Time Well Spent

Texas RNs dim call lights with hourly rounding strategy

In a growing number of hospitals across the country, nurses involved in a results-driven hourly rounding protocol are finding their shifts less stressful, their time more productive, and patient safety and satisfaction scores hitting all time highs.

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

“The response has been amazing,” says Christine Meade, PhD, chief researcher and health care coach with the Studer Group’s Alliance for Healthcare Research in Gulf Breeze, Fla. “Nurses know rounding works, especially those who have been practicing for 20 years, but nobody has ever done a study to prove it.”

Meade says she gets about 10 e-mails per day about the research results and is part of a team of coaches who present the rounding protocol to hospital units, including several in Texas. Also available is an interactive training video toolkit that shows study data and demonstrates how recommended behaviors and actions by nurses on hourly rounds can improve efficiencies and satisfaction rates while giving 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 –– and the patients love it,” Meade says. Of all the indicators of success, “satisfaction jumps through the roof,” Meade says. The savings potential from rounding is also attracting interest since patient falls cost hospitals an average $11,000 apiece.

Plano replicates study

The only hospital in the Southwest enrolled in last year’s six-week research project, Baylor University Medical Center in Dallas, was among eight facilities excluded for insufficient data in the study results announced in August. However, the Medical Center of Plano launched a similar pilot showing initial success after Meade gave a presentation at the hospital earlier this year.

“We were very intrigued, so we replicated the study in two nursing units to see how it worked, and, of course, it worked,” says Sandy Haire, RN, MSN, chief nursing officer. “We were able to change the way we operationalize care throughout the day.”

Haire says an emphasis was put on “hard-wiring” hourly rounding in the medical and surgical units, making the process a habitual part of the daily procedures. “The nurses were able to appreciate the significance of doing this, and it produced positive results,” she says.

An immediate reward for about 60 nurses and nursing assistants is that call light traffic dropped significantly, giving them more control over their day, says Haire. Now when a call light goes off, it’s usually for an unexpected patient need.

The hourly rounding strategy has also shown monthly improvements in patient satisfaction, along with fewer falls and skin breakdown problems.

With the initial success, hourly rounding is now being implemented in various degrees for about 400 nurses in six inpatient units, including critical care step-down and women’s services, says Haire.

“Not every unit is alike, so they’re looking at what we’ve done in med/surg and may modify the practice to some degree,” Haire says. “But routine patient rounding really should not be an option –– it should be part of the culture.”

The medical center is also gathering baseline data for a new Studer Group study that expands rounding research to ED nurses. There are unique challenges for ED nurses because of the ebb and flow of patients –– constant interruptions, unknown ambulance traffic, and lack of beds available in hospital units.

“Again, it’s about engaging the staff to set a routine for making rounds on a regular basis or to explain to patients why there’s a delay,” says Haire. “If patients are told someone has just come in by ambulance who needs immediate attention, they will understand and be more tolerant.”

Rounding rollout at Methodist

At The Methodist Hospital in Houston, the hourly rounding protocol is being phased in throughout the 900-bed facility following implementation in six inpatient units in August that reduced call light rings 25% in the first two weeks.

Leadership councils at the hospital voted to launch the program after being briefed on the Studer Group study by senior customer research analyst Kimberly Goode, who attended a conference detailing the project. Nurses in the initial phase received training via an online “webinar” by Studer coaches describing 18 behaviors common to successful rounding. The research training video also was utilized.

“An emphasis is on narrating, or telling patients the story of their care,” says Goode. “Nurses will say to a patient, ‘The reason I’m checking your armband is for your safety,’ and so forth. It’s about filling in the blanks for patients who are not as adept with clinical knowledge as we are.”

Among the behaviors are four drivers for increasing patient satisfaction –– courtesy, availability, confidence, and trust –– all of which are emphasized in nursing units, says Goode. As nurses spend more quality time with patients, the satisfaction scores increase and call lights decrease, she says.

“Hourly rounding is a focused process that gains nurses more control over their work and eliminates the pingpong effect of being bounced from room to room,” says Goode. “It’s about nurses being more proactive than reactive.”

Timely approach to care

Lyn Ketelsen, RN, MBA, is a Studer Group coach and co-author of the hourly rounding study who originated the research project after visiting numerous hospitals struggling to raise patient satisfaction rates.

“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 them well and they 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 that 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 within 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. “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 afterward. “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,” says Ketelsen.

Three P’s rule

Mary Shepherd, RN, nursing project director at Methodist, says a key to successful rounding is communication and focus on the protocol’s “three P’s” –– position, potty, and pain. Nurses always greet patients, explain they’re doing hourly rounds, and answer patient questions. They also remind patients that a nurse will be back in another hour and always ask, “Is there anything else I can do for you before I leave?”

By following the three P’s, 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 Shepherd.

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, a TV remote control, and a telephone. The protocol was enhanced at Methodist with distribution of patient-family communication booklets in which patients are encouraged to jot down any questions they might have for their physicians or nurses, says Shepherd.

“To me, hourly rounding is an additional tool for the staff to use that will have a positive impact on patient satisfaction and outcomes and potentially on hospital finances,” says Shepherd. “With this strategy, there’s nowhere to go but up; you can’t lose with it.”

System-wide change

Prior to the official opening of Catholic Healthcare West’s (CHW) 130-bed San Martin Hospital in Las Vegas, Sandra Rush, RN, MA, CHE, showed up to educate the entire nursing staff on four new protocols, including hourly rounding.

Rush says all CHW nurse managers were invited to a leadership retreat in January where a Studer Group coach gave a presentation on a nursing bundle that would be rolled out system-wide by the hospital chain, the first component being hourly rounding. The other protocols she introduced to the San Martin staff are bedside shift reports, individual patient care, and discharge phone calls.

“It’s really exciting to be opening a hospital with every piece of the nursing bundle in place,” says Rush, a care management specialist in patient satisfaction for CHW who has helped implement hourly rounding this year at 36 CHW hospitals in California, Arizona, and Nevada.

Rush says, if done correctly, the protocol can be very rewarding. While hourly rounding has some flexibility, she emphasizes eight behaviors that aren’t optional, including the three P’s and the opening key words, “Hi, I’m Sandy, and I’m here to do hourly rounds.”

Although too early to validate results at most of the CHW hospitals, Rush says her follow-up unit visits have been fruitful. “There’s been a true reduction in call lights, including one hospital where they were down 60%, she says. This results in a huge amount of nursing time that’s not being interrupted.”

Sudden impact

Researcher Ketelsen says she experimented with hourly rounding while coaching at hospitals for nearly a year before helping to launch the formal study that has resulted in an inpatient protocol being used by more and more hospitals across the country.

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. “The beauty of this protocol is the immediate results from fewer call lights,” says Ketelsen. “It doesn’t take long for nurses to feel the impact.”

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.

The next test for patient rounding is in the ER setting, and a research study is already under way at Medical Center of Plano and 30 other hospitals to determine the best proactive 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 safety and quality of care,” she says.

John Leighty is a freelance writer. To comment on this story, e-mail editorsc@nurseweek.com.