Patient Safety Tip of the Week
July 26, 2011 Hourly Rounding
We’ve been big advocates of “hourly rounding”, also known as “purposeful rounding” and other names. This concept has been employed in many healthcare settings and most people associate its widespread adoption to the advocacy of the Studer Group. While many organizations have adopted hourly rounding expressly to help improve patient satisfaction, hourly rounding clearly has an impact on patient safety, quality outcomes, workflow and efficiency improvement, and staff satisfaction.
Hourly rounding is a proactive intervention where nurses (or a combination of nurses and other healthcare workers) do bedside rounding on patients at regularly scheduled intervals, usually every hour. In some models, RN’s will round every two hours and an LPN or nurse’s aide will round on the hour in between the RN rounds. The nurses attend to the patients on a regular, timely basis and anticipate their needs. By doing this they actually minimize the number of times patients need to use their nurse call lights, thus avoiding interruptions that fragment nurses’ workflows. Typically, nurses address the “3 P’s” (pain, position, potty) during these rounds (many add a fourth “P” for proximity of personal items). These are the 3 things that patients most often use their nurse call lights for anyway. But when the patient knows and understands that the nurse will be in at a specified time, they are less likely to use the call light and will simply wait for the nurse to arrive at their next scheduled visit. Anticipating bathroom needs is often very helpful in reducing instances where patients try to get out of bed themselves to use the bathroom and end up falling.
There have been several articles recently discussing the evidence base for hourly rounding and some of the barriers to implementation. A recent review (Halm 2011) of 11 reports on outcomes of hourly rounding on a variety of hospital units (med/surg, orthopedic, telemetry, rehab, geriatrics, etc.) showed very positive outcomes. Overall patient satisfaction was improved in 8 of 9 studies, either on facility-administered patient satisfaction surveys or the publicly reported surveys like HCAPS. Call light use was reduced in 5 of 6 studies where it was specifically measured. One study even documented a reduction in the distance that nursing staff had to walk on a shift. Fall rates were reduced in 7 of 9 studies where specifically monitored. Some studies have documented reduction in pressure ulcer development and restraint use as well.
But there are challenges and barriers to implementation of a successful program (Deitrick 2011). There is often a disparity between leadership and frontline staff in understanding the purpose of and rationale behind hourly rounding. Similarly, even when the purpose is understood there may be inadequate education on the process and integration into the workflow. These factors often foster a lack of ownership by the staff and engender feelings that this is something that is being imposed upon them in a top-down fashion. Especially where the rounding will be “shared” the respective responsibilities are often not made clear. Accountability is usually monitored via rounding logs but staff are often reluctant to document on these (often fearing the logs might be used against them punitively) and in many cases the logs are not filled out at the time of the rounds but rather filled out at the end of the shift. And, importantly, the lack of feedback on the outcomes of the process has been problematic. If there is no measurement of outcome parameters staff are not reinforced or rewarded for their efforts. Deitrick et al. felt that implementing hourly rounding in a performance improvement fashion with PDSA cycles would be helpful. They also note that having a unit champion for hourly rounding is highly desirable. Many nurses have also felt that some of the “scripting” recommended for communication with patients has sounded too rigid and unnatural and would prefer that such communications be left up to them.
Halm had also noted challenges with documentation either on logs or on whiteboards but noted that such could be used to facilitate communication between staff (eg. documenting a patient’s preferred positioning on a whiteboard might be helpful for other staff).
Another challenge may be high acuity patients (Studer Group 2007) such as confused patients. The Studer Group also notes challenges that occur around scheduling breaks and changes of shift.
While sharing the hourly rounding between RN’s and LPN’s or aides is the model most commonly used, other models have popped up. Physical therapists as rounders were mentioned in the Halm paper. Another variant uses the concept of “unit hostess” (Ulanimo 2011), basically an unlicensed staff member who can perform rounding and monitoring that does not require interventions. This allowed prompt responses to call lights and improved patient satisfaction. One hospital even hired 21 hostesses to fill 10 vacant RN positions!
The Studer Group provides a wealth of resources on hourly rounding in addition to their training and implementation programs. A sample with multiple tools (Studer Group 2007) is a case study from Sacred Heart Hospital in Pensacola, Florida. That implementation produced a 71 percentile point improvement in patient satisfaction, while reducing call light utilization 40-50%, falls by 33% and new pressure ulcers by 56%. Pretty impressive! That downloadable sample has many good lessons for implemention.
Our experience is that when you first tell your staff about the concept of hourly rounding they think you are crazy. “We don’t have time for that!” “We’re already too busy.” So you have to start with a pilot implementation on one unit, making sure you have a unit-based champion for the program and good ways to measure patient outcomes, patient satisfaction, and staff satisfaction. Once other staff see that hourly rounding actually saves them time plus improves communication with patients, families, and other staff, they buy into the concept.
References:
Halm MA. Hourly Rounds: What Does the Evidence Indicate? Amer J Crit Care 2011; 18(6): 581-584
http://ajcc.aacnjournals.org/content/18/6/581.full
Deitrick LM, Baker K, Paxton H, et al. Hourly Rounding: Challenges With Implementation of an Evidence-Based Process. Journal of Nursing Care Quality., 5 July 2011
Ulanimo VM, Ligotti N. Patient Satisfaction and Patient Safety: Outcomes of Purposeful Rounding. VA National Center for Patient Safety TIPS 2011; 11(4): 1-4. July/August 2011
http://www.patientsafety.gov/TIPS/Docs/TIPS_JulAug11.pdf
Studer Group. Hourly Rounding Supplement. Best Practice: Sacred Heart Hospital, Pensacola, Florida. 2007
http://www.studergroup.com/hourly_rounding/hourly_rounding_supplement_sample_gs_1-5.pdf
http://www.patientsafetysolutions.com/
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