By Debra Wood, RN, contributor
August 11, 2014 - Intentionally rounding on patients every hour has caught on at hospitals across the country. Research has shown, for the most part, positive associations between outcomes and intentionally assessing patients’ pain, position, need to use the restroom and whether possessions are within reach. Yet little evidence exists about the best way to introduce nurse rounding.
Rebecca Krepper, PhD, MDA, RN, said hourly nurse rounding is a "no-brainer," but how it is
implemented should take some consideration.
“Checking on a patient on an hourly basis is a no brainer,” said Rebecca Krepper, PhD, MDA, RN, professor and at the Texas Women’s University College of Nursing in Houston and lead author of a new study about hourly rounding.
“There is no question that [hourly nurse rounding] is beneficial for the patient, family and the staff,” added Lucy D. Alexander, PhD, RN, a professor with Kaplan University School of Nursing. “For the patient, it is comforting--especially for the elderly--that someone ‘is there’ and readily present for help and questions.”
Families find it reassuring that someone will check on their loved one at least every hour. For nurses, it creates an opportunity for an assessment of the patient’s status, whether the IV is flowing as ordered, the dressing intact and other subtle clues. It also presents an ideal way to hand-off the patient to the next shift, she explained.
“Nothing replaces actually ‘eyeballing’ the patient,” Alexander continued. “An experienced nurse can assess a great deal about a patient’s status in just a few minutes.”
Hourly nurse rounding as developed by the Studer Group requires a structured approach to learning the process. A member of the nursing staff announces he or she is making rounds, using key words, and then proceeds to complete scheduled tasks and to assess the patient’s pain and position and whether the patient needs to use the bathroom. Before leaving the room, the nurse asks the patient whether there is anything else he/she can do for the patient, educates about when pushing the call light is appropriate and informs the patient when he or she will be back. Then the nurse documents the encounter both on a log in the room and in the electronic medical record.
Lyn Ketelsen, RN, MBA, a coach at Studer Group, created the blueprint for rounding and then tested its effectiveness at 14 hospitals. That initial 2006 study, published in the American Journal of Nursing, found hourly or every two-hour rounding decreased patients’ call light use, reduced falls and increased their satisfaction with nursing care.
Margo A. Halm, RN, PhD, CNS-BC, director of nursing research and quality at Salem Hospital in Oregon, reviewed 11 hourly rounding studies and reported in a 2009 American Journal of Critical Care article that 83 percent of studies examined showed a reduction in call lights, 77 percent a decrease in fall rates and 88 percent an improvement in patient satisfaction.
Halm reported that nurses find scripting conversations with patients problematic and often oppose keeping logs in each patient’s room every time they enter. She also cautioned that units with low fall rates and high patient satisfaction may not see much improvement with hourly rounding.
In 2011, the Agency for Healthcare Research and Quality (AHRQ) reported on the results at Memorial Health System in Springfield, Ill., after implementing hourly rounding. The hospital experienced a 50 percent reduction in falls, a one-third decrease in call light use and an increase in patient satisfaction.
Lucy D. Alexander, PhD, RN, believes an experienced nurse, familiar with the patient, is in the best
position to judge the patient’s status.
Hundreds of hospitals from coast to coast have implemented hourly rounding. Alexander reports that many of her graduate students report on a need for their facilities to adopt hourly rounding. Yet how they conduct hourly rounds varies and could account for the differences in results obtained.
“I believe the best way is when it is done by a RN who is familiar with the patient and educationally prepared to judge the patient’s status,” Alexander said.
While several published studies exist, most are short term. Krepper sought a longer look at the results and collected data for a six-month period, followed by an additional six months of trending results.
“For this particular hospital (St. Luke’s Episcopal in Houston), the process of checking on patients on a regular basis does work, but the intent here [in this study] was how it is implemented and staff trained,” Krepper said.
Krepper sought to determine whether a standardized hourly rounding processes implemented with a formal, four-hour education program, as recommended by a consultant, improved outcomes as compared to St. Luke’s traditional train-the-trainer method for introducing new policies.
“Our findings were that the success of hourly rounding was not dependent on that structured approach to the process,” Krepper said. “In that culture [St. Luke’s], train-the-trainer was the least expensive process to ensure everyone within the hospital was aware of why we were doing hourly rounding and the potential.”
Krepper and colleagues evaluated outcomes on two 32-bed cardiovascular surgery nursing units. All of the nurses on one unit received the structured, four-hour training workshop. In addition, that unit placed posters in each patient room, staff kept a paper log in the room and documented the visit electronically, and the nurses received coaching and mentoring for three months following the workshop. On the other unit, nurses learned about hourly rounding from a trainer. There were no posters, in-room logs or coaching. The researchers monitored outcomes for one year.
The investigators reported in the Journal for Healthcare Quality finding that call light volume decreased more on the workshop unit. Nurses on the day shift on the intervention unit reported taking fewer steps.
The current research did not confirm findings from prior studies, showing a decline in falls, but the authors said that falls happen so infrequently, it was not possible to determine a relationship with rounding. Krepper added that so many variables contribute to falls, including medications taken and the room environment, that it is difficult to determine the role hourly rounding plays.
Additionally, the researchers found no significant differences between the units for 30-day readmission rates and patients’ perceptions of care.
While Krepper said the findings of her study about training cannot be generalized to all facilities, but that those with established methods of implementing changes should consider using those familiar processes and cost-effective methods when rolling out hourly nurse rounding.
Alexander concluded that “more formal research studies need to be conducted to accumulate more evidence about the benefits of hourly rounding, which by the way has the potential for reducing the patients’ length of stay by preventing and identifying complications as soon as possible and more cost-effective care.”
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