Evidence Based Practice Paper: Patient fall Reduction Program - Coursework Example

? Evidence Based Practice Paper Patient fall Reduction Program The introduction of an evidence-based practice such as hourly rounding can be complex in any hospital setting. Hourly rounding represents a systematic, proactive nurse-driven evidence-based intervention that seeks to anticipate and respond to the needs in hospitalized patients. Purposeful rounding pursues to enhance the patient experience via the utilization of a structured hourly rounding routine. Some of the behaviours that inform the effectiveness of hourly rounding include: care with presence (minimizes anxiety and contributes to efficiency); complete schedules tasks (contributes to efficiency); address pain, positioning, toileting, and fall prevention; address additional personal needs and questions; and, undertake environmental assessment (such as bed alarms). I. Introduction Patient falls can be regarded ubiquitous, which necessitates nurses to seek fresh ways of solving the concern. Patient falls are serious challenges encountered in hospitals; indeed, some studies estimate that inpatient falls account for close to 70% of all inpatient accidents. Based on the risk of significant injury and the associated cost, reduction of falls within hospital settings shapes a major priority for fostering hospital quality and patient safety (Krauss, 2005). Falls among hospitalized patients have risen to become a persistent problem in healthcare settings with an incidence rate of 2.3-7 falls recorded per 1000 patients within American hospitals in which about 30-48% of the falls yield in injury costing hospitals over $4, 200 per fall. Fitpatrick (2011) notes that close to 50% of hospitalized patients may be exposed to risk for falls, and close to half of the patients who fall suffer an injury. Falls among hospitalized patients can yield to negative impacts such as extended recovery times, extended hospital stays, extended time off work, and heightened costs for patients. The typical hospital stays for patients who sustain a fall when still in admission is 12.3 days longer and the sustained injuries can yield to a 61% increase in patient-care costs. The elderly are mostly susceptible to suffering severe injuries such as hip fractures and head trauma after sustaining a fall. There are several means that diverse institutions have employed to assess inpatients for exposure to fall risks. As a result, some of the interventions that a majority of hospitals employ include side rails, illumination, call lights, bed alarms, and clutter free environment. The implementation of hourly rounding accompanied by the interventions outlined above can avail a holistic approach to safeguarding against inpatient falls (Perry, Potter, & Ostendorf, 2013). Hourly rounding helps patients to feel cared for and reassured and draws from evidence-based methodology and scripted tools such as documentation log, hourly reporting dashboard, competency checklist, and scheduled meetings between the shift leaders and nursing staff to review. The call light can be considered as a lifeline for hospitalized patients; nevertheless, it can also enforce considerable demands on nursing time. Implementation of hourly rounding delivers positive outcomes in minimizing falls and patient call usage, as well as enhanced patient satisfaction (Melnyk & Fineout-Overholt, 2011). Majority of studies has revealed a reduction in patient falls that are clinically and statistically significant, making hourly rounding one way of fostering clinical excellence. Excessive call light use frequently disrupts nurse workflow that has negative implications for quality care and nurse and patient satisfaction. The implementation of rounding fulfils mundane requests made through call lights, but also demonstrates nurse’s availability to the patient and his/her readiness to anticipate the patient’s needs (Christine, Amy, & Lyn, 2006). Hourly rounding with certain nurse actions is proactive, which allows nurses to manage both patient care and time efficiently. Instead of adding up to the nurse’s workload, hourly rounding takes reduced time compared to answering call lights and attending to repeated requests (Meade, Bursell, & Ketelsen, 2006). The rounding program will aid to minimize patient falls, call light use, and significantly contribute to enhancements in patient satisfaction within nursing. Regular rounding avails an attractive alternative to distraction and disruption generated by unpredictable call light use. Hourly rounding enables nursing staff to respond to non-urgent requests proactively while at the same time responding to patient needs prior to them gaining urgency (Halm, 2009). Regular rounding does not disrupt staff workflow, yielding to the potential for higher quality of care and nurse satisfaction. II. Review of Literature In clinical practice, there has been rising concern over the number of falls recorded among hospitalized patients. Hospital inpatient falls constitute the biggest single category of reported accidental falls. Patients may trip, slip, or fall owing to the unavailability of nurses to deliver aid when needed as is the case of delayed response to call lights. In patient falls can yield to lengthened hospital stays, absence of patient independence and attendant resource expenses. The alarming increase in the incidence of falls has signalled urgency to implement ways or measures to respond to this patient care issue. Hourly rounding can be regarded as one of the intervention that can be implemented to minimize the number of registered patient falls. Studies have proven that hourly rounding not only aid to minimize the incidence of patient falls, but also aid in enhancing patient satisfaction and safety, as well as minimizing the number of call light use. Patient frequently utilizes call lights to summon nurses to respond to both urgent and non urgent problems. Majority of non-urgent calls do not require a nurse, whereby patients utilize call lights for various reasons such as request information and/or assistance with pain management, carry out self-care tasks (such as ambulating, toileting, and eating), and comfort (such as repositioning or securing out-of-reach items). Furthermore, excessive call lights use may have a negative impact on quality and nurse/patient satisfaction given that it disrupts nurse workflow. These delays can generate safety risks such as heightening the risk of patient falling and minimizing patient satisfaction. Consequently, the excessive use can yield to nurse burnout and job dissatisfaction. A literature search from various database such as EBSCO and CINAHL reveal a number of studies exploring hourly rounding. A study conducted by Ford (2010) explored the efficacy of proactive hourly rounding approach and the impacts it possessed on patients and risk of inpatient calls. The study was based at Baltimore Washington Medical Centre, whereby the staff members checked on their patients every hour while carrying out tasks such as dispensing medications and dressing changes. Hourly rounding took place in the hours between 6:00 A.M and 10:00 P.M. and from 10:00 P.M. and 6:00 A.M in which nurses undertake rounding on patients in every two hours (see table A). In the event that the patients were asleep at the period, the nursing staff only undertook environmental checks. Prior to leaving the room, nursing staff should address the 4 P’s detailing pain, positioning, placement, and personal needs. The study confirmed the efficacy of hourly rounding in minimizing call light (52% decline). This allowed the fostering for quieter units and nursing staff given the opportunity to pay more attention to providing patient care and charting. Similarly, hourly rounding yielded to an increase in patient satisfaction. The practice of hourly rounding may differ from one institution to the other; however, there are certain aspects of the process that are widespread across all settings (Rondinelli et al., 2012). In the hourly visits, the staff members appraises and addresses the patient’s comfort needs, personal needs, pain, and safety for the room environment. The staff member should ask the patient about any unattended needs, and if there is none, the patient is informed that the staff member will return in an hour’s time. Research has proved that hourly nurse rounds aid to reduce falls, call light use, and contribute to a rise in patient satisfaction (Tea, Ellison, & Feghali, 2008). The evidence from the implementation of hourly rounding program comprises of pre- and post- implementation comparisons of a number of metrics, including fall rates, call light use, and patient satisfaction with nursing. Research indicates that the implementation of programs such as hourly rounds has yielded to a reduction in falls and pressure ulcers by close to 50%. Similarly, this has yielded to less call light use by roughly one-third. Regular nursing rounds should be conducted hourly during the day, as well as in the evening and every 2 hours during the overnight shift, which will enable nurses to address proactively to the patient needs that would otherwise necessitate the use of the call light. Each hour the nursing staff may be expected to round on all the patients within the unit, whereby nurse (RN) can round in even hours while patient associate rounds in even hours. The round on the hour can be conducted 6am-10pm in a period of every 2 hours. The hourly rounding goals centres on enhancing patient safety and satisfaction, awarding patients an amplified sense of security, decreasing the number the number of call lights for non-emergency concerns, and minimizing staff stress levels. Some of the limitations to explore research include the fact that conclusions about the influence on falls cannot be sufficiently determined owing to small sample (McCartney, 2009). Nevertheless, the research has demonstrated that rounding can be an effective intervention to minimizing call light use and enhance patient satisfaction. III. Protocol for Hourly Rounding Evidence on the efficacy of hourly rounds can be derived from a multisite study undertaken by the Alliance for Health Care Research (which is a subsidiary of the Studer Group). The Studer Group web site carries information on protocols for hourly rounds. The study tested the impacts of a protocol for 1-hour and 1-hour rounds on medical and surgical units. The study revealed that hourly rounds reduced patients’ utilization of call lights, enhanced patient satisfaction scores, and minimized patient falls (See Studer Hourly Rounding Supplement). The Studer Group (2006) can be regarded as a leader in outcome-based healthcare consulting and has generated hourly rounding implementation kit so as to aid healthcare organizations in implementing hourly rounding protocols, and enhance the quality and safety within patient care. The tool kit can be regarded as pertinent in anticipating and satisfying patient needs and fostering patient care (Studer Group, 2006). Implementation of a new practice The implementation of the program necessitates (a) first, highlight the potential impact of the program on quality of patient care; (b) demonstrate nurse leader commitment to the program; (c) train staff to conduct rounds purposefully, rather than casually “popping in” to enquire patients if they need anything. Institute calls light response standards It is essential to balance the time constraints faced by nursing staff with patient expectations to guarantee prompt service. Managing patient expectations by notifying patients of how long it mainly takes for call lights may reduce their impatience and frustration. Every hospital should institute standards for call bell response time and adequately communicate the standards to patients and staff (Bursell, Ketelsen, & Meade, 2006). Establish who will answer call lights Based on a staff perspective, the question regarding how timely call lights should be answered appears to be less controversial relative to the question of staff who should answer the call lights. Customs differ broadly in practice, whereby, in some instances, they are answered by nurses, patient service assistants, certified nursing assistants, or a combination of outlined personnel. In the event that the patient call is on, any qualified staff member should answer to assist the patient (Dykes et al., 2009). The team approach to approaching patient care translates to the notion that everyone is responsible for delivering care of all patients on the unit. This hinges on quality-of-care and quality-of-work-environment principle in which tasks can be shared. Track calls light data Majority of call systems incorporates elements such as tracking software that monitors the frequency of lights, as well as call light response times. A review of the data can help to highlight patterns of call light use, as well as informing fresh approaches to staffing or staff utilization. Implementation Plan Given that the implementation of hourly rounding represents a quality enhancement initiative, approval for the program is non-essential provided that patient information remains strictly confidential. A seamless implementation of the program necessitates that one obtains a staff buy-in when instituting change, whereby nurse managers foster change by sufficiently preparing to nurse staff before the implementation date. Previous studies have indicated that one-hour in-service training sessions can be applied to train staff within the performance of purposeful, hourly patient rounding (Jennifer, 2009). Nurses and nursing assistants at the hospital should conduct hourly patient rounds designed to enhance safety, and address needs that otherwise would prompt usage of call lights. During the rounds, the nurse should identify and address every patient’s pain level, position, and comfort; availing toileting assistance; and, guaranteeing that all needed items by the patients are within reach. The nurse is expected document key findings on a rounding log and informs the patient that he/she will be visited again in the next hour. Sustaining the hourly rounding program will necessitate thorough integration of the program into the existing workflow, careful monitoring of the program, and patience as the system can take about 12-18 months to become “hard-wired” into the nursing workflow (Olrich, Kalman, & Nigolian, 2012; Conner, 2008). The protocol may require that a registered nurse rounds on the even hours, and a licensed practical nurse or unlicensed assistant rounds on the odd hours. The study protocol instructions detailed actions such as pain rating, availing comfort, assessing the environment to ensure that the call light and other needs are available, asking the patient if there are any other needs and informing the patient on the time that the nurse will be back. The upfront costs of implementation of the program include time spent in rolling out the program and nurse time necessitated for attendance to in-service training sessions (nevertheless, no overtime costs are expected to be incurred in rolling out the program). Overall, the program necessitates no ongoing operational expenditures. Furthermore, the program does not require new staff as the existing will incorporate the program into their daily routines. Some nurses with no previous opportunity to implement rounds are likely to voice concerns and doubt, asserting that nurses “already round,” or that the proposed hourly rounds represent “one extra thing to do” while “there is not sufficient time to do it.” Nevertheless, those nurses who have the opportunity to implement hourly rounds may be quick to respond positively to the program by stating that the implementation is not as difficult as it sounds, and the program my minimize call bell use and amplify patient satisfaction scores (Krauss et al., 2005). Some of the barriers that may impede on a smooth roll-out of the program include difficulty of gaining “buy-in” from staff, staff completion of accountability tool exploring dissatisfaction or non-compliance with the rounding logs, consistency in the staff employing protocol, and staffing, admits, acuity, and discharges (Baker et al., 2012). Prior to the introduction of hourly rounding protocols, the culture of the organization needs to be appraised in readiness of change. Some of the facilities may be opposed to changing, especially owing to an organization that resists change. Some of the barriers that may manifest in the implementation include resistance to change at the unit level; high staff turn-over rates, patient acuity, and staff shortages; and, limited financial and human resources. The strategies for integrating clinical inquiry include an appreciation program for promoting the integration of evidence-based practices into the workflow pattern; offering complimentary workshops to foster the spirit of inquiry; and, generating fresh positions for resource nurses. The hourly rounding program should be documented within the electronic medical record, whereby the program represents a tool for communication and data collection directed at process improvement. In conclusion, hourly rounding shapes one of the ways that play a big role in cutting patient fall rates since, in most instances, the nurse can be able to intervene before a fall occurs. Hourly nursing rounds to determine and satisfy patients’ represent one of the evidence-based strategies that minimize dependence on call lights. Several multisite studies employing medical, surgical, and medical-surgical units have demonstrated that 1-hour nurse rounding significantly minimized call light use, decreased the rate of patient falls by close to half, and significantly enhanced patient satisfaction (Tseng & Yin, 2009). Once the nursing staff comprehends how the program functions within the system, they can appreciate the ways in which the program aids to keep patients safe. The hourly rounds are likely to yield to enhanced care since they build trust between the caregivers and patients. References Baker, K. et al. (2012). Hourly rounding: Challenges with implementation of an evidence-based process. Journal of Nursing Care Quality, 27 (1): 13-19. Christine, M. M., Amy, B., & Lyn, K. (2006). Effects of nursing rounds: On patients’ call light use, satisfaction, and safety. American Journal of Nusing, 106 (9): 58-70. Conner, C. (2008). Hardwiring inpatient hourly rounding. Retrieved from: http://www.studergroupmedia.com/WRIHC/presentations/hardwiring_inpatient_hourly_ Dykes, P. C. et al. (2009). Why do patients in acute care hospitals fall? Can falls be prevented? J Nurs Adm., 39 (6): 299-304. Fitzpatrick, M. A. (2011). Special Supplement to American Nurse Today-Best Practice for Falls Reduction: A Practical Guide. Retrieved from: www.americannursetoday.com/article.aspx?id=7634&fid=7364 Ford, B. M. (2010). Hourly rounding: Astrategy to improve patient satisfaction scores. Med surg Nursing, 19 (3): 188-191. Ford, B. M., (2010). Hourly Rounding: A Strategy to Improve Patient Satisfaction Scores. Medsurg Nursing, 19 (3): 188-191. Retrieved from: http://web.ebscohost.com.ezproxy.usd.edu/ehost/pdfviewer/pdfviewer?sid=a2b88160- ee37-4dd5-9956-8ab431c28080%40sessionmgr104&vid=6&hid=110 Halm, M. A. (2009). Hourly rounds: What does the evidence indicate? American Journal of Critical Care, 18 (1): 581-584. Jennifer, W. (2009). Effects of rounding on patient satisafction and patient safety on a medical-surgical unit. Clinical Nurse Specialist, 23 (4): 200-206. Krauss, M. J., et al. (2005). A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med., 20 (2): 116-122. McCartney, P. R. (2009). The new networking: An evidence-based practice. The American Journal of Maternal/Child Nursing, 34 (5): 327. 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. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Olrich, T., Kalman, M., Nigolian, C. (2012). Hourly Rounding: A Replication Study. to reduce fall rates that can be preventable with more consistent patient contact and care. for the nurses, but will also helMedsurg Nursing, 21 (1): 23-27. Retrieved from: http://web.ebscohost.com.ezproxy.usd.edu/ehost/pdfviewer/pdfviewer?sid=fde31d0e- 5534-481c-82d0-552e76a2c2f1%40sessionmgr112&vid=4&hid=110 Perry, A. G., Potter, P. A., & Ostendorf, W. (2013). Clinical nursing skills & techniques. Riverport, MO: Elsevier. Rondinelli, J., et al. (2012). Hourly rounding implementation: A multisite dscription of structures, processes, and outcomes. J Nurs Adm., 42 (6): 326-32. Studer Group. (2006). Improve clinical outcomes with hourly rounding. Retrieved from: http://www.studergroup.com/newsletter/Vol1_Issue7/fall2006_sec1.htm 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. Tseng, H. & Yin, C. (2009). Relationship between call light use and repsonse time and inpatient falls in acute care settings. Journal of Clinical Nursing, 18 (1): 3333-3341. Tseng, H., Titler, M. G., Ronis, D. L. & Yin, C. (2012). The contribution of staff call light response time to fall and injurious fall rates: An exploratory study in four US hospitals using archived hosital data. BMC Health Services Research, 12 (2): 84. Table A Table A: Nurse Specific Actions During Hourly Rounding The following items will be checked for each patient 1. Nursing staff enter room, greet patient and say, “Hi, Mrs./Mr Jones, I am here to do my rounds to check on your comfort. 2. Pain assessment using a pain assessment scale (if staff other than RNs are doing the rounding and the patient is in pain, RNs will be contacted immediately by the person rounding, so the patient does not have to use the call light for pain medication) 3. An hour prior to a pain medication is due the patient will be asked is s/he is starting to feel pain. If the answer is “yes” then the next hour the RN will schedule giving the pain medication 4. Toileting assistance will be offered 5. A patient positioning and comfort assessment will occur, including if the patient is covered and if he/she looks comfortable 6. Environmental check - A check for the call light being within reach -A check for the telephone being within reach - A check for the TV control and bed light switch being within reach - A check for the bedside table being next to bed - A check for the tissue box and water being within reach 7. Prior to leaving the room, each staff member must ask: “Is there anything I can do for you before I leave, I have time to do it?” 8. Staff will also tell the patient when they will be back in the room (i.e., in one hour) to round on them again. Read More