Background: Falls are a persistent problem in all healthcare settings, with rates in acute care hospitals ranging from 1.3 to 8.9 falls per 1,000 inpatient days, about 30% resulting in serious injury. Methods: A 30-day prospective pilot study was conducted on two units with pre- and postimplementation evaluation to determine the impact of patient-centered proactive hourly rounding on patient falls as part of a Lean Six Sigma process improvement project. Nurse leaders and a staff champion from Unit 1 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 outset, the 1-year baseline mean fall rate was 3.9 falls/1,000 patient days. The pilot period fall rate of 1.3 falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). On Unit 2, where there was no run-in period, the 1-year baseline mean fall rate was 2.6 falls/1,000 patient days, which fell, but not significantly, to 2.5 falls/1,000 patient days during the pilot period (P = 0.799). Discussion: Engaging an interdisciplinary team, including leadership and unit champions, to complete a Lean Six Sigma process improvement project and implement a patient-centered proactive hourly rounding program was associated with a significant reduction in the fall rate in Unit 1. Implementation of the same program in Unit 2 without engaging leadership or front-line staff in program design did not impact its fall rate. Conclusions: The active involvement of leadership and front-line staff in program design and as unit champions during the project run-in period was critical to significantly reducing inpatient fall rates and call bell use in an adult medical unit.
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 1.3 to 8.9 falls per 1,000 inpatient days in acute 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.3
The difficulty of preventing falls is exacerbated by shortened acute care lengths of stay, requiring that fall prevention interventions make an impact within short periods. To address these challenges, experts are recommending the use of multifactorial fall prevention programs.4,5 Successful programs typically include combinations of strong leadership and support, a culture of safety, front-line staff who are engaged in program design, a multidisciplinary team that guides the prevention program, staff education and training, and changes in pessimistic attitudes toward fall prevention.5,6
While preliminary evidence for multifactorial fall prevention programs is promising, and consistent themes are associated with successful implementation, the impact of individual components remains unclear. It has not yet been established whether effectiveness is primarily a function of successful implementation as opposed to characteristics of the components selected.
This article describes the development, implementation, and evaluation of patient-centered hourly rounding, a program built around a conceptual framework we proposed in “Patient Falls: Searching for the Elusive ‘Silver Bullet’” (Nursing, July 2014).7 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.8
Study overview and setting. We conducted a 30-day prospective pilot study with pre- and postimplementation evaluation to determine the impact of patient-centered proactive hourly rounding on patient falls. (See Glossary of research terms.) The intervention was implemented from September 23 to October 20, 2013, in two medical units at Christiana Hospital, a 907-bed hospital 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 adult medical stroke unit (Unit 1) and a 40-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 improvement expert, a researcher, and nurse leaders. It was designed around three 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 6-month Lean Six Sigma process improvement project based around the DMAIC principles: Define, Measure, Analyze, Improve, and Control. Lean Six Sigma methodology consists of tools and techniques used to understand and standardize process variation and to identify and eliminate waste. The goal of a Lean Six Sigma project is to achieve a breakthrough in performance, resulting in a sustained improved outcomes.
Nurse leaders and a staff champion from Unit 1 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.
Patient-centered proactive hourly rounding. This was conducted every hour between 0600 and 2200 hours and every 2 hours between 2200 and 0600 hours. Rounding was performed by nurses and patient care technicians (PCTs) (Unit 1) or nurses only (Unit 2) based on differences in RN staffing between the two units. (See Defining a patient-centered proactive hourly round.)
Program implementation. The two objectives that we defined as critical for communicating to staff during training were that:
- unit staff understand what patient-centered hourly rounding is, recognize its value, and receive the training and time required to complete 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 pilot period.
Mandatory education and training for all staff on both units began 2 weeks before implementation of the pilot. Staff development specialists and nurse managers did the training at regularly scheduled staff meetings and value improvement team meetings in the 2 weeks preceding implementation and supplemented it 2 weeks into the implementation period to refocus staff on the intervention's critical components. The unit-based value improvement team is charged with driving improvements in quality, safety, and patient-centered care. The slides developed as part of this process and used during training sessions are available from the corresponding author on request.
Evaluation of rounding and time periods. For Unit 1, the baseline period was defined as January to December, 2012. The project period was defined as January to September, 2013, during which time the Lean Six Sigma Define, Measure, Analyze, and Improve phases of the DMAIC process were completed. This involved the multidisciplinary team, nurse leaders, and clinical nurses and champions from Unit 1. For Unit 2, the baseline period was defined as January to September, 2013.
The pilot period for both units was the 30 days from September 23 to October 20, 2013. Rounding was performed by nurses and PCTs (Unit 1) or nurses only (Unit 2).
Study outcomes. The fall rate both before and during the pilot was measured as number of falls per 1,000 patient days. Compliance with the patient-centered proactive hourly rounding process was monitored using three different tools. First, the nurse manager on each unit randomly selected a patient flow sheet each day during the pilot and reviewed the recorded times of the rounding for the prior 24 hours. The average and median time between rounds was calculated for each unit. Second, the nurse manager on each unit randomly selected 60 unique patient-centered proactive rounds on his or her unit to observe during the pilot. Last, two researchers selected one staff member from each shift on each unit during the pilot to survey about the last round he or she completed. Researchers used convenience sampling, surveying the first staff member they encountered on the unit who was not engaged with a patient.
Staff perceptions about the pilot, particularly 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 1 week after the pilot period ended. Staff were sent an eight-item survey by e-mail to complete using an anonymous web-based interface (SurveyMonkey), and were given 10 days to reply, with one reminder e-mail.
Statistical analysis. The Mann-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 pilot and baseline period fall rates, Unit 1's project and pilot period fall rates, and Unit 2's pilot and project period fall rates. The one-sample Wilcoxon-signed rank test was used to allow comparison 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 indicate decreasing compliance with hourly rounding as prescribed. Robust regression analysis also was used to examine whether round completion percentages and staff report 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.).
Fall rate data. In Unit 1, the 1-year baseline mean fall rate was 3.9 falls/1,000 patient days, significantly above the National Database of Nursing Quality Indicators benchmark. A marginally significant drop occurred during the project period to 2.5 falls/1,000 patient days (P = 0.059). The pilot period fall rate of 1.3 falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). The project and pilot period fall rates did not differ significantly (P = 0.202). In Unit 2, the 1-year baseline mean fall rate was 2.6 falls/1,000 patient days, which fell, but not significantly, to 2.5 falls/1,000 patient days during the pilot period (P = 0.799).
Process compliance data. Fifty-six patient flow 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 pilot period for each unit. The overall time between rounds was very close to 1 hour for the period from 0600 to 2200 hours, as prescribed, but also close to 1 hour between 2200 and 0600 hours when rounds were required only every 2 hours. During the pilot, the mean time between rounds did not increase significantly on either Unit 1 (P = 0.133) or Unit 2 (P = 0.712).
Besides the documentation review, 108 rounds were observed, with 88% of the prescribed steps being completed on average. 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-often performed tasks in the patient-centered round, but communication of when the next round would occur took place 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). (See Observed compliance with patient-centered hourly rounding.) The extent to which each round was completed did not fall significantly over time for either Unit 1 (P = 0.704) or Unit 2 (P = 0.713).
Researchers surveyed 108 staff members who reported completing an average of 87% of the requirements of each round. Staff reported asking patients if they could do anything else for them most frequently (occurred in 96% of completed rounds), but reported addressing positioning with patients in only 73% of the rounds in which this would have been appropriate. (See Self-reported compliance with patient-centered hourly rounding.) The extent to which staff reported that each round was completed did not fall significantly over time for either Unit 1 (P = 0.827) or Unit 2 (P = 0.194).
Staff survey data. Ninety-four percent of staff on Unit 1 (17/18) reported that they believed patient-centered hourly rounding had either a positive or strong positive impact on patient care overall, and 89% (16/18) believed that patient-centered hourly rounding is an effective fall prevention strategy. Thirty-nine percent of staff on Unit 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 bell use by patients. Eighty-nine percent of staff surveyed on Unit 1 (16/18) would recommend that other units adopt patient-centered hourly rounding. (See Staff survey data.)
By contrast, only 25% of staff on Unit 2 (5/20) reported that they believed patient-centered hourly rounding had a positive impact on patient care overall and only 50% (10/20) believed that patient-centered hourly rounding is an effective fall prevention strategy. No staff on Unit 2 perceived their overall workload to have 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 2 (5/20) would recommend that other units adopt patient-centered hourly rounding.
We found that engaging an interdisciplinary team, including leadership and unit champions, to complete a Lean Six Sigma process 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 program in the absence of engaging leadership or front-line staff in program design did not impact the fall rate.
This discrepancy cannot be accounted for as a function of successful implementation because both units showed excellent compliance with the process. Since this compliance did not decline during the pilot, our data suggest that patient-centered hourly rounding is likely a sustainable strategy. However, the success of the program 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 program and its impact on their own workload and patients was highly positive. On Unit 2, only a minority of staff were positive about the impact of the program.
Our findings strongly endorse the inclusion of leadership support and engagement of front-line staff in successful fall prevention program design. As our data show, these features are not impacting process implementation. Rather, we believe, based on anecdotal evidence 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 fall prevention.9,10 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
On Unit 2, where hourly rounding did not impact 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 1, where hourly rounding combined with a project run-in period did impact the fall rate, two-way learning occurred through staff engagement in program development. This learning is typically much deeper and acknowledges that staff 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 period. 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 fall prevention and developing staff buy-in to the goals. While the significant reduction in fall rates was not observed until the cumulative stages of project development and program implementation had occurred, these data indicate that engaging an interdisciplinary team and including leadership and unit champions in fall prevention program development may be critical components of any fall prevention effort.
The primary limitation of our study was the short pilot period of just 30 days. The consistency of the process data suggests that patient-centered hourly rounding is a sustainable intervention, but further investigation of the impact over a longer period is needed. Much of the literature about falls has only limited data, but based on the success of the pilot, we have the support of our institution to implement patient-centered hourly rounding for a longer period. During this longer study, the issue of staff noncompliance, although low, must be addressed. The engagement of unit staff and leadership in program design on Unit 1 may actually have resulted in the effect 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 fall rates.13 Hourly rounding also has been shown to reduce call bell usage; call-bell usage is associated with patient falls.8,14 However, evidence regarding hourly rounding as 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 program that is suitable for the patient population may be effective if implemented through a process characterized by leadership support that engages front-line staff in program design.
Despite limitations, our findings provide compelling evidence that the implementation of a patient-centered hourly rounding program following specific design with leadership support and engagement of front-line staff is an effective fall prevention strategy. Staff buy-in and accountability should be fostered through the design and implementation processes and two-way learning should be used in staff training where possible.
We found that a patient-centered proactive hourly rounding program, where leadership and front-line staff were actively involved in program design and unit champions were designated during the project run-in period, significantly reduced inpatient fall rates in an adult medical unit and reduced call bell use. In the absence of leadership engagement, program development with front-line staff, and unit champions, patient-centered hourly rounding does not appear to be an effective fall prevention strategy.
Glossary of research terms
- Convenience sampling. Obtaining a sample by using the participants who are easiest to access; no attempt 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 It is used for comparing nonparametric, continuous data between two groups.
- N. Sample size.16
- P. Statistic indicating significance. P < 0.05 means the results are significant; the smaller the number, the less likely that the results are due to chance.16
- Robust regression analysis. This determines the relationship between an independent variable and a dependent variable when the data being examined contain outliers, or extreme values, that should not be excluded.
- Wilcoxon-signed rank test. A statistical test to compare the average values of the same measurements made under two different conditions. Used when the data are not normally distributed, this test compares median values.
Defining a patient-centered proactive hourly round
- Hello, I'm your nurse_______________. I'm here to do rounds.
- Assess patient's pain levels using appropriate assessment scale. If PCT is rounding, ask the patient if he or she is in pain, and contact nurse immediately. Provide pain medication as appropriate.
- Offer toileting assistance (urinal, bedside commode, bathroom).
- Assess the patient's position, and reposition if necessary.
- Put the call bell within reach, and have patient perform teach-back.
- Put telephone, TV, bedside table, tissues, and personal items within patient's reach.
- Place trash can next to the bed, straighten up room, and put any trash in the can.
- What else I can do for you before I leave? I have time.
- I, or another member of the healthcare team, will be back in the room at <state time>. Until then, please do not get up without notifying us. Please use your call bell.
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