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Study Shows Hourly Rounding Diminishes Patients’ Need to Use Call Lights

Monday January 15, 2007
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Nurses involved in an hourly rounding protocol are finding their shifts less stressful, their time more productive, and patient safety and satisfaction scores hitting all-time highs. The new interest in rounding comes in the wake of research results — from 27 nursing units in 14 hospitals across the country — that show a consistent strategy of checking on patient needs reduces monthly call-light use by 38%, patient falls by 50%, and skin breakdowns by 14%.

“The response has been amazing,” says Christine Meade, PhD, chief researcher and healthcare coach with the Studer Group’s Alliance for Healthcare Research, Gulf Breeze, Fla. “Nurses know rounding works, but nobody has ever done a study to prove it.”

The study, “Effects of Nursing Rounds on Patients’ Call Light Use, Satisfaction, and Safety,” by Meade, Amy L. Bursell, PhD, and Lyn Ketelsen, RN, MBA, was published in the September 2006 issue of the American Journal of Nursing.

Meade says she gets about 10 e-mails a day about the research results and is part of a team of coaches who present the rounding protocol to hospital units around the country.

Of all the indicators of success, “satisfaction jumps through the roof,” Meade says. The savings potential from rounding also attracts interest because patient falls cost hospitals an average $11,000 apiece and incidents of decubitus ulcers cost $14,000 each, not including possible costs because of lawsuits.

In most hospital units that have initiated the protocol, hourly rounding is shared by nurses and nursing assistants or patient technicians, with RNs doing the even hours and aides the odd hours, says Ketelsen. Also, some units opted for rounding every two hours, especially during late night hours when patients may not want to be disturbed, but hourly rounding shows better results, says Ketelsen.

Minding the P’s and Q’s

At Delnor Community Hospital in Geneva, Ill., hourly rounding in two med/surg units decreased call lights and resulted in a big jump in patient satisfaction over the past year, says Loretta Bogolin, RN, MSN, chief nursing officer and vice president of patient care services.
The units, which had a total of 55 beds and 117 nurses and patient care technicians, took part in the Studer Group study. The strategy is still being monitored and may be extended to other hospital units in early 2007.

“We’re seeing some success but want to watch the program a little longer before expanding,” Bogolin says.

Most staff resistance to the changes from their previous routine has been overcome as patient satisfaction scores climb, but there’s been continual “tweaking” of the rounding strategy.

For example, the nursing staff balked at a requirement to write down everything they offered or did for a patient on a sign-up sheet kept in patient rooms.

“They said, ‘This is crazy. We don’t need to write down everything we do.’” Bogolin says. “When I heard this, I pulled the sign-up sheets.”

Under the Delnor protocol, RNs round on even hours and nursing assistants on odd hours during a 16-hour period and every two hours during the late night sleeping period. When greeting patients, the staff follows a script of specific questions, such as “Do you need help to the bathroom?,” “Is your water cold enough?,” or “Are you in pain?”

“It was important to get the staff to buy into the concept that if they’re in the room more often with patients and their families, the necessity of patients using a call light is less frequent,” says Bogolin. “The key is what the staff offers patients while in the room.”

Bogolin says while rounding purportedly saves nurses time to spend on other tasks, hours saved is hard to quantify and isn’t always felt by the staff.

“You can’t take for granted that the staff will buy into the rounding concept as a way to save time, so our measure of success is based on patient satisfaction scores,” she says. “By tweaking protocols, we saw some huge jumps.”

Creating a comfort zone

A new strategy of hourly rounding has created a comfort zone for patients and better control over the flow of work for Brook Steele, RN, a pediatrics nurse at Sacred Heart Hospital in Eau Claire, Wis.

Since her unit launched a proactive approach to meeting patient needs, Steele has seen a sharp drop in call lights going off at inopportune moments.

“On days when the protocol works perfectly — when we’re able to see patients every hour on the hour — call lights go off once or twice or not at all during a shift,” says Steele. “It can put you a little more in charge of your own day.”

Some nurses initially balked at hourly rounding over concerns it would make their shifts busier, which is proving untrue, says Steele.

“We’re not adding more work; we’re just working smarter,” she says.

Two Sacred Heart nurses in med/surg units participated in last year’s pilot study to follow a Studer Group “script” of hourly rounding that proved so successful the concept is now being implemented for over 400 nurses throughout the facility, says Faye Deich, RN, MS, CNAA, chief nursing officer.

“It’s a cultural shift for the nursing staff,” says Deich. “They’re moving toward a more proactive approach to care instead of waiting for patients to call in and interrupt what they’re doing.”

As implementation of the protocol nears 100% at the hospital, nursing directors audit the progress by making their own rounds, asking patients if nurses come in every hour and follow the rounding procedure. Nurses also document what takes place during each round.

“It takes attention and focus to make sure that we’re fully implemented and that the process sticks, and that’s where we’re at right now,” says Deich.

Units at Sacred Heart where the protocol has been “hardwired” into the routine not only show a drop in call lights but a decline in patient falls, a reduction of skin breakdowns, and an upward trend in patient satisfaction similar to that of the national study.

Steele says nurses have learned they can stay ahead of patient needs and help patients feel more comfortable about asking questions and communicating with their caregivers. She says white boards kept in each room give specifics on patient treatments and have comment sections to pass on information, such as notes about patient’s No.1 complaint and pain management or something as simple as remarking that a patient does not like ice in his or her water.

“Little things often make a difference.” Steele says.

Proactive vs. reactive

Ketelsen, a Studer Group coach, originated the research project after visiting numerous hospitals struggling to raise patient satisfaction rates.

“I did some observations, and it became clear that practicing in a reactive manner wasn’t serving nurses well, and they needed to transition to a more pro-active nursing approach,” Ketelsen says. “One of the biggest motivations for me was related to the efficiencies this was going to create for the nursing staff. In a finite way, rounding gives some time back to nurses, and they’re not as tired at the end of their shift.”

Informally, she had nurses wear pedometers at one hospital and found they walked 5.2 miles per shift prior to implementing hourly rounding and 4.3 miles per shift afterwards. “They were shaving 20% off the steps they were taking to meet patient needs by being more proactive — that’s pure time given back to the staff,” Ketelsen says.

While nurses are professional and have the best interests of their patients in mind, changing work habits is difficult, which is why the researchers developed a formal set of behaviors for nurses to follow, says Ketelsen.

Ketelsen says it was once standard practice to round hourly but nurses often just peeked in the door and moved on unless a call light was pushed, signaling a real urgency.

“The new rounding is more about engaging the patients — going in and finding out their needs and accomplishing tasks. It’s more comprehensive and more effective,” she says.

The next test for patient rounding is in the emergency room setting, and a research study is already under way at 31 hospitals to determine the best approach for nurses in the busy, fluid environment, says Ketelsen.

“My hope would be that this research begins to establish a standard of practice for nurses that reinforces good, basic, solid nursing practice; gives time back to the staff; and increases the safety and quality of care,” she says.

John Leighty is a freelance writer. To comment on this article, e-mail jboivin@gannetthg.com.

The ‘Three P’s’ Rule

By remembering th “three P’s,” the main reasons for call light rings, nurses find their time less disrupted by call lights since patients will usually wait on non-urgent matters knowing a nurse is coming by within the hour, says Loretta Bogolin, RN, MSN, chief nursing officer and vice president of patient care services at Delnor Community Hospital, Geneva, Ill.
The three P’s include —

    • Pain — Asking patients to describe their pain level on a scale of zero to 10 and doing whatever is necessary to alleviate the pain.
    • Potty (personal needs) — Scheduling patient trips to the bathroom to avoid unsafe conditions and possible falls.
    • Positioning — Making sure the patient is comfortable and assessing the risk of pressure ulcers.

Nurses also make sure items a patient may need are available and within easy reach, such as a fresh pitcher of water, tissues, the TV remote control, and the telephone. Before leaving a patient’s room, a nurse should always ask, “Is there anything else I can do for you before I leave?”