of various interventions while hospitalized, the effectiveness of strategies aimed at preventing falls, and the instructions received upon discharge with regards to fall prevention. Others include the most effective discharge instructions related to fall prevention, patients’ personal strategies to prevent falls, talking about fall prevention, and doing fall prevention. From the findings, it is recommended that healthcare providers engage patients and their families more fully in understanding the interventions for falls and the factors that contribute to falls in the duration of their hospital stay and upon discharge. Staff Education Staff education and evaluation of compliance with the purposeful hourly rounding program and other fall prevention programs are crucial to reducing the number of patients falls. Lack of knowledge combined with lack of a caring attitude from nursing staff is detrimental to the successful implementation of the program (Tzeng & Yin, 2014). Adequate staff knowledge about the program is significant in bringing down the rate of falls (Wilbert, 2013). Therefore, nurses have a responsibility to assess and reassess patients using their knowledge and apply their knowledge of the program as appropriate (Graham, 2012). Saleh, Nusair, Zubadi, & Shloul (2011) report that actions taken during purposeful hourly rounding significantly reduce the fall rate. Other Tested Interventions Ang, E., Mordiffi, S., & Wong, H. (2011) conducted a prospective randomized controlled trial in a Singaporean acute care hospital between April and December, 2006. The study aimed to determine the efficiency of a targeted multiple intervention strategies in reducing the number and frequency of patient falls by the bedside in the acute care setting. Two groups were created; an intervention group and a control group. The latter group only received usual medical care, while targeted multiple interventions were directed to the intervention group over eight months. The study was based on patients identified by the hospital’s nursing staff as high-risk for falls. Of the 6,498 patients who were evaluated for risk of falls, the researchers recruited 1,822 participants. 912 of them were allocated to the control group while the other 910 were allocated to the intervention group. The standard features for both groups were similar for Hendrich score, race and ethnicity, the patients’ current condition, and age. 52 percent of patients in the first group were women. Women constituted 48 percent of the participants in the second group. The average Hendrich score for both groups was eight, the median was seven, and the standard deviation was two. 18 of the participating patients fell at least once by the bedside. Of the 18, 14 were from the control group while the rest were from the other group. The proportion of high-risk participants who fell was substantially lower in the intervention group than in the control group. Applying targeted multiple intervention strategies was effective in reducing the patients’ risk of falls to 71 percent as compared to the conventional fall prevention interventions applied. No major injuries from falls were reported, and the majority of the participants who fell were not injured. However, the study had some limitations. It was a single-centered study, implying it is not possible to oversimplify the findings to other similar settings or other patient groups. The number of participating patients who fell during the eight months of the trial was small; hence the evidence to carry out an analysis of the subjects was insufficient. The scale of the interventions’ effects may be smaller when implemented in the clinical setting since the nurses who took part in the study dedicated their time and attention to put the interventions into action. Nurses in the conventional clinical setting have multiple roles which run concurrently and may lack the capacity to adopt an individualized approach to the implementation of the interventions. Sahota, Drummond, Kendrick, Grainge, Vass, & Sach, T. et al., 2013) conducted a parallel-arm, pragmatic, individual randomized controlled trial. To assess whether it is possible to successfully and cost-effectively reduce falls in the clinical setting by making use of pressure sensor-pager technology. They assessed the effectiveness of using pressure sensors that use radio pagers and are attached to either a patient’s bed or bedside chair. The researchers used two groups- an intervention group and a control group. This study took place in a large teaching hospital in the United Kingdom, and it targeted older patients admitted to the hospital’s acute, general medical wards. Primary outcome measure used by the researchers was the number of inpatient falls by the bedside per 1,000 bed days. Of the 3,292 eligible patients, only 1,839 were included in the random controlled trial. 918 patients went to the intervention, while the other 921 went to the other group- the control group. Patients had to be above 60 years of age. The average age at randomization was 84.6 years. Female participants were more than male participants as they comprised 55 percent of the total. The median Barthel score was twelve, and 65.1 percent of the participants had a median MMSE of greater than 23/30. 65 participants from the intervention fell cumulative 85 times, at a fall rate of 8.71 every 1,000 bed days. 64 participants from the control group fell cumulative 83 times, at a fall rate of9.84 every 1,000 days. The number of major injuries from the falls was small, as the control group had only three fractures, with the intervention group- T - recording only three fractures. Among the patients who experienced a bedside fall, their length of stay at the hospital was significantly longer, median twenty days, than those participants who did not fall, median nine days. However, there are several limitations to this study. The study was powered to identify a 35 percent drop in the rate of falls by the patients’ bedside, on the basis of the sample size estimates drawn from the researchers’ pilot study. They assert that it is possible that the pressure sensor- pager technology intervention may be associated with a smaller reduction in falls which may have been missed. Staffs were blinded to the intervention which may have caused differential reporting of falls. Underreporting of falls may also have occurred. Rounding Strategies An action research design study conducted by Rondinelli, Ecker, Crawford, Seelinger, & Omery in 2012 encompassed eleven acute care facilities. The study was concerned with the facilities’ structures, processes, and outcomes with purposeful hourly rounding by nurses. The study was confined to one state, and it found that the implementation of multiple interventions with hourly rounding led to reduced team focus and overuse of resources. As such, they recommend that rounding is customized to a unit, staff, and patient needs if falls are to reduce. For rounding strategies to work, it is imperative that acute care unit and institutional leaders are on board with all the implementation strategies. It is also essential to obtain means of continuous feedback from both nurses and patients. Rondinelli et al. (2012) outline the critical aspects involved when a unit is rolling out a rounding improvement program. The study emphasized the unique capacity of the facilities’ processes, structures, and outcomes to meet staff and patients’ needs within the scope of acute care. Hicks (2015) conducted an integrative literature review of approximately 14 studies within the scope of acute care to analyze and synthesize existing knowledge and help guide future nursing practice. His evidence demonstrated that fall rates reduced as a result of purposeful hourly rounding in 11 of the 14 studies. The study recommends that additional research is carried out with different populations lasting the same amount of time to compare results (Hicks, 2015). It is essential for nursing staff to be informed and committed towards purposeful hourly rounding to realize the benefits of the practice. Theoretical Framework This projects heavily applies Johns Hopkins nursing evidence-based model which makes use of a problem-solving approach for clinical decision making in a bid to assimilating the best evidence into practice. The model assures high-quality care, promotes patient satisfaction and optimal outcomes, and improves the quality of life while establishing a culture of ongoing learning and critical thinking (White & Dudley-Brown, 2012). The project also incorporates Kurt Lewin’s model that works in 3 stages when a change is being implemented. The stages are unfreezing, movement, and refreezing. It assures clinical excellence patient outcomes by facilitating the improvement of the quality of healthcare and, subsequently, patient satisfaction. Methodology Evidence-based Practice Model or Research Design Quantitative descriptive designs give a picture of situations as they happen. As such, it is essential in the identification of problems that exist in current practice. The project will use a case study- which is a form of a descriptive design that explores an individual, a group or a community that has huge variables. An advantage of case studies is that they allow observations of day-to-day interventions applied in nursing practice. Participants/Population The population sample includes male and female residents of a long-term care unit in North-East United States. There are no exclusion criteria since all individuals are already in an acute care setting. Sample/Setting There are no exclusion criteria for diagnosis, the age of participants, use of assistive devices, and medications. The majority of participants are aged 65 years and above. Most of them are ambulatory and diagnosed with dementia. Residents admitted for rehabilitation purposes in the unit are also included. Recruitment There are no exclusion criteria, and all participants are free to participate in the study. Instruments Shewhart’s PDCA cycle will be used in this study especially in evaluating staff compliance to the implemented program. The Studer Group rounding tool will also be used, and it will be modified to meet the practice needs of the unit and ensure staff have buy-ins to the documentation process. It uses 4Ps (pain, potty, position, and possessions). Hard copy hourly rounding sheets will be used to collect data. Procedures The Studer Group Model is an evidence-based hourly rounding protocol that will help in reducing the number of patients’ falls in the acute care unit. Nurses will be educated on eight rounding behaviors utilizing keywords before the study to make sure that they are all transmitting the same information on their shifts and that their actions are not reactive but proactive. Key Personnel Key personnel will include the nurse leader, who will lead the multidisciplinary group. Others include a nurse educator, recreational and physical therapists, long-term care provider, two registered nurses, and a pharmacist. Stakeholders The primary stakeholders are the patients since the program affects them directly. Others include nurses, physicians, patients’ families, hospital management, clinical officers, and the entire community. Barriers to Implementation and Sustainability Hospital culture may inhibit the implementation and sustainability as nurses will need an adjustment period to reach full compliance and achieve a form completion rate of 100 percent. Data Collection Plan Unlicensed nursing staff will be designated to document a hard copy hourly rounding tool for all participants. That data collected on the rounding tool will address comfort, toileting, safety, and personal possessions as per the Studer Group model. The nurse manager will assign acronyms to each form for accountability purposes to address whether the participants were sleeping, out on pass, or in the lounge/dining area. The unlicensed nursing staff will be instructed to document a task’s letter code next to the hour it is completed. The data will then be reviewed after three months and again after six months. Data Analysis Plan The process of data analysis includes preparation of data, description of the sample, exploring and confirming analysis, and ensuring reliability. Care will be observed to prevent data entry errors, measurement errors, and identifying missing information. The statistical analysis will be confirmed with a statistician at the university. Ethical Considerations Human rights protections uphold the dignity, health, and self-respect of study participants. Before implementation, this study will be reviewed by the hospital’s Internal Review Board as well as the University. The review will ensure that the program poses no harm to participants, that the research question is important enough to warrant research and that it is worth the potential risk. Each phase of the program will maintain nurse and patient confidentiality, rights, and anonymity. Timeline The study will take six months, from February 2018 to July 2018. Approvals for Implementation The Research and Development Service: Human & Animal Research Protection Office will be sought to approve the request to conduct a review of an operational level non-research quality improvement project, and the university’s Institutional Review Board (IRB) department will be sought to approve and confirm that the project meets ethical standards. No personal identifying information will be collected from either the nursing staff or the patients. Evaluation Plan Fall rates will be compared six months before and after the implementation of the purposeful hourly rounding program. Nursing staff will be educated on the importance of appropriately filling the documentation sheets to reduce instances of incomplete hourly rounding forms. Incomplete forms can make it hard to accurately account for all evidence-based actions and interventions applied.