Though we’ve been big advocates of “hourly rounding”, also known as “purposeful rounding” and other names, we’ve only done a couple columns about it. Our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding” discussed how hourly rounding, when done well, not only improves patient satisfaction but also reduces nurse interruptions and may improve patient safety outcomes.
We think implementing hourly rounding programs is a no-brainer. Yet many hospitals have not implemented such programs. One of the reasons is that it involves a major change in nurse workflow and mindset and usually requires a significant investment of time and money in training and education.
So researchers at St. Luke’s Episcopal Hospital in Houston, Texas, already proponents for hourly rounding, sought to see if a “train the trainer” program could lead to successful implementation of an hourly rounding program without the more time- and cost- intensive structured programs typically utilized in such implementations (Krepper 2014). They compared the two approaches on two comparable 32-bed cardiovascular surgery nursing units. One unit received the structured approach, which consisted of a 4-hour workshop for staff, posters in patient rooms informing patients and families what to expect, charting of the rounding activities both in the electronic medical record and a separate paper log kept in the patient rooms, use of rounding “scripts”, and coaching/mentoring. The other unit received its training via a “train the trainer” approach that had been successfully used in the organization for several other improvement initiatives. One staff member (the “trainer”) received in-depth training but the rest of the staff on that unit just learned from that trainer. There were no in-room logs and no posters or ongoing coaching/mentoring for this unit. The nurses on this unit did chart their rounds in the electronic medical record and the nurse manager of the unit did follow up with staff.
The researchers collected data over a 6-month implementation period and another 6 months to determine whether the results were sustainable. There was less call light use and fewer steps taken by the day-shift staff during the study period on the full intervention unit but no significant difference between the two units in staff perception of “having enough time”. There were no statistically significant differences in the number of patient falls, 30-day readmission rates, and patients’ perception of care between the two untis.
The authors concluded that adding additional structure did not provide any significant advantage over use of the “train the trainer” program. The hospital did make several changes after the study was completed. They did away with the in-room paper logs and posters but installed white boards in patient rooms to inform the patients and families when to expect regular “comfort care rounds”. Staff are not coached to use a specific “script”. Each nursing unit is now allowed to decide the best time for rounding and who will do the rounding (i.e. nurse vs. patient care assistant).
The latter issue is of interest. In our August 28, 2012 Patient Safety Tip of the Week “New Care Model Copes with Interruptions Better” we described an innovative program at University of Pittsburgh Medical Center (UPMC) that was successful in improving care while handling interruptions (Kowinsky 2012). They basically categorized two types of work: “predictable” and “unpredictable”. The predictable work occurs repetitively and reliably and can be scheduled. This includes things like rounding, feeding, repositioning, vital signs, etc. The unpredictable work consists of tasks that tend to occur randomly over the course of the day and includes things like answering call bells, blood draws, transporting patients, handling admissions and discharges, etc. Because of the two types of work they created two types of roles to deal with them. The “reliable rounder” addressed the predictable work and the “variable rounder” addressed the unpredictable work. During the simulation exercise carried out on an unoccupied available nursing unit, they developed scenarios and scripts and had observers watch and critique those doing role-playing. Frontline nurses participated with leaders and quality improvement staff and provided feedback to improve the model. They then piloted the new model on a telemetry unit. It was budget neutral since the same number of personnel was required as in the old model. The model was well received by hospital staff and at both 90 days and one year there were significant improvements in call bell response times, blood collection times, and other quality/service metrics.
So we remain advocates of the hourly rounding concept. It appears that hospitals now have a choice as to the specific staff members who do the rounds and the amount of resources needed to implement an hourly rounding program.
For those of you who wish to know more about hourly rounding we suggest that you read our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding” which describes the concepts and elements of such programs, the evidence for improvement in patient care and patient satisfaction, and has good references.
Krepper R, Vallejo B, Smith C, et al. Evaluation of a Standardized Hourly Rounding Process (SHaRP). Journal for Healthcare Quality 2014; 36(2): 62–69, March/April 2014
Kowinsky AM, Shovel J, McLaughlin M, et al. Separating Predictable and Unpredictable Work to Manage Interruptions and Promote Safe and Effective Work Flow. Journal of Nursing Care Quality 2012. 27(2): 109-115, April/June 2012
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