Proactive Patient Rounding Reduces Call Light Use and Falls, Eliminates Pressure Ulcers, and Enhances Patient and Staff Satisfaction

Problem Addressed

• Many nonurgent calls, most of which do not require a nurse: Patients use call lights for many reasons, including pain management, assistance with self-care tasks (such as toileting, ambulating, and eating), comfort requests (such as repositioning or securing out-of-reach items), and information requests.¹ A large proportion of these requests are not urgent and/or could be handled by someone other than a nurse, such as a certified nursing assistant (CNA).¹ Nurses at Northeastern Hospital found that patients used call lights excessively, primarily for nonurgent needs.²
• Negative impact on nurses, quality of care: The negative implications of excessive call light use include nursing workflow interruptions, less nurse time available to provide medical care to patients, nurse burnout and job dissatisfaction, and lower patient satisfaction.¹ In addition, excessive call light use can prompt a delayed response time by nurses, leading to safety risks such as an increase in patient falls.¹ At Northeastern Hospital, the constant ringing of call lights caused nursing staff to become desensitized, and as a result they did not answer the calls promptly.²

Description of the Innovative Activity

• Rounding logistics: A member of the nursing staff visits each patient every hour between 6 a.m. and 10 p.m., and every 2 hours between 10 p.m. and 6 a.m. Rounds are usually performed by CNAs, who receive a list of patients at the start of their shift. If the CNA is busy caring for another patient with many needs and thus cannot accomplish an hourly round, he/she notifies the registered nurse (RN), who then performs the rounding. RNs also perform rounding duties if they enter the patient’s room to administer medications or provide other medical care; this activity replaces the need for the round by the certified nurse assistant during that hour.
• Rounding activities: During the first round of a shift, the staff member takes the patient's vital signs. At each visit, the nursing staff member greets the patient, assesses pain levels, offers toileting assistance, looks at the patient’s intravenous (IV) site, assesses the patient’s position and level of comfort, ensures that all necessary items (e.g., call light, telephone, television remote control, bed light switch, bedside table, tissues, water, garbage can) are within the patient’s reach, and asks the patient if he/she has any other needs. If the patient is in pain, the CNA notifies the RN immediately so that he/she can administer pain medication and/or discuss pain management with the patient’s physician. Staff generally do not wake sleeping patients, but they will awaken and turn bedridden patients and check incontinent patients for cleanliness and skin integrity at each rounding visit as a required part of care.
• Departure script: At the end of the visit, the staff member asks if the patient needs anything else and reminds him or her that someone will be back in an hour (or 2 hours during the overnight shift).
• Rounding log: A Patient Safety Rounding Log is kept for each patient, hung on a clipboard outside the room. After each visit, the nurse or CNA writes his/her name, the time of the round, and any relevant comments on the log sheet, such as the patient reporting pain, patient being turned, visitors present, or toileting assistance provided.
• Rounding log review: The nurse manager on the unit reviews the comments on the rounding log sheets after each shift to identify problems to be addressed (such as patients who continually report pain) and other information that can be valuable in providing patient care (e.g., presence of family members who can be consulted).
• Reminders to ancillary staff: Small posters (called "Keep Everything in Reach") placed above each bed remind ancillary caregivers (e.g., physical therapists, respiratory therapists, transport personnel, and others) to replace any items moved out of the patient’s reach while providing care.

References/Related Articles

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Results

• Fewer calls: The number of call lights fell by 65 percent on Northeastern's medical-surgical unit (actual data are not available).¹ Anecdotal feedback reveals that call lights blinked constantly prior to program implementation, but now they light up very rarely. Most calls now come from patients with truly important needs or from newly admitted patients (who quickly stop using the call lights once they learn the routine). While nursing staff had previously become desensitized to the call lights because of their frequency, they now answer them very promptly, as they know they have been activated for a meaningful need.
• Fewer falls: Falls have been reduced by roughly 65 percent since hospital-wide implementation of the rounding program, reaching 3.0 per 1,000 patients by the end of 2008.
• Elimination of pressure ulcers and skin breakdown: After implementation of rounding, the incidence of hospital-acquired ulcers and skin breakdown fell to zero and remained there through 2008 (incidence rates prior to implementation are not available).
• Anecdotal reports of fewer medication errors and IV complications: While no hard data are available, the nurse manager reports a significant decline in medication errors, likely because nurses are less distracted by call lights. The manager also reports fewer IV complications (e.g., IV infiltration due to a dislodged IV, collapsed vein, etc.), largely because staff check IV lines during each rounding visit and address any swelling, redness, pain, or other early signs of complications immediately.
• Higher patient and staff satisfaction: The percentage of patients rating patient care as “excellent” increased from the 50-60 percent range before program implementation to 99 percent afterwards. These high rates have been maintained through 2008. Anecdotal reports suggest that nurses and certified nursing assistants are highly satisfied with the rounding system; at weekly meetings, nursing staff members report fewer interruptions and more time for activities such as patient education and better documentation.
• Lower overtime costs: The nurse manager reports that overtime costs have declined considerably since implementing the rounding process as a result of better time management on the part of the nursing staff (no data available).

• Fewer calls: In groups implementing 1-hour rounding, call light use declined by 37 percent between the baseline 2-week period (weeks 1 and 2) and the second 2-week analysis period (weeks 5 and 6). In groups implementing 2-hour rounding, call light use declined by 19 percent during this same time period. While decreases occurred in all five categories of use (serious medical concerns, secondary medical concerns, nonserious personal or health issues, room amenities, and no reason/miscellaneous), the largest declines occurred in calls for nonserious personal or health issues and room amenities, with declines of 43 and 40 percent, respectively, in the 1-hour rounding group, and declines of 24 and 44 percent, respectively, in the 2-hour rounding group.
• Fewer falls: In the 1-hour rounding group, the number of falls declined by more than 50 percent, from 25 in the 4 weeks prior to implementation to 12 in the 4 weeks afterwards. The number of falls also declined in the 2-hour rounding group, but this change was not statistically significant.
• Higher patient satisfaction: In the 1-hour rounding group, the mean patient satisfaction score rose from 79.9 (on a 100-point scale) during the 4 weeks the program began to 91.9 in the 4 weeks after implementation. In the 2-hour rounding group, the mean patient satisfaction score increased from 70.4 to 82.1 during the same time period.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Presentation to staff: The Studer Group made a presentation to the 28 nursing staff members on Northeastern Hospital’s medical/surgical unit; the presentation discussed the rationale for the pilot project, described the rounding process and activities, and provided scripting for use with patients.
• Nurse manager-staff discussions to win support: The nurse manager of the medical/surgical unit talked to staff members individually and emphasized that, over the long term, the new process would help save time during their 12-hour shifts.
• Amendment of rounding log sheets: Staff amended a rounding log template provided by the Studer Group to meet hospital needs, shifting from round-the-clock hourly rounds to the adopted schedule of hourly rounds between 6:00 a.m. and 10:00 p.m. and rounds every 2 hours from 10:00 p.m. to 6:00 a.m. This change was made to accommodate tighter nighttime staffing and to reflect the reduced needs of sleeping patients.
• Pilot study and expansion: The unit participated in the 6-week pilot study. Based on its success, leaders decided to expand the program throughout the hospital.
• Staff training: All nursing staff members attended a 3-hour mandatory training session; this training is now incorporated into the orientation process for new hires.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: Development costs included 3 hours of overtime per staff member for mandatory training.

Funding Sources

Northeastern Hospital

Getting Started with This Innovation

• Highlight nurse-specific benefits to staff: While patient satisfaction is clearly important, nurses may be more enthusiastic about participating if made aware of the potential benefits to workload and satisfaction.
• Discuss rounding with individual staff: The nurse manager should let each staff member know that his/her rounding activities and entries in the rounding log are important. In particular, managers should provide encouragement to nursing aides, who may feel more empowered with regard to patient care as a result of the program. 

Sustaining This Innovation

• Monitor carefully: The nurse manager should expend considerable time and effort in monitoring the rounding process, particularly during the first 3 months when staff may try to take “shortcuts.” For example, at Northeastern Hospital, some staff completed the rounding sheet for the whole shift at the start of the shift (in other words, prior to actually performing the rounding activities). Eventually, with ongoing monitoring and emphasis on expectations and penalties for falsification of documentation, staff members began to understand that rounding was a required part of their work day that should be taken seriously.
• Be patient: The program can take between 6 and 12 months to become "hard-wired" into the nursing workflow.

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