Patient Safety

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RESEARCH CORNER
Hourly rounding and patient falls:
What factors boost success?
By Jennifer Goldsack, MChem, MA, MS; Meredith Bergey, MA, MPH, MSc; Susan Mascioli, MS, BSN, RN, CPHQ, NEA-BC;
and Janet Cunningham, MHA, RN, NEA-BC, CENP
Background: Falls are a persistent
problem in all healthcare settings,
with rates in acute care hospitals
ranging from 1.3 to 8.9 falls per
1,000 inpatient days, about 30%
resulting in serious injury. Methods:
A 30-day prospective pilot study was
conducted on two units with pre-
and postimplementation evaluation
to determine the impact of patient-
centered proactive hourly rounding
on patient falls as part of a Lean Six
Sigma process improvement project.
Nurse leaders and a staff champion
from Unit 1 were involved in the
process from the start of the imple-
mentation period, while Unit 2 was
introduced to the project for training
shortly before the intervention began.
Results: On Unit 1, where staff and
leadership were engaged in the proj-
ect from the outset, the 1-year base-
line mean fall rate was 3.9 falls/1,000
patient days. The pilot period fall rate
of 1.3 falls/1,000 patient days was
significantly lower than the baseline
fall rate (P = 0.006). On Unit 2,
where there was no run-in period,
the 1-year baseline mean fall rate
was 2.6 falls/1,000 patient days,
which fell, but not significantly,
to 2.5 falls/1,000 patient days dur-
ing the pilot period (P = 0.799).
Discussion: Engaging an interdisci-
plinary team, including leadership
and unit champions, to complete a
Lean Six Sigma process improvement
project and implement a patient-
centered proactive hourly rounding
program was associated with a sig-
nificant reduction in the fall rate in
Unit 1. Implementation of the same
program in Unit 2 without engaging
leadership or front-line staff in pro-
gram design did not impact its fall
rate. Conclusions: The active involve-
ment of leadership and front-line staff
in program design and as unit cham-
pions during the project run-in
period was critical to significantly
reducing inpatient fall rates and call
bell use in an adult medical unit.
Background
Falls are a pervasive and persistent
problem in all healthcare settings,
with adverse clinical, social, and eco-
nomic outcomes for patients, staff,
and institutions involved. Reported
rates range from 1.3 to 8.9 falls per
1,000 inpatient days in acute care
hospitals,1
with an estimated 30% of
these resulting in serious injury.2
The
Centers for Medicare and Medicaid
Services have transferred the financial
burden of inpatient fall prevention to
hospitals, and reporting of patient falls
now impacts both ranking and pay-
ment systems for hospitals and other
healthcare organizations. Yet no clini-
cal data support the value of evidence-
based guidelines for preventing falls.3
The difficulty of preventing falls is
exacerbated by shortened acute care
lengths of stay, requiring that fall pre-
vention interventions make an
impact within short periods. To
address these challenges, experts are
recommending the use of multifacto-
rial fall prevention programs.4,5
Suc-
cessful programs typically include
combinations of strong leadership
and support, a culture of safety,
front-line staff who are engaged in
program design, a multidisciplinary
team that guides the prevention pro-
gram, staff education and training,
and changes in pessimistic attitudes
toward fall prevention.5,6
While preliminary evidence for
multifactorial fall prevention pro-
grams is promising, and consistent
themes are associated with successful
implementation, the impact of indi-
vidual components remains unclear.
It has not yet been established
whether effectiveness is primarily a
function of successful implementa-
tion as opposed to characteristics of
the components selected.
This article describes the develop-
ment, implementation, and evaluation
of patient-centered hourly rounding,
a program built around a conceptual
framework we proposed in “Patient
Falls: Searching for the Elusive ‘Silver
Bullet’” (Nursing, July 2014).7
We
hypothesized that this process would
lend itself to successful and sustain-
able implementation, reduced patient
falls and, based on previous evidence,
decreased call bell usage.8
Methods
Study overview and setting. We
conducted a 30-day prospective
pilot study with pre- and postimple-
mentation evaluation to determine
the impact of patient-centered pro-
active hourly rounding on patient
falls. (See Glossary of research terms.)
The intervention was implemented
from September 23 to October 20,
2013, in two medical units at Chris-
tiana Hospital, a 907-bed hospital in
Newark, Del. It is part of Christiana
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2. 26 l Nursing2015 l February www.Nursing2015.com
RESEARCH CORNER
Glossary of research terms
• Convenience sampling. Obtaining a sample by using the participants who are
easiest to access; no attempt is made to ensure that the sample is truly represen-
tative of the target population.16
• Mann-Whitney test. A test that compares differences between two groups.16
It
is used for comparing nonparametric, continuous data between two groups.
• N. Sample size.16
• P. Statistic indicating significance. P < 0.05 means the results are significant; the
smaller the number, the less likely that the results are due to chance.16
• Robust regression analysis. This determines the relationship between an
independent variable and a dependent variable when the data being examined
contain outliers, or extreme values, that should not be excluded.
• Wilcoxon-signed rank test. A statistical test to compare the average values of
the same measurements made under two different conditions. Used when the
data are not normally distributed, this test compares median values.
Care Health System, a not-for-profit,
nonsectarian, independent academic
medical center. The study units com-
prised a 35-bed adult medical stroke
unit (Unit 1) and a 40-bed inpatient
hematology/oncology unit (Unit 2).
Intervention design and imple-
mentation. The patient-centered
hourly rounding intervention was
designed collaboratively by clinical
nurses, a pharmacist, a physician,
a physical therapist, a process
improvement expert, a researcher,
and nurse leaders. It was designed
around three core principles:
• avoiding redundancy with existing
strategies
• engaging patients as active partners
in fall prevention where possible
• establishing a culture of account-
ability to the strategy and staff buy-in.
The design was a result of a
6-month Lean Six Sigma process
improvement project based around
the DMAIC principles: Define, Mea-
sure, Analyze, Improve, and Control.
Lean Six Sigma methodology con-
sists of tools and techniques used to
understand and standardize process
variation and to identify and eliminate
waste. The goal of a Lean Six Sigma
project is to achieve a breakthrough in
performance, resulting in a sustained
improved outcomes.
Nurse leaders and a staff cham-
pion from Unit 1 were involved in the
process from the start of the imple-
mentation period, while Unit 2 was
introduced to the project for training
shortly before the intervention began.
Patient-centered proactive
hourly rounding. This was con-
ducted every hour between 0600 and
2200 hours and every 2 hours
between 2200 and 0600 hours.
Rounding was performed by nurses
and patient care technicians (PCTs)
(Unit 1) or nurses only (Unit 2) based
on differences in RN staffing between
the two units. (See Defining a patient-
centered proactive hourly round.)
Program implementation. The
two objectives that we defined as
critical for communicating to staff
during training were that:
• unit staff understand what patient-
centered hourly rounding is, recognize
its value, and receive the training and
time required to complete patient-
centered hourly rounding.
• patient-centered hourly rounding
occurs, as defined, each hour from
0600 to 2200 and once every 2
hours from 2200 to 0600, for each
patient on the units during the pilot
period.
Mandatory education and training
for all staff on both units began
2 weeks before implementation of the
pilot. Staff development specialists
and nurse managers did the training
at regularly scheduled staff meetings
and value improvement team meet-
ings in the 2 weeks preceding imple-
mentation and supplemented it
2 weeks into the implementation
period to refocus staff on the inter-
vention’s critical components. The
unit-based value improvement team
is charged with driving improve-
ments in quality, safety, and patient-
centered care. The slides developed
as part of this process and used dur-
ing training sessions are available
from the corresponding author on
request.
Evaluation of rounding and time
periods. For Unit 1, the baseline
period was defined as January to
December, 2012. The project period
was defined as January to September,
2013, during which time the Lean
Six Sigma Define, Measure, Analyze,
and Improve phases of the DMAIC
process were completed. This
involved the multidisciplinary team,
nurse leaders, and clinical nurses and
champions from Unit 1. For Unit 2,
the baseline period was defined as
January to September, 2013.
The pilot period for both units
was the 30 days from September 23
to October 20, 2013. Rounding was
performed by nurses and PCTs (Unit
1) or nurses only (Unit 2).
Study outcomes. The fall rate both
before and during the pilot was mea-
sured as number of falls per 1,000
patient days. Compliance with the
patient-centered proactive hourly
rounding process was monitored
using three different tools. First, the
nurse manager on each unit randomly
selected a patient flow sheet each day
during the pilot and reviewed the
recorded times of the rounding for the
prior 24 hours. The average and
median time between rounds was
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3. www.Nursing2015.com February l Nursing2015 l 27
calculated for each unit. Second, the
nurse manager on each unit randomly
selected 60 unique patient-centered
proactive rounds on his or her unit to
observe during the pilot. Last, two
researchers selected one staff member
from each shift on each unit during
the pilot to survey about the last
round he or she completed. Research-
ers used convenience sampling,
surveying the first staff member they
encountered on the unit who was not
engaged with a patient.
Staff perceptions about the pilot,
particularly the burden on nursing
time, the efficacy of the strategy, and
its potential as a sustainable, successful
fall prevention measure were assessed
using an anonymous survey adminis-
tered 1 week after the pilot period
ended. Staff were sent an eight-item
survey by e-mail to complete using an
anonymous web-based interface (Sur-
veyMonkey), and were given 10 days
to reply, with one reminder e-mail.
Statistical analysis. The Mann-
Whitney test was used to compare
baseline fall rates with project period
fall rates for Unit 1. The one-sample
Wilcoxon-signed rank test was used
to compare Unit 1’s pilot and baseline
period fall rates, Unit 1’s project and
pilot period fall rates, and Unit 2’s
pilot and project period fall rates. The
one-sample Wilcoxon-signed rank
test was used to allow comparison
between a single fall rate measure for
both units’ pilot periods and the fall
rates from the other study periods.
Robust regression analysis was used
to assess whether median intervals
between rounds increased, which
would indicate decreasing compliance
with hourly rounding as prescribed.
Robust regression analysis also was
used to examine whether round com-
pletion percentages and staff report of
completion percentages increased.
Similarly, this would indicate deterio-
rating compliance with the program.
P < 0.05 was considered statistically
significant. All analyses were con-
ducted using Stata v. 12 (Stata Corp.,
College Station, Tex.).
Results
Fall rate data. In Unit 1, the 1-year
baseline mean fall rate was 3.9
falls/1,000 patient days, significantly
above the National Database of Nurs-
ing Quality Indicators benchmark. A
marginally significant drop occurred
during the project period to 2.5
falls/1,000 patient days (P = 0.059).
The pilot period fall rate of 1.3
falls/1,000 patient days was signifi-
cantly lower than the baseline fall
rate (P = 0.006). The project and
pilot period fall rates did not differ
significantly (P = 0.202). In Unit 2,
the 1-year baseline mean fall rate was
2.6 falls/1,000 patient days, which
fell, but not significantly, to 2.5
falls/1,000 patient days during the
pilot period (P = 0.799).
Process compliance data. Fifty-
six patient flow sheets were selected
randomly for review during the pilot,
27 from Unit 1 and 29 from Unit 2.
The times that rounding was
recorded were then examined to
determine if intervals between rounds
increased during the pilot period for
each unit. The overall time between
rounds was very close to 1 hour for
the period from 0600 to 2200 hours,
as prescribed, but also close to 1 hour
between 2200 and 0600 hours when
rounds were required only every
2 hours. During the pilot, the mean
time between rounds did not increase
significantly on either Unit 1
(P = 0.133) or Unit 2 (P = 0.712).
Besides the documentation review,
108 rounds were observed, with
88% of the prescribed steps being
completed on average. Attention to
patients’ comfort needs (which
occurred in 98% of rounds) and
access to the call bell (which
occurred in 97% of rounds) were the
most-often performed tasks in the
patient-centered round, but commu-
nication of when the next round
would occur took place in only 67%
of rounds completed. For both units
combined, the midnight shift
showed the greatest compliance with
an average extent of completion of
97% (N = 12). (See Observed compli-
ance with patient-centered hourly
rounding.) The extent to which each
round was completed did not fall
significantly over time for either Unit
1 (P = 0.704) or Unit 2 (P = 0.713).
Researchers surveyed 108 staff
members who reported completing
an average of 87% of the requirements
Defining a patient-centered proactive hourly round
1. Hello, I’m your nurse_______________. I’m here to do rounds.
2. Assess patient’s pain levels using appropriate assessment scale. If PCT is
rounding, ask the patient if he or she is in pain, and contact nurse immediately.
Provide pain medication as appropriate.
3. Offer toileting assistance (urinal, bedside commode, bathroom).
4. Assess the patient’s position, and reposition if necessary.
5. Put the call bell within reach, and have patient perform teach-back.
6. Put telephone, TV, bedside table, tissues, and personal items within patient’s reach.
7. Place trash can next to the bed, straighten up room, and put any trash in the can.
8. What else I can do for you before I leave? I have time.
9. I, or another member of the healthcare team, will be back in the room at
<state time>. Until then, please do not get up without notifying us. Please use
your call bell.
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4. RESEARCH CORNER
28 l Nursing2015 l February www.Nursing2015.com
Observed compliance with patient-centered hourly rounding*
Breakdown by
unit and shift
Total Greet-
ing
Toilet-
ing
Pain Posi-
tion
Other
com-
fort
needs
Room
envi-
ron-
ment
Call
bell
“Is there
anything
else I can
do for
you?”
Specified
when
coming
back
Number
of obser-
vations
All 88% 77% 86% 91% 92% 98% 90% 97% 91% 67% 108
Shift Day 87% 71% 89% 91% 92% 98% 85% 100% 94% 60% 56
Evening 86% 80% 80% 90% 90% 97% 95% 95% 85% 70% 40
Midnight 97% 100% 91% 100% 100% 100% 100% 91% 100% 91% 12
Unit 1 90% 77% 96% 87% 96% 100% 96% 100% 90% 68% 54
Unit 2 86% 77% 75% 96% 88% 96% 85% 94% 92% 66% 54
*As defined.
of each round. Staff reported asking
patients if they could do anything else
for them most frequently (occurred
in 96% of completed rounds), but
reported addressing positioning with
patients in only 73% of the rounds in
which this would have been appro-
priate. (See Self-reported compliance
with patient-centered hourly rounding.)
The extent to which staff reported
that each round was completed did
not fall significantly over time for
either Unit 1 (P = 0.827) or Unit 2
(P = 0.194).
Staff survey data. Ninety-four
percent of staff on Unit 1 (17/18)
reported that they believed patient-
centered hourly rounding had either
a positive or strong positive impact
on patient care overall, and 89%
(16/18) believed that patient-centered
hourly rounding is an effective fall
prevention strategy. Thirty-nine
percent of staff on Unit 1 (7/18)
perceived their overall workload to
have been reduced following the
introduction of patient-centered
hourly rounding, and 83% (15/18)
reported a reduction in call bell use
by patients. Eighty-nine percent of
staff surveyed on Unit 1 (16/18)
would recommend that other units
adopt patient-centered hourly round-
ing. (See Staff survey data.)
By contrast, only 25% of staff on
Unit 2 (5/20) reported that they
believed patient-centered hourly
rounding had a positive impact on
patient care overall and only 50%
(10/20) believed that patient-centered
hourly rounding is an effective fall
prevention strategy. No staff on Unit
2 perceived their overall workload to
have been reduced following the
introduction of patient-centered
hourly rounding and only 10%
(2/20) reported a reduction in call
bell use by patients. Only 25% of
staff surveyed on Unit 2 (5/20) would
recommend that other units adopt
patient-centered hourly rounding.
Discussion
We found that engaging an interdisci-
plinary team, including leadership and
unit champions, to complete a Lean
Six Sigma process improvement proj-
ect and implement a patient-centered
proactive hourly rounding program
was associated with a significant
reduction in the fall rate. Implementa-
tion of the same patient-centered
proactive hourly rounding program in
the absence of engaging leadership or
front-line staff in program design did
not impact the fall rate.
This discrepancy cannot be
accounted for as a function of suc-
cessful implementation because both
units showed excellent compliance
with the process. Since this compli-
ance did not decline during the
pilot, our data suggest that patient-
centered hourly rounding is likely a
sustainable strategy. However, the
success of the program is associated
with staff perceptions of the inter-
vention. On Unit 1, where leader-
ship and front-line staff were actively
involved in program design and unit
champions were designated during
the project run-in period, staff per-
ception about the program and its
impact on their own workload and
patients was highly positive. On
Unit 2, only a minority of staff were
positive about the impact of the
program.
Our findings strongly endorse the
inclusion of leadership support and
engagement of front-line staff in suc-
cessful fall prevention program
design. As our data show, these fea-
tures are not impacting process
implementation. Rather, we believe,
based on anecdotal evidence we
observed during the pilots, that they
may be impacting the patient cen-
teredness of the rounds. This would
be consistent with observations that
systems that foster staff accountabil-
ity may contribute to success in fall
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5. www.Nursing2015.com February l Nursing2015 l 29
prevention.9,10
The discrepancies in
the staff survey data also suggest that
staff buy-in to the fall prevention
program and its goals may be limited
in the absence of leadership support,
engagement of front-line staff in pro-
gram design, and a clinical nurse
champion. Staff buy-in is a critical
component of any process improve-
ment project,11
and leadership
including staff in the development
process has been shown to nurture a
sense of ownership of the outcome.12
On Unit 2, where hourly rounding
did not impact the fall rate, staff were
asked to recognize the value of
patient-centered hourly rounding
through one-way learning, where
information passes from decision
makers to those in practice roles. On
Unit 1, where hourly rounding com-
bined with a project run-in period
did impact the fall rate, two-way
learning occurred through staff
engagement in program develop-
ment. This learning is typically much
deeper and acknowledges that staff
can add to the knowledge base dur-
ing program design.
Much of the reduction in fall rate
observed on Unit 1 occurred during
the transition from the baseline
period to the project run-in period.
This was the time when leadership
and staff were working closely
together with the goals of reducing
falls through establishing a culture of
accountability for fall prevention and
developing staff buy-in to the goals.
While the significant reduction in fall
rates was not observed until the
cumulative stages of project develop-
ment and program implementation
had occurred, these data indicate that
engaging an interdisciplinary team
and including leadership and unit
champions in fall prevention program
development may be critical compo-
nents of any fall prevention effort.
The primary limitation of our
study was the short pilot period of
just 30 days. The consistency of the
process data suggests that patient-
centered hourly rounding is a sus-
tainable intervention, but further
investigation of the impact over a
longer period is needed. Much of the
literature about falls has only limited
data, but based on the success of the
pilot, we have the support of our
institution to implement patient-
centered hourly rounding for a lon-
ger period. During this longer study,
the issue of staff noncompliance,
although low, must be addressed.
The engagement of unit staff and
leadership in program design on
Unit 1 may actually have resulted in
the effect on fall rates being observed
prior to the start of the pilot.
Incorporating hourly rounding
into an already-established fall pre-
vention program has been shown to
strengthen the program and decrease
fall rates.13
Hourly rounding also has
been shown to reduce call bell
usage; call-bell usage is associated
with patient falls.8,14
However, evi-
dence regarding hourly rounding as
a primary strategy to reduce patient
falls is inconclusive.15
Further investi-
gation into whether hourly rounding
is a robust stand-alone fall prevention
strategy is required. Similarly, future
studies should consider whether any
fall prevention program that is suit-
able for the patient population may
be effective if implemented through a
process characterized by leadership
support that engages front-line staff
in program design.
Despite limitations, our findings
provide compelling evidence that the
implementation of a patient-centered
hourly rounding program following
specific design with leadership
support and engagement of front-
line staff is an effective fall preven-
tion strategy. Staff buy-in and
accountability should be fostered
through the design and implementa-
tion processes and two-way learning
Self-reported compliance with patient-centered hourly rounding*
By shift and
by unit
Total Greet-
ing
Toilet-
ing
Posi-
tion
Pain Com-
fort
needs
Room
envi-
ron-
ment
Call
bell
"Is there
anything
else I
can do
for you?"
Speci-
fied
when
coming
back
Docu-
menta-
tion
com-
pleted
Num-
ber of
surveys
All 87% 95% 89% 73% 90% 90% 76% 93% 96% 76% 89% 165
Shift Day 88% 93% 88% 71% 91% 88% 84% 93% 97% 80% 80% 45
Evening 88% 100% 87% 75% 89% 90% 81% 92% 96% 73% 89% 65
Midnight 87% 90% 92% 72% 92% 90% 65% 96% 96% 76% 96% 55
Unit 1 89% 100% 90% 70% 87% 88% 82% 97% 97% 77% 93% 81
Unit 2 86% 90% 89% 76% 94% 91% 71% 90% 96% 75% 84% 84
*As defined.
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6. RESEARCH CORNER
30 l Nursing2015 l February www.Nursing2015.com
should be used in staff training where
possible.
Conclusion
We found that a patient-centered
proactive hourly rounding program,
where leadership and front-line staff
were actively involved in program
design and unit champions were
designated during the project
run-in period, significantly reduced
inpatient fall rates in an adult medi-
cal unit and reduced call bell use. In
the absence of leadership engage-
ment, program development with
front-line staff, and unit champions,
patient-centered hourly rounding
does not appear to be an effective fall
prevention strategy. ■
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toolkit/fallpxtk4.html.
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At Christiana Care Health System in Wilmington, Del.,
Jennifer Goldsack is a research associate at the Value
Institute, Susan Mascioli is the director of nursing
quality and safety, and Janet Cunningham is vice
president of professional excellence and associate
CNO. Meredith Bergey is a research associate at the
Value Institute of Christiana Care Health System.
The authors acknowledge the work of the LeSS Falls
Team: Courtney Crannell, RN; Christine DeRitter,
RN; Amy Harty, PCT; Constance Jordan, RN; Kristi
Lester, RN; Denise Lyons, RN; Barbara Marandola,
RN; Carys Price, PT; James Ruther, MD; Eva Smith,
RN; Scott Shoop, PharmD; Amy Spencer, RN; Janice
Sullivan, MPT; and Teresa Zack, RN. The authors also
acknowledge Natalie Dyke for her diligent collection
of compliance data from staff on the study units
and Lisa Maturo for her excellent work entering and
formatting all of the process data.
Research Corner is coordinated by Cheryl Dumont,
PhD, RN, CRNI, director of nursing research and the
vascular access team at Winchester Medical Center
in Winchester, Va., and a member of the Nursing2015
editorial board.
The content in this article has received appropriate
institutional review board and/or administrative
approval for publication.
The authors have disclosed that they have no
financial relationships related to this article.
DOI-10.1097/01.NURSE.0000459798.79840.95
Staff survey data*
Unit 1 (N=18) Unit 2 (N=20)
Impact of patient-centered hourly rounding on patient care overall
Strong negative impact
Negative impact
No impact
Positive impact
Strong positive impact
0 (0%)
0 (0%)
1 (6%)
10 (56%)
7 (39%)
0 (0%)
0 (0%)
15 (75%)
5 (25%)
0 (0%)
Patient-centered hourly rounding as an effective fall prevention strategy
Highly ineffective
Ineffective
No impact
Effective
Highly effective
0 (0%)
0 (0%)
2 (11%)
8 (44%)
8 (44%)
1 (5%)
1 (5%)
8 (40%)
9 (45%)
1 (5%)
Impact of patient-centered hourly rounding on overall workload
Significant increase in workload
Some increase in workload
No impact on workload
Some decrease in workload
Significant decrease in workload
0 (0%)
3 (17%)
8 (44%)
7 (39%)
0 (0%)
0 (0%)
9 (45%)
11 (55%)
0 (0%)
0 (0%)
Impact of patient-centered hourly rounding on call bell use
Significant increase in call bell use
Some increase in call bell use
No impact on call bell use
Some decrease in call bell use
Significant decrease in call bell use
0 (0%)
0 (0%)
3 (17%)
9 (50%)
6 (33%)
0 (0%)
1 (5%)
17 (85%)
2 (10%)
0 (0%)
Recommendation of patient-centered hourly rounding to other units
Recommendation not to adopt
Recommendation to adopt
No recommendation
1 (6%)
16 (89%)
1 (6%)
4 (20%)
5 (25%)
11 (55%)
*Some percentages do not add up to 100% due to rounding.
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