Effects of Nursing Rounds on Patients Fall Rates
Condition: Nursing
Study type: Observational

Summary: 
      The purpose of this study is to determine the effects of hourly rounding on patient falls,
      patient satisfaction, and patient call light usage. This is a replication of research which
      determined that hourly rounds conducted by nursing personnel decreased patient falls and call
      light usage and increased patient satisfaction. The study design is quasi- experimental. One
      unit will be used as its own control (4S). On this unit, hourly nursing rounds will be
      implemented by Registered Nurses, Licensed Practical Nurses, and Nursing Assistants. A second
      unit, 6S, will maintain current practices and data from this unit will be used to determine
      if there are any hospital-wide fluctuations for fall rates, patient satisfaction, or call
      light usage. Data for patient falls, patient satisfaction, call light usage, and reasons for
      call light use will be collected on both units using fall rate reports, patient satisfaction
      survey data, and the call light system.

      Falls among hospital patients are a persistent problem, with 2.3 to 7 falls occurring in U.S.
      hospitals every 1000 patient days. Approximately 30-48% percent of these falls result in
      injury and 5 to 10 percent of them result in serious injury. Fall related deaths occurred at
      a rate of 46.2 per 100,000 in 2003. Hospital falls affect both young and old patients and
      many of them occur when the patient is alone or involved in elimination-related activities.
      Falls that result in injury may lead to an extended hospitalization and increased costs.
      Patients who fall and sustain injury are reported to have hospital charges of more than
      $4,200 higher than patients who do not fall. Hourly nursing rounds have been shown to
      decrease falls by 52%.

      Hospitalized patients often require assistance with basic self-care tasks, such as using the
      toilet, ambulating, and eating; they ask for assistance by using the call light. Therefore, a
      patient's level of satisfaction with nursing care depends principally upon the patient's
      perception of how well the nursing staff has been able to meet his or her needs. The call
      light can be a lifeline for hospitalized patients, but it can also impose considerable
      demands on nurses' time. Several studies have documented the unfavorable effects of patients'
      frequent use of call lights on the effectiveness of patient-care management on inpatient
      units, which may already be compromised by staffing shortages.
    

Detailed description: 
      Falls among hospital patients are a persistent problem, with 2.3 to 7 falls occurring in U.S.
      hospitals every 1000 patient days. Approximately 30-48% percent of these falls result in
      injury and 5 to 10 percent of them result in serious injury. Fall related deaths occurred at
      a rate of 46.2 per 100,000 in 2003. Hospital falls affect both young and old patients and
      many of them occur when the patient is alone or involved in elimination-related activities.
      Falls that result in injury may lead to an extended hospitalization and increased costs .
      Patients who fall and sustain injury are reported to have hospital charges of more than
      $4,200 higher per admission than patients who do not fall. Hourly nursing rounds have been
      shown to decrease falls by 52% .

      Hospitalized patients often require assistance with basic self-care tasks, such as using the
      toilet, ambulating, and eating; they ask for assistance by using the call light. Therefore, a
      patient's level of satisfaction with nursing care depends principally upon the patient's
      perception of how well the nursing staff has been able to meet his or her needs. The call
      light can be a lifeline for hospitalized patients, but it can also impose considerable
      demands on nurses' time. Several studies have documented the unfavorable effects of patients'
      frequent use of call lights on the effectiveness of patient-care management on inpatient
      units, which may already be compromised by staffing shortages.

      Current data at Crouse Hospital show that the fall rate on 4S is 5.05 per 1000 patient days,
      demonstrating significant opportunity for improvement. Data from the 6S shows a fall rate of
      5.26 per 1000 patient days. As far as patient satisfaction, the percentage of patients who
      gave the 4S a 9 or 10 out of a possible score of 10 for overall rating of care was 56.29%.
      Likewise the number of patients who would definitely recommend Crouse Hospital to others was
      56.25%. Both satisfaction questions (Core IP Key Results: I would prefer to return to X
      without hesitation, if care is needed and I would recommend X without hesitation to others)
      show significant opportunities for improvement. Preliminary call light usage gathered from
      the Hill Rom call light system, which is currently available only on 6S, showed 6,909
      individual uses of the call light within a 4-week period. One can surmise from this number
      that patient issues are not being addressed in a timely manner and therefore significant
      opportunities for improvement exist. Only aggregate data will be collected. No subjects will
      be identified directly or through any identifiers.

      The objectives of the study are to:

        1. Correlate the effects of hourly nursing rounds, if any, to patient falls and call light
           use.

        2. Determine if there are any changes in patient satisfaction levels

      All subjects 18 years and over admitted to 4 South Irving (Oncology/OBGYN) or 6 South Irving
      (Orthopedic/Neurology) during the twelve month study will be included as research subjects.

      Exclusion Criteria: Any patient not admitted to 4 South Irving or 6 South Irving at Crouse
      Hospital will be excluded from the study. Patients under the age of 18 years are not admitted
      to these units.

      Sample sizes for the study were determined for call light usage rates, patient satisfaction
      scores, and fall rates. Current process averages for sample size calculations were obtained
      as follows: 1) fall rates from existing fall rate reports 2) patient satisfaction from Avatar
      surveys, and 3) call bell usage from preliminary Hill Rom system data. For all sample size
      calculations, α=0.05 and β=0.10 were used. Based on these calculations, the study baseline
      data for patient satisfaction will be calculated using Avatar patient satisfaction data from
      the six-month period prior to study initiation. The baseline data for falls will be collected
      from existing fall rate reports using the six months of data prior to study initiation. Data
      for these variables will continue to be collected for 6 months after the implementation of
      nursing rounds. For call bell usage rates the data for 2 weeks prior to rounding
      implementation will be collected as baseline data. Data will be collected for 4 weeks
      following the implementation of nursing rounds. Data for average patient age, length of stay,
      and severity of illness for both units will be obtained from Transition Systems, Inc. TSI, a
      financial data base is a type of Decision Support System. In order to get the information on
      a patient's age a query will be made of TSI. It will then print up average ages of a
      particular unit within a specified time. Measures of central tendency and spread will be
      calculated for these variables to compare both units. Chi-square tests, rank sum tests, and
      tests of means will be used to compare baseline and post-intervention demographic
      characteristics and reasons for call light usage on both units. Rate ratios comparing post-
      to pre-intervention fall rates and call rates will be calculated on both. For both fall rates
      and call rates, significance tests will be conducted to determine whether the rate ratios
      differ between the two units. The change in the proportion of patients who indicated they
      were satisfied with their care in each unit before and after the intervention will also be
      calculated and compared. The data will be analyzed using SAS®9. No data involving individual
      patient identifiers will be presented with the analysis. Findings from this study will
      potentially be used to change nursing practice at Crouse Hospital.

      4-South Irving, the experimental unit, will be used as its own control. A second unit, 6S,
      will maintain current practices and data from this unit will be used to determine if there
      are any hospital-wide fluctuations for fall rates, patient satisfaction, or call light usage.
      Age, gender, and severity of illness of subjects on the control and experimental units will
      be compared. Because the patient populations differ from the experimental to control unit,
      the reasons why patients use the call light will be collected to verify that these two groups
      use the call lights for similar reasons.

      The principal and co-investigators of this study will be educating all nursing personnel on
      both units on how to collect and document call light data 1 week prior to the start of the
      data collection process. Baseline call light data for the reasons why patients use the call
      light and number of patient calls will then be collected for 2 weeks. After baseline call
      light data are collected the principal and co-investigators will be educating all nursing
      personnel on 4 South Irving on how to round on patients. Education will last for 2 weeks and
      includes what questions to ask of the patient while in the room, what tasks need to be done
      each time they are in the room, when to round on patients, and how to document rounds. An
      hourly rounding toolkit purchased from the authors of the original study, which includes an
      educational video, will be used to assist in this education phase. Nursing leadership, which
      includes the nurse manager, Director of Medical-Surgical Nursing, the Chief Nursing Officer
      and Clinical Nurse Specialists, will be educated on techniques to ensure rounding is
      consistently completed by nursing personnel. The implementation of nursing rounds will begin
      after the two weeks of rounding education is completed.

      One member of the nursing staff, including RNs, LPNs, and Nursing Assistants, will be
      required to perform nursing rounds every hour on 4 South Irving Patients will not be awakened
      if they are sleeping unless it is necessary for treatment. During nursing rounds, nursing
      personnel will assess pain levels using a pain-assessment scale, offer toileting assistance,
      assess the patient's position and position comfort, make sure the call light is within the
      patients reach, put the television remote control and bed light switch within the patients
      reach, put the bedside table next to the bed, put the tissue box and water within the
      patient's reach and prior to leaving the room ask "Is there anything I can do for you before
      I leave? I have time while I am here in the room." Nursing personnel will also tell the
      patient that a member of the nursing staff (name will be written on white board in room) will
      be back in an hour to round again. Nursing staff members are expected to complete all
      patient-care tasks, unless they are not authorized to dispense medication or work with IVs.
      Laminated pocket cards will be given to nursing staff so they are continually reminded of the
      actions to perform on the rounds. Patients will not be awakened to check for pain,
      positioning, or the need to use the bathroom; however the environmental check can be
      completed during rounds. Members of the nursing leadership team including the nurse manager,
      Director of Medical-Surgical Nursing, Chief Nursing Officer, and Clinical Nurse Specialists
      will be making frequent observations of staff, using rounding documentation sheets and
      patient interviews, to verify that rounding is occurring as expected.

      Call light usage will be collected through the use of the Hill Rom call light system.
      Recently, Hill Rom Beds were added to 4 South. Now the two units are equipped with Hill Rom
      Beds and corresponding Hill Rom call lights. All call lights placed from individual patient
      rooms are recorded on a central server located in each nursing station. The central server
      can generate and print reports for all call lights used in a user specified time frame.
      Reports include the time a call light was placed, area it was placed from and call light
      response time. Reasons for call light usage will be documented by bedside nursing personnel
      on a standard sheet. The documentation forms will be collected every day at 7a.m. by the
      principal investigator or co-investigators of the study. New documentation forms will be
      posted daily at 7a.m. Inter-rater reliability will be performed by comparing manual call
      light data to the computerized call light data collected within the Hill Rom call light
      system. Documentation of rounding times and frequency will also be documented by nursing
      personnel on a standard form . This form will be collected every day at 7a.m. by either the
      principal investigator or co-investigator of the study. New rounding documentation forms will
      be posted daily. Rounding documentation forms will be used to calculate the percentage of
      rounds completed as expected.

      On both units, baseline data collection for falls and patient satisfaction will be collected
      for 6 months prior to the start of nursing rounds and 6 months after the start of the
      implementation of nursing rounds. Fall rates will be collected through pre-existing fall rate
      reports and reported as falls per 1000 patient days. Patient satisfaction will be collected
      through pre-existing Avatar patient satisfaction surveys that are randomly sent to discharged
      patients. All data will be analyzed to determine if statistically significant differences in
      patient fall rates, satisfaction, or call light usage occurred.

      A limitation in this study is that nurses from the medical surgical float pool may work on 4
      South and subsequently be assigned to 6 South within the 6 month post-intervention time
      period. This potential movement of nurses between the control and experimental unit may
      influence the results on the control unit. This will be addressed by limiting the number of
      float pool nurses who are scheduled to work on both the experimental unit and the control
      unit for the six months following the education phase of the study.
    

Sampling method: Non-Probability Sample
Study population: 
        In patients on 2 units: an Oncology/OBGYN unit and an Orthopedic/Neurology unit.