Let There Be Less Light

Author: John Leighty
Publication Name: Nursing Spectrum
Published Date: 12/04/2006

COVERSTORY

Patient safety improves, while nurses spend less time answering call lights, thanks to a research study’s

In a growing number of small and large hospitals across the country, including ones in Florida and North Carolina, nurses involved in a results-driven rounding protocol are finding their shifts less stressful, their time more productive, and patient safety and satisfaction scores at all-time highs.

The new interest in rounding comes after research results from 27 nursing units in 14 hospitals showed that a consistent strategy of checking on patient needs effectively reduces monthly call light use by 38%, patient falls by 50%, and cases of skin breakdown 14%, while satisfaction scores move upward.

“The response has been amazing,” says Christine Meade, executive director/chief researcher of the Studer Group’s Alliance for Health Care Research, Gulf Breeze. “Nurses know rounding works, especially those who have been practicing for 20 years. But nobody’s ever done a study to prove it.”  

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, including several in the southeastern states. An interactive training video toolkit is also available for $1,495 that shows study data and demonstrates how recommended behaviors and actions by nurses on hourly rounds can improve efficiency and satisfaction rates and give nurses more free time.

“It’s essentially like adding the time of one full-time RN to complement the staff for a week because of the hours not used answering call lights,” says Meade. “And the patients love it.”

Of all the indicators of success, “satisfaction jumps through the roof,” she says. The savings potential from rounding is also attracting interest since falls cost hospitals an average $11,000 per patient affected, while the incidence of decubitus ulcers costs $14,000 each. And those dollar figures don’t factor in legal stemming from lawsuits.

Dramatic data

Before initiating hourly rounding for the Studer Group study, about 70 nurses and nursing assistants monitored every patient call light for two weeks in a 36-bed med/surg unit at Carolinas Medical Center in Charlotte, N.C.

“It was an overwhelming number,” recalls Nurse Manager Emily Cornelius, RN. “In some 24-hour periods, there were as many as 800 or 900 calls.”

Once hourly rounding began, nurses experienced a noticeable drop-off in call lights during the second week and a dramatic plunge the third week. Patients had learned to stop ringing for minor requests since they knew a nurse was giving them special attention every hour. By the end of the four-week study period, there were very few call lights going off. When they did go off, it usually involved something urgent, says Cornelius.

“Nurses found this freed up their time to do other things with patients,” she says. This could involve educating patients on their conditions, talking with family members, and doing more detailed discharge planning focused on patient needs.

Meade met with nurses in the unit initiating rounding and with the staff of a 33-bed medical unit that served as the study control group. Besides coaching and giving a presentation on rounding techniques, Meade used preliminary data to keep nurses abreast of how they were doing.

Consistency’s the challenge     

Jeff Stout, RN, MSN, CNAA, BC, assistant vice president of patient care services, says before the study ended, the control group couldn’t wait to get on board, followed by inpatient nursing units throughout the 810-bed hospital.

The only departments that aren’t formally doing hourly rounding today are ICU units and the ED, says Stout, where nurses deal with more intense and unpredictable patient care issues. “The challenge,” he says, “is to take variability out of the process and maintain a consistency of hourly rounding over 800-plus beds.”

The protocol has resulted in a steady rise in patient satisfaction scores. “If you look at call lights alone, there’s a significant difference when we’re proactive,” says Stout. “When call lights decrease, we’re meeting our patients needs.”

While the hospital doesn’t gather data on rounding’s effect on patient falls or skin breakdown, Stout says it’s only logical that patient safety would be enhanced by hourly nursing care that emphasizes making patients comfortable.

Joann Riley, RN, a clinical nurse specialist and researcher, says participating in a national study created an intensity for hospital nurses to get engaged in the rounding protocol. “The study was very credible and the scientific rigor appropriate,” says Riley, adding that the dramatic outcomes announced in August had a positive impact for the staff in terms of their actions around patients and how they responded to patient needs.

Timely approach to care

Lyn Ketelsen, RN, MBA, is a Studer Group coach and coauthor of the hourly rounding study. She originated the research project after visiting numerous hospitals that were struggling to raise patient satisfaction scores.

“One issue was responding to call lights and meeting patient needs in a timely manner,” says Ketelsen. “I did some observations, and it became clear that practicing in a reactive manner wasn’t serving patients well. [Hospitals] needed to transition to a more proactive nursing approach.”

The researchers set up specific “scripts” and tactics for hourly rounding that assured consistency and continuity of patient care, which in turn would lead to the best outcomes and satisfaction measures. Nurses were asked to follow 12 directives, the final one telling patients a nurse would return within an hour — or sometimes in two hours during the late-night period.

“One of the biggest motivations for me was related to the efficiencies this was going to create for the nursing staff,” says Ketelsen. “Rounding gives 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 on average 5.2 miles per shift before implementing hourly rounding — but 4.3 miles afterward. “They were shaving 20% off the steps they were taking to meet patient needs — that’s pure time given back to the staff.”

Ingrained routine

At Largo Medical Center, nurses in the 21-bed telemetry unit were asked to round every two hours during the data-gathering phase of the research study. Shortly afterward, the strategy was implemented for some 350 nurses at inpatient care units throughout the 256-bed hospital.

It was a slow process getting nurses accustomed to using rounding in this fashion, but the practice is now part of the hospital’s culture.

“We discuss rounding in new-nurse orientation so nurses are familiar with it before they come to the floor,” says Theresa Alfano, RN (left), director of med/surg/telemetry. “This makes it a lot easier for rounding to be ingrained in the daily routine.”

Alfano says two-hour instead of hourly rounding was adopted to temper resistance in selling the program to busy staff nurses. And while nurses were trained to follow a script on how to greet patients, assess their needs, and assure them they’d be back for another round in two hours, there was some leeway for RNs to improvise.

Nurses must ask patients if there’s anything they need, attend to the Three P’s (see sidebar), and assure patients that their requests aren’t a problem. Another important task is making sure items a patient may need are available and within easy reach, such as a fresh pitcher of water, tissues, TV remote control, and the phone.

“We have nurses tell patients, ‘I have the time,’” says Alfano. “It’s common for pa-tients to have the perception nurses are very busy. We need to make them feel comfortable enough to tell us what their needs are.”

Quality questions    

When the results of the national research study were announced in August, Alfano was excited but not surprised at the positive outcomes in patient satisfaction, reduced falls, and fewer cases of skin breakdowns — data that closely mirrors what’s being experienced at Largo. She says call light data isn’t that significant at Largo, though, because nurses carry patient call devices with them and don’t have a central station where bells go off.

Alfano says nurses are in patient rooms far more often than during the two-hour rounding, but formalizing the protocol puts patients more at ease in the acute-care setting because of the extra attention.

“Patient’s aren’t always able to verbalize everything they need, so nurses ask, ‘Are you in pain?’ ‘Do you need to go to the bathroom?’ or even, ‘Is your water cold enough?’” Alfano adds that by asking questions, “we take care of needs that won’t impact us a little later, and it’s definitely a bonus for patients who don’t know how to ask for things.”

One measure of success, she says, is that patient satisfaction measures have risen throughout the hospital. If satisfaction scores do dip in a particular unit, nurse managers become more diligent in documenting the rounding procedure and how well nurses respond to patient requests.

The hospital has also made the rounding strategy a formal part of its quality control program for reducing patient falls.

“Rounding makes sense,” says Alfano. “I think anything that we can do to be with the patient more often and that offers a proactive way to take care of their needs can only be a plus.”

Sudden impact

Ketelsen says she experimented with hourly rounding while coaching at hospitals before she helped launch the formal study that has resulted in the use of an inpatient protocol by facilities across the country.

While nurses are professional and have the best interests of their patients in mind, changing work habits is difficult. That’s why the researchers developed a formal set of behaviors for nurses to follow, says Ketelsen. “The beauty of this protocol is the immediate results from fewer call lights. It doesn’t take long for nurses to feel the impact.”

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 patients — going in and finding out their needs and accomplishing tasks. It’s more comprehensive and more effective.”

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, says Ketelsen. Also, some units opted for rounding every two hours, especially during late-night hours when patients may not want to be disturbed. Still, hourly rounding shows better results, says Ketelsen.

The next test for patient rounding is in the ED setting, and a research study is already under way at 30 hospitals to determine the best, most proactive approach for nurses in this busy 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.”

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John Leighty is a freelance health care writer. To comment, e-mail kgodar@nursingspectrum.com.

Associated Links:
Let There Be Light