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The Impact of Nurse Hourly Rounding on Patient FallsAn Integrated Literature ReviewKristina A. ZuritaUniversity of Central FloridaAbstractPatients fall in the hospital is a significant problem that health care organizations are facing today. Falls are one of the leading causes of adverse events in the hospital and can cause injury-related deaths to the elderly population. Patient falls are also costing hospitals millions of dollars and insurance companies are no longer reimbursing for falls and related injuries that happened in the hospital. There is clearly a need for intervention to reduce patient falls and increase patient safety. Hourly rounding is being used as a means to answer this need. Hourly rounding is an autonomous intervention in which the nurse checks on the patient every hour to make sure basic needs are being met which includes assisting the patient to the bathroom to ensure safety. Since most patient falls occur in or near the bathroom, rounding has been indicated as a method to reduce fall rates. This integrative literature review aims to show the impact that nurse hourly rounding has on adult patient falls in the acute care setting. A literature search was conducted using a number of databases that yielded 10 articles that matched the inclusion/exclusion search criteria. The results showed that hourly rounding may decrease the incidence of patient falls in the hospital setting. Additionally, the research showed that hourly rounding may also increase patient satisfaction and decrease patient call light usage. Proper training, implementation, and commitment to the process are needed to ensure quality hourly rounding is being conducted. Overall, hourly rounding has been demonstrated to be an effective intervention that promotes patient safety and satisfaction, leading to better patient outcomes. Table of ContentsAbstract…………………………………………………………………………………………..2Significance and Background…………………………………………………………………….4Research Question………………………………………………………………………………..5Methods…………………………………………………………………………………………..5Search Strategies……………………………………………………………………….....5Definitions and Terms…………………………………………………………………….6Inclusion/Exclusion Criteria………………………………………………………………6Validity and Level of Evidence……………………………………………………….......6Findings...…………………………………………………………………………………………7Study Characteristics……………………………………………………………………...7Sample Characteristics…………………………………………………………………….8Themes……………………………………………………………………………….........8Recommendations for Nursing Practice……………………………………………………........10Conclusion……………………………………………………………………………………….11References………………………………………………………………………………………..13Appendix A………………………………………………………………………………………16Appendix B………………………………………………………………………………………23The Impact of Nurse Hourly Rounding on Patient Falls: An Integrative Literature ReviewSignificance and BackgroundThe American Nurses Association-National Database of Nursing Quality Indications defines a fall as “an unplanned descent to the floor” (Tucker et al., 2012, p. 19). Patient falls can result in morbidity, mortality, and an increased fear of falling again and are one of the most common adverse events in the acute care setting (Tucker et al., 2012). The number of falls on an inpatient unit have been reported to range from 1.7 to 25 falls per 1,000 patient days (Tucker et al., 2012), with approximately 30% of these falls resulting in a serious injury (Goldsack, Bergey, Mascioli, & Cunningham, 2015). It is estimated that falls can cost hospitals $5,317 per patient fall and can cost $19,440 over one year period for an older adult patient fall (Tucker et al., 2012). By 2020, patient falls are projected to cost hospitals over $54 billion in direct and indirect annual costs (Hicks, 2015). The Centers for Medicare and Medicaid Services in 2008 recognized the financial costs of these falls and no longer reimburse hospitals for these conditions, stating that these falls could have been prevented (Hicks, 2015). The occurrence of patient falls now has an impact on hospital rankings as well as payment systems; therefore falls prevention has become of great interest to hospital administrators, nurse managers, and nursing staff (Goldsack et al., 2015). The majority of falls in the hospital setting have been reported to occur near the patient’s bed, in the room, or in the bathroom (Tucker et al., 2012). Most frequent falls are occurring during ambulation to or from using the bathroom or bedside commode (Tucker et al., 2012). Research shows that about one-third of falls could have been prevented (United States Department of Health and Human Services, 2015). Nurses can play an important role in preventing patient falls and maintaining patient safety (Cann & Gardner, 2011). There are a variety of interventions that have been studied and utilized in order to reduce patient falls: falls risk assessments, bed alarms, lab belts, direct observation, falls prevention agreements, and restraints. One of the most current interventions is the use of nurse hourly rounding to improve patient safety and prevent falls (Hicks, 2015). The use of hourly rounding has been noted to be a promising intervention in preventing patient falls (Tucker et al., 2012). It has been reported that hourly rounding can reduce patient falls as much as 50% in the acute care setting (Hicks, 2015). Hourly rounding has also been reported to increase patient satisfaction, reduce call-light use, reduce medication errors, and increase staff satisfaction (Cann & Gardner, 2011; Olrich, Kalman, & Nigolian, 2012).Research QuestionIn the adult acute care setting, how does nurse hourly rounding impact patient falls?MethodsSearch StrategiesA literature search was performed in a variety of databases, including Medline, Academic Search Premier, the Cochrane Database of Systematic Reviews, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus. The following keywords were used as search criteria: “adult”, “acute care”, “hospitalization”, “nurse”, “rounding/hourly rounding”, “falls/fall prevention” and “patient safety”.After conducting a search of peer-reviewed articles published from 2010-2015, 12 articles were found in CINAHL Plus, 10 articles in Medline, 12 articles in Academic Search Premier, and none were found in the Cochrane Database of Systematic Reviews for a total of 34 articles. 10 articles were used for this review based on the inclusion/exclusion criteria.Definitions and termsHourly rounding can be referred to as “intentionally rounding”, “rounds”, “nursing rounds”, “comfort rounds”, “routine rounds”, “care rounds”, “Model of Care”, “patient-centered hourly rounding”, and “patient rounds”. Hourly rounding is the process of intentionally checking on the patient to addresses a patient’s basic needs by the nursing staff at regular intervals (Hicks, 2015). Hourly rounding by the nurse requires the nurse to assess the patient’s need to use the bathroom, repositioning, pain management, ensure a clean surrounding and patient’s personal items within reach, and telling the patient when the nurse will return to reduce patient anxiety (Mitchell, Lavenberg, Trotta, & Umscheid, 2014). Hourly rounding occurs every hour, though some hospitals utilize a 2-hourly rounding during the evening hours to minimize sleep disturbances of patients. Inclusion/Exclusion CriteriaArticles that were included in this search addressed the adult population on an inpatient unit in a hospital, nurses who implemented patient hourly rounding on the unit and those who do not, and articles where patient safety and/or falls prevention was evaluated. Exclusion criteria consisted of articles that included pediatric patients, articles that focused primarily on leader rounding only or rounding by personnel other than the nurse, and studies that were conducted on outpatient or emergency department units. Validity of Findings and Level of EvidenceEach of the 10 articles used in this literature review were assessed for validity using the Quelly tool (2007). Three studies yielded a score of 11 points (Hicks, 2015; Krepper et al., 2012; Spanaki, 2012), six studies scored 10 points (Cann & Gardner, 2012; Goldsack et al., 2015; Kessler et al., 2015; Mitchell et al., 2014; Olrich et al., 2012; Saleh et al., 2011) and one study scored 9 points (Tucker et al., 2012). According to Quelly (2007), all of the articles used in this review were ranked a level 3, meaning they were high quality studies. The level of evidence was assessed based on the “rating system for the hierarchy of evidence for intervention/treatment questions” published by Melnyk & Fineout-Overholt (2011). Eight articles were ranked level III (Cann & Gardner, 2011; Goldsack et al., 2015; Kessler et al., 2012; Krepper et al., 2012; Saleh et al., 2011; Spanaki et al., 2012; Olrich et al., 2012; Tucker et al., 2012) and two articles were ranked level II (Hicks, 2015; Mitchell et al., 2014). Most of the studies used a pre/post implementation design.FindingsStudy CharacteristicsAll of the articles included in this literature review were peer reviewed and ranked as Level II systematic reviews or Level III cohort/quasi-experimental studies. All ten articles addressed the impact that hourly rounding has on patient falls and some of studies stated other benefits of hourly rounding as well. All of the studies compared hourly rounding to the previous standard of care in the adult population. The measurement tool used for the cohort studies (Cann & Gardner, 2012; Kessler et al., 2012; Spanaki et al., 2012; Tucker et al., 2012) and the quasi-experimental studies (Krepper et al., 2012; Olrich et al., 2012; Saleh et al., 2011) were that of a pre/post evaluation design. The two systematic reviews (Hicks, 2015; Mitchell et al., 2014) evaluated studies of a pre/post design as well. The standard method of previous care for all studies was that of not using hourly rounding as a method of preventing patient falls. Five studies implemented a 2-hourly rounding protocol during the evening hours (Hicks, 2015; Kessler et al., 2012; Mitchell et al., 2014; Olrich et al., 2012; Saleh et al., 2011). The time periods for assessing the impact of hourly rounding varied among the studies, lasting as short as 30 days to as long as 6 years. The majority of the studies lasted about one year. Limitations to these studies included non-randomization samples, weak research design, small sample sizes, and variations in the length of time that these studies were conducted. Follow-up on these studies were also lacking.Sample CharacteristicsOf the ten studies reviewed, eight of the studies were conducted in the United States, one in Australia (Cann & Gardner, 2012) and one in Saudi Arabia (Saleh et al., 2011). The majority of the studies included both male and females of the adult population on medical-surgical units. One study was conducted on an all male stroke unit (Saleh et al., 2011), one on an epilepsy monitoring unit (Spanaki et al., 2012), and another study was done on an orthopedic unit (Tucker et al., 2012). The age range of these subjects was from 18 to 90 years old. The total number of participants could not be determined due to some studies not reporting the sample size. ThemesDecreases patient falls. Nine of the studies reviewed concluded that some form of hourly rounding has a positive impact on reducing patient falls. Of these nine studies, two studies provided statistically significant results. Saleh et al. (2011) had 25 falls in a 4 week period prior to implementation and then only 4 falls during implementation of hourly rounding, (p < 0.01). Goldsack et al. (2015) compared two units that implemented hourly rounding. One unit had trained and actively engaging staff participating in hourly rounding, while the other unit had no training and non-compliant staff that did not engage regularly in hourly rounding (Experimental Unit: p=0.006, Control Unit: p=0.799). The other studies in this review showed increases in patient safety with the implementation of hourly rounding; however, they did not show statistical significance. Cann & Gardner (2012) used a “Model of Care” where hourly rounding was one component of a patient-centered quality improvement framework. There was improvement in falls post-implementation (p=0.500), but not enough to show significance. Kessler et al. (2012) and Olrich et al. (2012) had a decrease in the fall rate post implementation (p=0.07; p=0.672). Spanaki et al. (2012) and Tucker et al. (2012) also showed that hourly rounding reduces fall rates but did not report statistically significant results (p=0.694; p=0.088). The two systematic reviews showed that hourly rounding did have an effect on decreasing patient falls. Hicks (2015) found 10 studies where falls were decreased, 3 studies that showed no change and 1 study that had variations in the results. Mitchell et al. (2014) found 9 studies where the median fall reduction rate was 57% and two studies were able to report statistically significant decreases when hourly rounding was implemented. Krepper et al. (2012) showed that fall rates on the experimental and control units were similar and no conclusions could be made. Increases patient satisfaction. Five of the studies in this literature review addressed the impact that hourly rounding has on patient satisfaction. Cann & Gardner (2012), Kessler et al. (2012), Olrich et al. (2012), and Saleh et al. (2011) concluded that hourly rounding has the potential to increase patient satisfaction but none of the studies showed statistically significant data (p=0.081; not reported; p=0.383; p<0.05). One of the systematic reviews found 4 studies that showed statistically significant improvements in patient satisfaction (Mitchell et al., 2014).Decreases call light usage. Four studies in this review addressed the impact that hourly rounding has on patient call light usage. These studies revealed that hourly rounding significantly reduces the amount of times a patient presses the call light. Mitchell et al. (2014) revealed a median reduction of 54% in call light usage in 10 studies reviewed. Krepper et al. (2012), Olrich et al. (2012), and Saleh (2011) all stated statistically significant decreases in call light usage due to hourly rounding implementation (p=0.001; number not reported; p<0.001). Proper implementation and compliance is necessary for success. Four studies discussed the importance of how proper implementation is essential for hourly rounding to be successful (Goldsack et al. 2015; Kessler et al., 2012; Olrich et al., 2012; Tucker et al., 2012). Proper compliance by staff was also addressed in these four studies. Hourly rounding appears to be effective when the patient trusts that the nurse will return when he/she says they will (Olrich et al., 2012). If the nurse is not efficient in properly implementing the rounds, then the patient will not trust the nurse, therefore leading to a breakdown in the process (Tucker et al., 2012). Validation and consistency by those implementing hourly rounding is the key to success (Kessler et al., 2012). The buy-in, commitment, and accountability by the staff become a crucial component to hourly rounding (Goldsack et al., 2015). Recommendations for Nursing PracticeThe impact that patient falls have on hospital costs and overall patient well-being is significant. The evidence reviewed in these studies indicates that hourly rounding positively impacts the prevention of patient falls. Despite most of the evidence not demonstrating statistically significant results, there is a decrease in patient falls when hourly rounding is implemented. Using the Strength of Recommendation Taxonomy (SORT), the strength of recommendation for implementing hourly rounding to prevent patient falls in the acute care setting yields a recommendation A (Ebell et al., 2004). Of the ten articles reviewed, two Level II systematic reviews and seven Level III cohort/quasi-experimental studies all found that hourly rounding should be implemented as it may help nurses to keep patients safe by reducing patient falls.A number of studies reviewed showed evidence that hourly rounding does not only impact patient falls, but also plays a crucial role in reducing call light usage and increasing patient satisfaction (Mitchell et al, 2014). When patients believe in the process, they begin to build a trusting relationship with the nurse which may lead them to not use the call light as often because they know the nurse will be returning soon to care for their needs. Hourly rounding has a positive impact on reducing call light usage and increasing patient satisfaction which can lead to better patient outcomes (Mitchell et al., 2014).Hourly rounding may be more effective if proper nursing training and implementation is provided. Hourly rounding is an autonomous intervention that nurses can perform to keep their patients safe (Hicks, 2015). Without commitment and believability of the process, a positive outcome for hourly rounding is unattainable (Hicks, 2015). Hospital administration should be aware that for proper implementation of hourly rounding, special attention should be placed on training, promoting commitment to the cause, and compliance by nursing staff members (Olrich et al., 2012). ConclusionHourly rounding is an autonomous intervention that nurses can easily implement to ensure patient safety and reduce patient falls. When nurses are trained properly and believe in the process and cause of the intervention, hourly rounding has been shown effective to increase a patient’s safe stay in the hospital. This review has also shown there are secondary benefits to hourly rounding, such as an increase in patient satisfaction and a decrease in call light usage. Hospital administrators and managers should consider implementing hourly rounding, as it may also reduce unnecessary hospital costs as a result of patient falls. This review demonstrated the benefits of hourly rounding in the acute care setting. Further longitudinal research may be beneficial to ascertain the sustained effects of hourly rounding.ReferencesCann, T., & Gardner, A. (2012). Change for the better: An innovative model of care delivering positive patient and workforce outcomes.?Collegian,?19(2), 107-113. doi:10.1016/j.colegn.2011.09.002Ebell, M. H., Siwek, J., Weiss, B. D., Woolf, S. H., Susman, J., Ewigman, B., & Bowman, M. (2004). Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature.?Journal of the American Board of Family?Practice, 17?(1), 59-67Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success? ?Nursing,?45(2), 25-30. doi:10.1097/01.NURSE.0000459798.79840.95Hicks, D. (2015). Can hourly rounding reduce patient fall in acute care? An integrative literature review. MEDSURG Nursing,?24(1), 51-55.Kessler, B., Claude-Gutekunst, M., Donchez, A. M., Dries, R. F., & Snyder, M. M. (2012). The merry-go-round of patient rounding: Assure your patients get the brass ring.?MEDSURG Nursing,?21(4), 240-245.Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., & ... Myers, K. (2014). Evaluation of a standardized hourly rounding process (SHaRP).?Journal For Healthcare Quality: Promoting Excellence In Healthcare,?36(2), 62-69. doi:10.1111/j.1945-1474.2012.00222.xMelnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: A systematic review.?The Journal Of Nursing Administration,?44(9), 462-472. doi:10.1097/NNA.0000000000000101Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study.?MEDSURG Nursing,?21(1), 23-36.Quelly, S. (2007). Determining quality and validity of findings. Saleh, B. S., Nusair, H., AL Zubadi, N., Al Shloul, S., & Saleh, U. (2011). The nursing rounds system: Effect of patient's call light use, bed sores, fall and satisfaction level.?International Journal Of Nursing Practice,?17(3), 299-303. doi:10.1111/j.1440-172X.2011.01938.xSpanaki, M. V., McCloskey, C., Remedio, V., Budzyn, D., Guanio, J., Monroe, T., & ... Schultz, L. (2012). Developing a culture of safety in the epilepsy monitoring unit: A retrospective study of safety outcomes.?Epilepsy & Behavior: E&B,25(2), 185-188. doi:10.1016/j.yebeh.2012.06.028Tucker, S. J., Bieber, P. L., Attlesey-Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units.?Worldviews on Evidence-Based Nursing,?9(1), 18-29. doi:10.1111/j.1741-6787.2011.00227.xUnited States Department of Health and Human Services. (2015). Preventing falls in the hospital. Retrieved from ALiterature TableCitationPatient Group and Sample SizeStudy Design and Level of EvidenceOutcome VariablesKey Results DATAValidityThemesCann & Gardner (2012)29-bed surgical unit over a one year period:1115 patients pre-implement, 1069 post-implementN=2,184Pre/post test designCohort studyLevel IIIComfort rounds, previous care, patient safetyPer 100,000 patient hours:Pre-implementation: 13.9Post-implementation: 10.9P=0.500Not statistically significantQuelly score: 10Possible bias due to self reporting, no randomizationLarge sample sizeAdequate length of time“Model of Care” (hourly rounding) increases patient safety “Model of Care” increases patient satisfaction. Goldsack et al. (2015)Unit 1: 35 bedsUnit 2: 40 bedsFor 30 daysPre/post implementation evaluationCohort studyLevel IIIHourly rounding, previous care, nurse compliance, patient fallsUnit 1: P=0.006Unit 2: P=0.799Statistically significant for Unit 1Quelly score: 10Short pilot period, convenience sampling, no randomizationHourly rounding is effective in falls preventionStaff compliance and leadership involvement is critical to implementationHicks (2015)14 studies reviewed addressing fall rates Systematic Review of non-RCTLevel IIHourly rounding, 2-hourly rounding, previous care, patient fallsFall rates decreased in 10 studies, unchanged in 3 studies, and varied in 1 study. Quelly score: 11No randomization, varying sample sizes, varying lengths of timeHourly rounding has an effect on decreasing patient fallsKessler et al. (2012)Two critical care units and three medical-surgical units6 year studyPre/post implementation surveysCohort studyLevel IIIHourly rounding, previous care, nurse compliance, patient safetyHourly rounding fall rate: 2.19%Previous care fall rate: 5.46%P=0.07Not statistically significantQuelly score: 10Length of time (6 year study), variations in staff members completing rounds, no randomizationDecrease in patient falls due to hourly roundingHourly rounding can promote patient and staff satisfactionStaff compliance and continuation is key in implementationKrepper et al. (2012)Two 32-bed cardiovascular surgery units6-month study period, 6-month post studyA two-group quasi-experimental designLevel IIIQuality/safety of patient care, hourly rounding with extensive training, hourly rounding with very little training, previous carePrior to study:Experimental: 3.97Control: 2.6P=0.25During study: Experimental: 2.68Control: 2.42P=0.706-montsh post study:Experimental: 2.42Control: 1.43P=0.07Not statistically significantQuelly score: 11Small sample size, no randomizationAdequate length of timeNo significant differences possibly due to infrequency of fallsHourly rounding significantly reduced call light usage. Mitchell et al. (2014)11 studies reviewed, 9 studies focused on reduction of falls (pre/post test)Systematic review of non-RCTsLevel IIHourly rounding, 2-hourly rounding, previous careReduction in falls ranged from 24%-80%, with a median reduction of 57%2 studies were able to report statistically significant decrease in falls rateQuelly score: 10Variations sample size and length of time, no randomization, publication biasHourly rounding reduces patient fallsReduction in call light useImproves patient satisfactionImproves patients’ perceptions of nursing staff responsivenessOlrich et al. (2012)Two med-surg units over 1 yearN=4,418Quasi-experimentalLevel IIIRounding, previous care, patient fallsExperimental unit: 23% reduction in falls, P=0.672Control unit: falls increasedNot statistically significantQuelly score: 10Small sample size, no randomization, hospital-wide patient census decreased during studyHourly rounding decreased fall rates. Proper implementation is needed to gain positive resultsHourly rounding has the potential to increase patient satisfactionHourly rounding has the potential to decrease call light usage.Saleh et al. (2011)Male stroke unit (26 beds), 104 patients over 4 month periodN=104Quasi-experimental non-equivalent groups designLevel IIIHourly rounding, 2-hourly rounding, previous care, fall incidenceHourly rounding: 4 falls during implementation (second 4 weeks)Previous care: 25 falls prior to implementation (first 4 weeks)P<0.01Statistically significantQuelly score: 10Short study period, no randomizationReduction in fall incidence due to hourly roundingHourly rounding yielded a significant reduction in call bell usageHourly rounding reduced the occurrence of pressure ulcersHourly rounding increased patient satisfactionSpanaki et al. (2012)971 consecutive patients in a 4 year study on epilepsy monitoring unitPre/post implementation evaluationRetrospective cohort studyLevel IIIHourly rounding, previous care, “falls prevention agreement”Pre: 12 fallsPost: 7 falls15% reductionP=0.694Not statistically significantQuelly tool: 11Large sample size, adequate length of time for study, all patient data used on this specific unit, no randomizationHourly rounding decreased fall ratesHourly rounding significantly decreased the amount of missed seizuresTucker et al. (2012)Two 29-bed postoperative orthopedic units2,295 hospitalizations during study timeframe (682 baseline period, 775 intervention period, 838 post-intervention)1 year studyDescriptive and repeated measures designCohort studyLevel IIIFall rates, fall risk scores, hourly rounding fidelity, previous careImplementation vs. baseline: P=0.088Post-implementation vs. baseline: P=0.375Post-implementation vs. implementation: P=0.319Not statistically significantQuelly tool: 9Fidelity of implementation, no randomization, no control group, low baseline fall rates, large sample sizeRounding reduces fall rates Proper and consistent implementation effects outcomes of roundingPrimary Theme:Hourly rounding decreases patient falls.Secondary Themes:Hourly rounding increases patient satisfaction.Hourly rounding decreases call light usage.Proper implementation and compliance is necessary for the success of hourly rounding.Appendix BDetermining Quality and Validity of FindingsResearch question, hypothesis, or problem is clearly stated.Purpose is clearly stated and relevant to research question or problem.Review of literature and background evidence supports study purpose.Research design is appropriate for research question or purpose.Variables are appropriate for study purpose.Methodology is strong and clearly stated.Sampling method is appropriate and adequate in size and demographics to support external validity.Instrument validity and reliability are appropriate and clearly described.Data is collected and managed systematically.Analysis of results is complete and sound.Study limitations are acknowledged and described.Conclusions are supported by analysis of findings.Each criterion receives 1 point and evaluated from total points as:Level 3 (High quality): 9 – 12Level 2 (Moderate quality):5 – 8Level 1 (Low quality):0 – 4 ................
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