You Called? Hourly Rounding Cuts Call Lights

Yvonne Kirk, RN, MSN, vice president of nursing at Mercy Medical Center in Roseburg, Ore., says patient satisfaction rates have jumped 8% since the hospital started its rounding program in June. Courtesy of Mercy Medical Center

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

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

“The response has been amazing,” says Christine Meade, PhD, chief researcher and health care coach with the Studer Group of Gulf Breeze, Fla. Meade published the study, “Effects Of Nursing Rounds On Patients’ Call Light Use, Satisfaction, And Safety,” in the September 2006 issue of the American Journal of Nursing with co-authors Amy L. Bursell, PhD, and Lyn Ketelsen, MBA, RN. “Nurses know rounding works, ... but nobody’s ever done a study to prove it.”

Meade is part of a team of coaches who present the rounding protocol to hospital units. An interactive training video toolkit demonstrates how recommended behaviors and actions by nurses on hourly rounds can improve efficiencies 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 — and the patients love it,” Meade says.

Of all the indicators of success, “satisfaction jumps through the roof,” Meade adds. The savings potential from rounding is also attracting interest, since patient falls cost hospitals an average of $11,000 apiece.

Rounding for all

The only California hospital participating in the study, Sharp Memorial Hospital in San Diego, had seen some benefits from a unit doing hourly rounding and wanted to expand the strategy.

Chief Nursing Officer Jennifer Jacoby, RN, MSN, says nurses received one-on-one instruction on what to do during hourly rounding, along with follow-up meetings with managers to validate their progress.

The 340-bed hospital has since implemented hourly rounding for 800 nurses and nursing assistants in all inpatient units. Jacoby says even wound teams, case managers, and chaplains are expected to do patient rounds, not hourly, but every day, and everyone has memorized the final catchphrase: “Is there anything else I can do for you before I go?”

When touring units, Jacoby says she sometimes finds no call lights going off in areas where there used to be 10-15 per hour. However, precise measurements of changes in call-light traffic have yet to be compiled.

What has been measured are fall rates that are compared to other hospitals in California through data from the California Nursing Outcomes Coalition (CalNOC). Jacoby says on four floors, there have been no patient falls in four months, and overall, the fall rate in the last quarter was lower than those of 90% of other hospitals in the state.

“We also have one of the lowest numbers of pressure ulcers, again better than 90% of hospitals in California,” Jacoby says, adding that pain control is also a big success.

Proactive approach to care

Co-author Ketelsen is also a Studer Group coach 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,” Ketelsen says. “I did some observations, and it became clear that practicing in a reactive manner wasn’t serving [the hospitals] well and they needed to transition to a more proactive nursing approach.”

The researchers set up specific “scripts” and tactics for hourly rounding. 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,” Ketelsen says. “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 before the implementation of 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.”

“Four Ps” rule

When hourly rounding was implemented in the seventh-floor medical/surgical unit at Northern California’s Peninsula Medical Center on Jan. 11, the staff of 80 nurses and nursing assistants was ready to put the protocol’s “four Ps” of patient care into action: positioning, personal needs, pain, and placement.

Jim Benney, RN, MPA, director of medical/surgical nursing and skilled nursing units at the Sutter Health-affiliated hospital, says the regimen is now formalized as standard practice for the hospital’s 350 staff nurses. By following the “four Ps,” nurses find their time disrupted less often by call lights, since patients will usually wait on non-urgent matters when they know a nurse is coming within the hour.

The upshot has been patient satisfaction scores hitting the 90th percentile and a sharp decline in fall rates.
“Believe me, when our patient satisfaction scores go up, the whole morale of the floor goes up,” says Marisa Parsons, RN, charge nurse of the 40-bed med/surg unit that initiated the rounding procedure.

Systemwide rollout

Before the 130-bed facility at Catholic Healthcare West’s St. Rose Dominican Hospitals – San Martín campus opened Nov. 7 in Las Vegas, Sandra Rush, RN, MA, CHE, educated the entire nursing staff on four new protocols, including hourly rounding

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

Rush, a care management specialist in patient satisfaction for CHW, has helped implement hourly rounding this year at 36 CHW hospitals in California, Arizona, and Nevada. She says that if the protocol is done correctly, it can be very rewarding. While hourly rounding has some flexibility, she emphasizes eight behaviors that aren’t optional, including the four Ps and the opening key words, “Hi, I’m Sandy and I’m here to do hourly rounds.”

Although it’s too early to validate results at most of the CHW hospitals, Rush says her follow-up unit visits to assess the results of the rounding have been fruitful. “There’s been a true reduction in call lights — including one hospital where they were down 60%.”

Since the implementation of hourly rounding, reactions to it have been overwhelmingly positive, Rush reports. A nurse on the night shift at Chandler Regional Hospital in Chandler, Ariz., sent Rush an e-mail saying that for two nights after she implemented the protocol, she didn’t have one call light, when she normally has to respond to 10 or 12.

Improving efficiencies

At Mercy Medical Center in Roseburg, Ore., nurses round every hour during the day and every two hours from 7 PM to 7 AM.

“We are looking at new efficiencies and processes that help meet the needs of nurses, so we thought this was the best time to implement the rounding strategy,” says Yvonne Kirk, RN, MSN, vice president of nursing. Since the program started in med/surg and a clinical observation unit in June, patient satisfaction rates have jumped 8%, and more improvement is expected.

Staff Nurse Lise Gard, RN, says the rounding protocol has steadily reduced call-light volume and that there are fewer bed sores because patients are repositioned during each visit. “We check on patients regularly anyway, but now we’re more structured. The patients like to know we’re going to be there. It decreases their anxiety and decreases our work.”

Sudden impact

Researcher Ketelsen says that 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, which would have signaled a real urgency. “The new rounding is more about engaging the patient: 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 hours, Ketelsen says. Also, some units opted for rounding every two hours, especially during late-night hours when patients may not want to be disturbed. However, hourly rounding shows better results, Ketelsen reports.

The next test for patient rounding is in the emergency room setting, and a research study is already underway at 31 hospitals to determine the best proactive approach for nurses in the busy, fluid environment, Ketelsen says.

“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.”

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