: EBP Project Introduction and Title Page
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CapstoneSamplePaper_RoundingtoPreventFalls.docx
ROUND WITH A PURPOSE: PURPOSEFUL HOURLY ROUNDING AND THE IMPACT ON THE REDUCTION OF FALLS IN HOSPITALIZED PATIENTS WITH IMPAIRED MOBILITY
by
Student Name
Evidence-based Practice Project
Submitted to the Faculty of NUR 49800 Capstone Course in Nursing
College of Nursing
of Purdue University Northwest,
Hammond, Indiana
in partial fulfillment of course requirements for the degree of
Bachelor of Science
February, 2019
© copyright
bethany galezio
2019
all rights reserved
acknowledgments
As I complete this evidence-based practice project proposal, many thanks go out to Gail D. Wegner, DNP, RN, CNS, Ellen M. Moore, DNP, RN, FNP, Bridget Shoulders, MS, ACNP-BC, CCRN-CMC, and my clinical liaison, D. H., MSN, RN, CMSRN, RN-BC. Their support and scholarly criticism have helped me accomplish this project which has meant a lot to me as I pursue excellence in my professional nursing practice.
table of contents
Section Page
acknowledgments iii
table of contents iv
abstract v
Sections
1. Introduction 1
2. Review of Literature and Synthesis of the Evidence 4
3. Plan for Implementation 16
4. Plan for Evaluation 25
5. Conclusions, Recommendations and Implications 33
references 35
List of tables
Table Page
Table 1 Summary of Reviewed Evidence 10
Table 2 Estimated Timetable Blueprint for Implementation 23
Table 3 EBP Evaluation Plan 29
ABSTRACT
Purpose: The purpose of this evidence-based practice project is to determine if implementing purposeful hourly rounding and standardizing this practice will result in reducing the number of falls that occur.
PICO Question: “In hospitalized adult patients with impaired mobility, what is the effectiveness of purposeful hourly rounding compared to not doing routine purposeful hourly rounding on reducing the number of falls?”
Significance of the Problem: Falls are a prevalent issue in healthcare facilities and the community worldwide. Despite the numerous fall interventions in place to prevent them, falls continue to occur. Falls are a patient safety and quality of care issue that are associated with negative outcomes including extended hospital stay, injury, death, anxiety, and decreased satisfaction as well as increased financial costs.
Synthesis of the Evidence: A review of research and evidence suggests that consistent purposeful hourly rounding while implementing the 4Ps (pain, potty, position, possessions) can reduce the incidence of falls that occur in hospitals. Purposeful hourly rounding is a suggested technique to address patient needs while enhancing their safety and overall healthcare experience.
Recommended Implementation for Practice Change: Sufficient research suggests that consistent purposeful hourly rounding leads to positive patient outcomes including reduction in the number of falls. Thus, this knowledge should prompt the development and implementation of an evidence-based purposeful rounding program by taking a multidisciplinary approach.
Conclusions/Recommendations for Practice: The recommendation is to pursue an evidence-based purposeful rounding program to prevent and reduce the incidence of falls in hospitalized adult patients. Once developed, the program should be attempted through a trial run on a unit with a high incidence rate of falls. The trial run outcomes will determine the practicability of implementing the program hospital wide.
Key Words: fall prevention, hourly rounding, purposeful rounding, purposeful hourly rounding, rounding
ROUND WITH A PURPOSE ii
section 1
Round with a Purpose: Purposeful Hourly Rounding and the Impact on the Reduction of Falls in Hospitalized Patients with Impaired Mobility
Falls continue to be a major safety issue in healthcare facilities despite all that is done to prevent them and maximize patient safety. Falls can lead to numerous negative health outcomes and continue to be a day-to-day challenge in healthcare facilities worldwide.
Purpose
The purpose of this evidence-based practice project is to determine if implementing purposeful hourly rounding and standardizing this practice will result in reducing the number of falls that occur.
Relevance
A fall is defined as an unexpected or unintentional descent to the floor, whether it is with or without injury (Agency for Healthcare Research and Quality [ARHQ], 2018, p. 1). Falls are a prevalent issue in healthcare facilities and the community worldwide and they account for the largest amount of reported adverse events in hospitals. Falls can cause non-fatal and fatal injuries, most being non-fatal, but approximately 424,000 people die each year due to falls worldwide (Avanecean, Calliste, Contreras, Lim, & Fitzpatrick, 2017, p. 3007). The ARHQ estimates that in the United States, 700,000 to 1 million falls occur in hospitals each year (2018, p. 1). When falls occur, patients may develop a fear of falling which can cause them to limit their physical activities which can lead to decreased mobility, strength, and independence, only further increasing their risk of falling (Hicks, 2015, p. 51). Other negative patient outcomes of falls include extended hospital stay, injury, death, anxiety, and decreased satisfaction with the care they receive.
Although elderly individuals are the most common population considered to be vulnerable to falls, any patient of any age can be at an increased risk for falls due to medications, medical conditions, and procedures because of an altered physical or mental state. Nurses are responsible for assessing the patient’s risk for falling on admission to the hospital unit and each shift, using a fall risk assessment tool. Fall risk assessment tool scores show the level of risk which guides the patient-specific fall prevention interventions implemented. Despite the numerous fall interventions (bed/chair alarms, non-slip footwear, gait belts, fall signage, etc.) in place to prevent them, falls continue to occur which is why change is necessary. The nursing staff is ultimately responsible for patient safety and the number of falls that occur can be directly associated with the quality of care that is provided.
Potential Outcomes
The 4South Orthopedic/Neurology unit of Hospital A needs to evaluate the effectiveness of implementing purposeful hourly rounding. Standardizing the practice of purposeful hourly rounding and using it consistently could potentially reduce the number of falls. Also, patient falls typically mean higher healthcare costs and increased length of hospital stay. By anticipating the needs of patients and being more proactive, rather than reactive, positive outcomes such as decreased fall rates could occur and thus increasing the safety of patients, and decreasing the length of hospital stay and healthcare costs. Overall, these ensure a higher quality of nursing care.
Clinical Question (PICO)
“In hospitalized adult patients with impaired mobility, what is the effectiveness of purposeful hourly rounding compared to not doing routine purposeful hourly rounding on reducing the number of falls?”
Section 2
Review of Literature and Synthesis of Evidence
To address the clinical question (PICO), “In hospitalized adult patients with impaired mobility, what is the effectiveness of purposeful hourly rounding compared to not doing routine purposeful hourly rounding on reducing the number of falls?”, a literature review was completed using keywords. These keywords included, “fall prevention”, “hourly rounding”, “purposeful rounding”, “purposeful hourly rounding”, and “rounding”. The databases/websites used were The Joanna Briggs Institute, AHRQ National Guideline Clearinghouse, CINAHL, The Joint Commission, and Cochrane Library-Cochrane Database of Systematic Reviews. When using these databases, advanced search limits were used such as “English language”, “full text”, “peer-reviewed”, and date range (2014 to present) as well as Boolean operators (and, or) to narrow the search for the best available evidence. This search generated sixteen journal articles, clinical guidelines, or studies that offered pertinent information relating to answering the clinical question (PICO) of interest. After appraisal of the evidence using Melnyk’s level of evidence hierarchy (2011), a total of eight articles were utilized to address the clinical question (PICO): Level 1- two sources, Level 3- two sources, Level 4- two sources, Level 5- one source, and Level 7- one source.
Literature Common Themes
Common themes found in the literature were the definition of purposeful hourly rounding, the implementation process of hourly rounding, and the impact hourly rounding can have on the prevention and reduction of falls. Other common topics discussed were the impacts hourly rounding can have on call light usage, patient and nurse satisfaction, safety, and healthcare costs.
Definition of purposeful hourly rounding. The literature consistently discusses that purposeful hourly rounding involves intentionally checking on patients at systematic and routine intervals to meet their fundamental needs proactively, rather than reactively (Hicks, 2015, p. 51). Rounding is considered an intervention that can be applied to all patients regardless of their level of fall risk (Avanecean et al., 2017, p. 3010). Typically, purposeful rounding also demands focus on addressing the 4Ps (pain, potty, position, possessions) or a similar method. Other key components include assessing the environment for safety concerns and letting the patient know when staff will return (The Joanna Briggs Institute, 2016, p. 2). Purposeful hourly rounding, also known as intentional rounding, is a suggested technique to address patient needs while enhancing their safety and overall healthcare experience.
Implementing hourly rounding. Evidence consistently supports that nursing rounding be performed hourly or at least every two hours during the evening hours. Additionally, The Joanna Briggs Institute (2016) is one of numerous other clinical practice guidelines and studies that recommends implementation of evidence-based practice protocols such as, the “12 steps” or “4Ps” to further reduce the number of patient falls (p. 2). The ARHQ (2018) created a toolkit that includes methods of assessing the fall risk of a patient, interventions to implement to prevent falls (with a section focused on hourly rounding), and ways to evaluate the effectiveness of these interventions. The toolkit also offers a specific scheduled rounding protocol for nursing to follow which is consistent with other sources reviewed regarding implementation of hourly rounding (p. 130).
Inconsistencies involving the frequency of rounding, who performs the rounding, and documentation of the rounding were found in the literature review. While evidence supports rounding being done hourly or at least every two hours during evening hours, the exact times varied between studies. Some studies compared hourly rounding from 0600 to 2200 and then every two-hour rounding from 2200 to 0600, while others did rounding at all hours or just every two hours (Olrich, Kalman, & Nigolian, 2012, p. 25). Other studies performed hourly rounding from 0700 to 2200 and then every two-hour rounding from 2200 to 0700 (The Joanna Briggs Institute, 2016, p. 1). Variances regarding who performed the rounding were evident as well. Some studies were found to have only Registered Nurses (RNs) or other nursing staff such as Certified Nursing Assistants (CNAs) or Patient Care Technicians (PCTs) do the rounding. In other studies, a combination of both RNs and CNAs/PCTs with each rounding on alternating hours was performed (Mitchell, Lavenberg, Trotta, & Umsheid, 2014, p. 469). There were also few studies that discussed methods of documenting or recording the hourly rounding being done. One study mentioned keeping a logbook to record the rounding (in which elements were found to have been missing from the logbook), but other methods were not discussed (Mitchell et al., 2014, p. 470).
Fall prevention and reduction. Evidence found in the literature consistently supports the implementation of purposeful hourly rounding in hospitals to reduce falls. One quasi-experimental study (506-bed U.S. hospital; two medical-surgical units-one experimental unit, one control unit), compared data before and after implementation of hourly rounding and found that there was a 23% decrease in fall rates (Olrich et al., 2012, p. 25). In another quasi-experimental study (consisting of 22 hospitals and 27 units), implementation of hourly rounding, including a 12-step nursing round protocol, reduced falls (The Joanna Briggs Institute, 2016, p. 1). Another study discussed in an integrative review (34-bed orthopedic-medical-surgical unit), found that when purposeful hourly rounding and the 4Ps (pain, position, potty, possessions) were used, falls decreased from 5.42 to 3.94 per 1,000 patient days. In that same integrative review, eleven out of the fourteen studies had decreased fall rates when some type of nursing rounding was implemented (Hicks, 2015, p. 52). A systematic review (involving five randomized control trials-RCTs), discussed that when patient-centered interventions (including regular rounding) were implemented, decreased fall rates were found to have occurred in three of the five studies (Avanecean et al., 2017, p. 3023). Lastly, a mixed method approach implementation project conducted on a 28-bed hospital unit found that when purposeful hourly rounding involving the 4Ps was implemented, patient falls decreased by 50% (Daniels, 2016, p. 249).
In one systematic review involving sixteen studies, it was found that the evidence supporting the use of hourly rounding in hospitals was of low to moderate strength compared to others. According to the review, this was due to weak research design of the studies and inconsistent reporting of the quality, quantity, and consistency of the evidence of hourly rounding. Regardless, it is believed that additional research and evidence would only support the practice of hourly rounding to reduce falls (Mitchell et al., 2014, p. 472).
Existing Knowledge Gaps
When examining the various sources, there were some gaps in knowledge and research that were discussed. For example, several of the studies failed to provide evidence to support that positive effects of hourly rounding could be sustained over an extended period of time. More research is needed on how to sustain hourly rounding over an extended period of time and convince staff of the benefits of practice changes such as purposeful hourly rounding. Additionally, many of the studies were nonrandomized and of small sample sizes so more randomized control trials and of larger sample sizes are necessary to obtain improved results. Based on the review of literature, it is still unclear if there is a more effective method (i.e., 4Ps vs. 12 steps vs. use of a script or checklist) to hourly rounding compared to others and why. Research involving accurate documentation of purposeful hourly rounding is necessary as well. Further research regarding staffing and budget constraints and the effect they can have on the implementation of purposeful hourly rounding could be beneficial too. Lastly, more experimental design studies should be conducted to enhance the levels of evidence surrounding the topic of hourly rounding.
Findings
Overall, evidence suggests that consistent purposeful hourly rounding leads to positive patient outcomes including reduction in the number of falls. There is sufficient research that supports purposeful hourly rounding reduces the number of patient falls when implemented effectively, although additional research involving specific aspects of hourly rounding could be beneficial.
ROUND WITH A PURPOSE 2
PICO Question: “In hospitalized adult patients with impaired mobility, what is the effectiveness of purposeful hourly rounding compared to not doing routine purposeful hourly rounding on reducing the number of falls?”
Keywords: fall prevention, hourly rounding, purposeful rounding, purposeful hourly rounding, rounding
Databases Searched: Joanna Briggs Institute, AHRQ National Guideline Clearinghouse, CINAHL, Cochrane Library-Cochrane Database of Systematic Reviews
Table 1
Summary of Reviewed Evidence
|
Author(s) and Date of Publication ONLY |
Sample/Setting/ Design
|
Data Collection Tools |
Findings/Results
|
Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions |
Level of Evidence (LOE) |
|
Agency for Healthcare Research and Quality (2018) |
Design: Clinical practice guideline Setting: Quality improvement teams at six medical centers in the U.S. developed toolkit from various studies Sample: N=55 papers |
Numerous databases were searched for fall prevention studies. Studies include: systematic reviews, expert opinion, and consensus recommendations. Strategies used by program studies across the U.S. in acute care hospitals are referenced. |
The guideline discusses recommendations of interventions for preventing falls in the hospital setting. Methods of assessing the fall risk of a patient, interventions to implement to prevent falls (with a section focusing on hourly rounding), and ways to evaluate the effectiveness of these interventions were discussed. Offers a specific scheduled rounding protocol for nursing to follow. |
Strengths: The toolkit was created by a team of leaders who are experts in organizational change and prevention of falls. The six hospitals tested out the toolkit recommendations and their results are part of the finalized toolkit. The toolkit was developed through research and quality improvement initiatives. Weaknesses: Does not discuss fall incidence data from the six medical centers that developed the toolkit and applied it to their practice. Data comparing before and after fall prevention program implementation could be useful. Conclusions: This clinical guideline includes valuable recommendations that should be considered for implementation of a fall prevention program, specifically highlighting purposeful hourly rounding. |
LOE: Level 5 |
|
Avanecean, D., Calliste, D., Contreras, T., Lim, Y., & Fitzpatrick, A. (2017) |
Design: Systematic review Setting: Medical/surgical acute care units in four different countries Sample: N=5 articles (RCTs) |
Studies analyzed in the systematic review included quantitative data from five randomized control trials (RCTs), cluster RCTs. JBI-SUMARI tool was used for critical appraisal and quantitative data extracted by four independent reviewers. |
Three of the five RCTs showed significant decreases in fall rates. In these studies, personalized care plans and patient-centered education based on patients’ fall risk was implemented. The other two studies showed no difference in fall rates. |
Strengths: Only RCTs were included in this systematic review. To ensure methodological validity, the Joanna Briggs Institute System for the Unified Management, Assessment, and Review of Information (JBI-SUMARI) tool was used for critical appraisal of the studies before the systematic review was developed. Weaknesses: A meta-analysis is not available. Due to the studies implemented multiple interventions at a time, no conclusion can be made as to which interventions are most effective in preventing falls. Also, not every study mentioned hourly rounding as an intervention. Conclusions: This indicates that patient-centered interventions (such as rounding) and education can potentially reduce the number of falls in acute care settings. |
LOE: Level 1 (systematic review with RCTs) |
|
Daniels, J. (2016) |
Design: pre-post design; implementation project Setting: 28-bed hospital unit in the U.S. Sample: N=32 observations on day shift and N=12 observations on night shift for timeliness of rounds. N=44 observations on combined day and night shifts on the use of the 4Ps protocol when rounding. |
The Joanna Briggs Institute’s Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit tool was used. Direct observation of nurses was done to assess the baseline for when the interventions (hourly rounding) were established. |
Patient falls decreased by 50% when hourly rounding was executed. Highlights the importance of the “4Ps” protocol (pain, position, potty, and possessions/placement). |
Strengths: The JBI tools (evidence-based) are utilized in this implementation project. Offers ideas to “hard wire” new practice and protocol changes with employees. Weaknesses: The results were not compared to a control unit. Direct observation could lead to biased nursing behaviors. Conclusions: The implementation project showed that with the appropriate approach, practice changes can be successful. Practice changes (like hourly rounding) can be a challenge to sustain and further follow up is required to ensure they continue successfully. |
LOE: Level 4 |
|
Hicks, D. (2015) |
Design: N/A Setting: Acute care settings Sample: Fourteen studies (that implemented hourly rounding in their acute care setting) used rounding as a tool in fall prevention were reviewed |
Data was analyzed in acute care settings. Relevant articles were read several times to identify patterns, similarities, and differences between them. Data from each was made into a table organized by source, purpose, sample, interventions, and findings pertinent to falls. |
Eleven of fourteen studies reviewed had decreased number of falls when some type of rounding was implemented. One study had no falls during their time of implementation and two had unchanged fall rates. Rounding varied between the studies (rounding times, who was doing the rounding, and the use of a prepared script/plan) as well as the use of the 3 Ps (pain, position, and personal needs) or 4 Ps (pain, position, potty, and possessions) while rounding. |
Strengths: Only published articles that discussed research in acute care settings were reviewed. The search was performed on credible databases (CINAHL, Healthsource, Journals@ Ovid, and Proquest Nursing databases). Weaknesses: The studies that were selected for review have small sample sizes and nonrandomized samples. In several studies, the length of time for the studies was brief which does not show the effects hourly rounding could have if sustained over time. The use of 4 Ps was not consistent in the sample studies. Conclusions: The reviewed studies showed hope for positive impacts of hourly rounding on reducing falls. |
LOE: N/A |
|
Mitchell, M., Lavenburg, J., Trotta, R., & Umscheid, C. (2014) |
Design: review of pre-post studies Setting: Studies done in hospitals around the world Sample: N=16 studies |
Studies in this were mostly pre-post design and non-randomized. Each study’s evidence was assessed by using the GRADE analysis (based on quality, quantity, consistency) |
This found that there is considerable evidence to support hourly rounding has benefits principally on the reduction of falls, but further research is necessary. |
Strengths: Supports the idea of purposeful hourly rounding as an intervention to reduce falls. GRADE analysis tool was utilized to examine each study’s evidence. Weaknesses: Most studies were pre-post design and non-randomized which can lead to bias. Weak research design and inconsistent interventions (hourly rounding) between the studies makes it difficult to see precise findings concerning hourly rounding and the impact on fall rates. Conclusions: The evidence that supports hourly rounding in acute care settings is of low to moderate strength (based on the GRADE analysis of the studies reviewed). More research needs to be conducted. |
LOE: Level 4 |
|
Olrich, T., Kalman, M., & Nigolian, C. (2012) |
Design: Replication study (quasi-experimental) Setting: 506-bed teaching hospital in northeast U.S. Sample: N=4,418 patients (all patients discharged from the units during the 1-year study period) |
Two medical-surgical units comparable in size were selected for the study. One unit was the control group and the other was the experimental group. Data regarding patient falls was collected for 6 months before hourly rounding was implemented (on the experimental unit) and then for 6 months during implementation. |
Prior to the study, the fall rate on the experimental unit was 3.37/1,000 patient days. The rate decreased to 2.6/1,000 patient days with implementation of hourly rounding (not statistically significant, but it is clinically significant). Fall rates were reduced by 23% on the experimental unit. |
Strengths: Falls decreased on the experimental unit when hourly rounding was implemented. The study had one unit as the control and one as the experimental unit. The focus was only on one intervention (just hourly rounding) to reduce falls. Weaknesses: This experimental study was not original nor was it randomized. It was also a small sample and not done for an extended length in time. Conclusions: The replication study suggests that hourly rounding can positively impact patient fall rates. |
LOE: Level 3 |
|
The Joanna Briggs Institute (2017) |
Design: Clinical practice guideline Setting: Acute in-hospital settings around the world Sample: N=10 papers (of various levels of evidence) |
The guideline’s evidence comes from 3 different clinical practice guidelines, 3 systematic reviews, an umbrella review (of 10 meta-analyses of RCTs), a cluster RCT, and an integrative review. |
The guideline discusses evidence-based practice recommendations for the prevention/reduction of falls in acute care settings-hospitals. Topics discussed involve a multifactorial program: fall risk assessment tools (ex: fall risk due to impaired mobility), patient specific interventions, hourly rounding, and patient education. |
Strengths: Clinical practice guideline is the highest level of evidence. The best practice recommendations are graded based on effectiveness. Weaknesses: Does not include fall incidence data associated with each type of intervention (specifically hourly rounding). Conclusions: This guideline consists of recommended evidence-based interventions (including hourly rounding) that should be included in fall prevention programs specifically involving hospitalized patients with impaired mobility. |
LOE: Level 1 |
|
The Joanna Briggs Institute (2016) |
Design: Clinical practice guideline Setting: Hospitals/Acute care Sample: N=12 studies/papers (of various levels of evidence) |
The guideline’s evidence comes from 5 quasi-experimental designs, 3 systematic reviews, a mixed method study (survey and semi-structured interview), and a pre-post test with a control group. |
The guideline discusses evidence-based practice recommendations to reduce fall rates. Fall rates declined when hourly rounding and use of the 4Ps protocol was implemented from 0700-2200 and every 2 hours 2200-0700. A systematic review cited in the guideline found that hourly rounding showed moderate strength to improve fall rates. |
Strengths: The best practice recommendations are graded based on effectiveness. Weaknesses: Does not include fall incidence data and specific statistics associated with hourly rounding and the 4Ps. Conclusions: This guideline strongly recommends using the 4Ps protocol while hourly rounding to decrease fall rates. |
LOE: Level 3 |
|
The Joint Commission (2015) |
Design: Clinical practice guideline Setting: U.S. healthcare facilities (hospitals) Sample: Not applicable |
The data from the Joint Commission Sentinel Event database supplied the statistics pertaining to falls. |
The guideline outlines evidence-based best practices for the prevention/reduction of falls and references several valuable resources. Provides numerous links to toolkits and resources that have been developed through quality improvement initiatives. |
Strengths: Offers evidence-based actions and recommendations that healthcare organizations can utilize and implement to prevent/reduce falls. Also offers additional resources and tools developed through quality improvement initiatives (i.e. ARHQ toolkit) Weaknesses: The reporting to the Joint Commission is voluntary and only represents a small quantity of actual events that occur. Conclusions: This guideline consists of recommended evidence-based interventions that are beneficial to ensure reduced fall rates and offers valuable statistics to emphasize the current problem of falls.
|
LOE: Level 7 |
Section 3
Plan for Implementation
The 4South Orthopedic/Neurology unit has repeatedly had the highest rate of falls in Hospital A. Consistently implementing an evidence-based practice, such as purposeful hourly rounding, can improve this quality indicator as well as decrease the length of hospital stay and healthcare costs. It can also improve patient and staff satisfaction and ultimately the safety and quality of the patient care provided.
To implement an evidence-based practice, such as purposeful hourly rounding, it can be beneficial to utilize a framework for organizing the change process and promoting action. One framework that can be helpful is the PARIHS (Promoting Action on Research Implementation in Health Services) framework. To ensure successful implementation, the PARIHS framework consists of three key concepts: evidence, context, and facilitation (Hopp & Rittenmeyer, 2012, p. 56-57). The first concept, evidence, involves utilizing knowledge gained through research, clinical experiences, and patient preferences. As the aforementioned literature review has shown, there is evidence to support that reduced fall rates can occur when purposeful hourly rounding is implemented. The second concept, context, involves the environment (4South unit) that the practice change will be implemented in. Context also comprises of considering the 4South unit’s organizational culture, leadership, and evaluation practices when implementing the project. The last component, facilitation, is “the process of enabling or making easier the implementation of evidence into practice” (Hopp & Rittenmeyer, 2012, p. 57). Overall, implementation is more likely to be successful when the “evidence and context are strong and expertly facilitated” (Hopp & Rittenmeyer, 2012, p. 57). These key concepts of the PARIHS framework- evidence, context, and facilitation- will be discussed in depth further and applied to the implementation process of the evidence-based practice project. Stakeholders
The target population for this evidence-based practice project is all patients admitted to the 4South Orthopedic/Neurology unit. The stakeholders for this project include all individuals who are affected by or are involved with the implementation of purposeful hourly rounding. The active stakeholders are the individuals who have a substantial role in making the project successful. The active stakeholders include patients admitted to the 4South Orthopedic/Neurology unit, registered nurses, patient care technicians/assistants (PCT/PCA) , professional staff development specialists, clinical nurse specialists, clinical advisors, and unit managers. The passive stakeholders are the individuals who are not actively involved in the project, but can help it succeed. These individuals include the quality improvement team, finance department, risk management, and nursing administration (Chief Nursing Officer).
To ensure the success of the project, a multidisciplinary purposeful rounding (PR) support team of key individuals will be developed. This PR support team will consist of a team leader, a clinical nurse specialist (who specializes in evidence-based practice regarding fall prevention), a clinical advisor, a professional staff development specialist, a quality improvement representative, a risk management representative, and a group of volunteer PR nurse and PCT/PCA champions who are enthusiastic and encourage other staff members to adapt to the practice change.
Various individuals will need to be persuaded for support of this project. These individuals include: nursing administration, 4South unit manager, clinical nurse specialists, clinical advisors, professional staff development specialists, the finance department (financial analysts), quality improvement management, and risk management. Once approval is attained at the management level, then a few PR support team members (PR team lead, clinical nurse specialist, and clinical advisor) can meet individually with the other indicated areas to explain the fall rate on 4South, the evidence-based practice project outcomes, and to pursue their support. After the necessary project approvals are gained, then information and education regarding the purposeful rounding project will need to be provided to the unit staff members through email communication and unit meetings. Organizational Fit
The purposeful rounding evidence-based practice project has a focus on the 4South Orthopedic/Neurology unit to start, but has the potential for hospital-wide action which is why the project should align with the Hospital’s A mission, vision, and values. The mission statement is “to improve the health of our patients and community through innovation, and excellence in care, education, research, and service.” One of the project outcomes involves improving patient outcomes (specifically falls) which ultimately improves the health of patients and is done through extensive education and research to find the best evidence to positively impact our practice. The vision is “the best care, designed for you” which is shown in the project as patient-centered care through interventions such as purposeful rounding to meet the needs of our patients. The hospital organization values: “purpose, compassion, excellence, and team.” These values will be incorporated into the project as 4South will show that they: 1.) have a true purpose in providing quality patient care by utilizing evidence-based practice, 2.) display an environment filled with compassion through interventions to keep patients safe 3.) cultivate excellence by providing patient-centered care, and 4.) work as a team to improve patient outcomes.
The 4South unit has implemented various other evidence-based practices in the past and continue to do so to ensure the highest quality of care possible for patients. One of these is that waffle mattresses are placed on all beds of patients being admitted for a hip fracture to prevent skin breakdown/pressure-related injuries due to immobility. Another intervention is giving Chlorhexidine Gluconate (CHG) baths to prevent CLABSIs and CAUTIs to those with central lines and foley catheters as well as preoperative and isolation patients. These are both evidence-based interventions that have reduced the number of infections and pressure-related injuries. Looking at how those interventions were put into everyday practice and sustained over time can help gain insight on strategies to successfully implement the PR project.
B arriers to EBP Implementation One potential barrier to implementing the EBP project is the time and resources it takes to educate staff members on the why and how of purposeful rounding. Educating PRN (as needed) staff members can be especially challenging because they are not always as readily available to communicate with and relay current information to compared to full-time staff. Also, educating float pool staff is important as 4South gets help from various float pool staff members and it is key to keep purposeful rounding consistent even when 4South staff members are not present on the unit. Additionally, implementing purposeful rounding and changing the nursing workflow may have staff members concerned about the amount of time spent with each patient to address their needs and the additional tasks at hand.
Another potential barrier is the resistance to change practice based on evidence. Staff members who have been in the nursing field for several years may be comfortable with the routine they have and not as receptive to change. PR training will need to occur to combat this barrier as it will show the need for change to enhance the quality and safety of our patients through improving patient outcomes. The professional staff development specialists and clinical advisors will have a key role in scheduling PR competencies (teach-back/return demonstration) for staff members to demonstrate their understanding of the practice change so that they are capable of and comfortable with applying PR to their practice.
Facilitation Strategies for EBP Implementation
As previously mentioned, facilitation involves making the process of project implementation easier. The individuals who have an impact on the facilitation process, comprise the purposeful rounding (PR) support team. The PR support team’s nurse and PCT/PCA champions can help enable others to become involved in the implementation process and adapt the practice change to ensure success. Also, the PR support team’s clinical advisors and clinical nurse specialists possess the background knowledge that is necessary for successful implementation of an evidence-based practice project such as this one.
Another facilitation strategy is to run a trial of the project on the 4South unit. The trial run will give the PR support team an opportunity to examine purposeful rounding and the implementation strategy closely, gain feedback from patients and staff, review project outcomes (falls, patient/staff satisfaction, call lights, etc.) and determine if implementing the practice on 4South and potentially hospital wide is practicable. Resources Needed
Resources will be essential for successful implementation of the purposeful rounding project. Financial resources will be needed to make the project possible and will be used for: 1.) unit meeting, education, training, and skills competency expenses (e.g. printing expenses) and 2.) printed materials used by staff during purposeful rounding (e.g. rounding log, 4Ps handout). Another critical resource is the additional time that staff will need to dedicate outside of their normal shifts on the unit. These additional time commitments involve unit meetings, education/trainings, and skills competencies as well as responsibilities specific to the PR support team. It will also be expected that leadership management members dedicate time to rounding on the unit to verify the performance of the rounding by staff.
Approval for these necessary resources will first be confirmed for the trial run of the project. After the trial run occurs and data is collected, the outcomes (such as fall rate) can be evaluated further to predict the financial feasibility of the project continuing on the 4South unit and potentially expanding to the entire hospital.
Table 2
Estimated Timetable Blueprint for Implementation
|
Task |
Estimated Date of Start |
Estimated Date of Completion |
Person Responsible |
|
-Gain approval from nursing management for PR project
|
3/4/19 (2 weeks) -concurrent task |
3/15/19 |
-Nursing Management -Student -Clinical advisor -Clinical nurse specialist (EBP expert) |
|
-Gain approval from finance department (project expenses) |
3/4/19 (2 weeks) -concurrent task |
3/15/19 |
-Finance Department -Student -Clinical advisor -Clinical nurse specialist (EBP expert) |
|
-Establish PR support team members (roles and responsibilities) |
3/18/19 (2 weeks) |
4/5/19 |
-PR team leader -Clinical advisor -Clinical nurse specialist (EBP expert) |
|
-Gain support for project from important departments (risk management, quality improvement, etc.) and encourage interdisciplinary collaboration by holding a meeting -Inform them of project at the meeting and encourage open discussion |
4/8/19 (1 week) |
4/12/19 |
-PR team leader -Clinical advisor -Clinical nurse specialist (EBP expert) -Risk management -Quality improvement |
|
-Determine and design education/training materials for educating nursing staff |
4/15/19 (2 weeks) |
4/26/19 |
-PR support team -Clinical advisor -Clinical nurse specialist (EBP expert) |
|
-Present PR project plan to 4South unit nursing staff through mandatory meetings to discuss falls, rounding, 4Ps, outcome measures, expectations, etc. -At this meeting, provide education/training to nursing staff on new PR project and when trial run will begin |
4/29/19 (3 weeks) -meetings offered at various times |
5/17/19 |
-PR support team -Clinical advisor -Clinical nurse specialist (EBP expert) -Nursing unit staff (nurses, PCTs/PCAs) |
|
-Determine the nurse and PCT/PCA champions (have meetings for them to attend if they are interested in learning more and being involved) |
5/20/19 (2 weeks) |
5/31/19 |
-PR team leader -Clinical advisor -Clinical nurse specialist (EBP expert) -Nursing management -Volunteer champions |
|
-Skills competency check-offs |
6/3/19 (3 weeks)
|
6/21/19 |
-PR support team -Clinical advisor -Clinical nurse specialist (EBP expert) -Nursing unit staff (nurses, PCTs/PCAs) |
|
-Launch/implement 6-month trial run on 4South Orthopedic/Neurology unit |
6/24/19 (24 weeks) |
12/6/19 |
-PR support team -Clinical advisor -Clinical nurse specialist (EBP expert) -Nursing unit staff (nurses, PCTs/PCAs) |
|
-Measure/document data and project outcomes (fall rate) |
6/24/19 (24 weeks) -concurrent task |
12/6/19 |
-PR support team (including team leader) -Clinical advisor -Clinical nurse specialist (EBP expert) |
|
-Present PR project trial run findings and outcomes (fall incidence rate, number of call lights, and patient satisfaction survey- Hospital Consumer Assessment of Healthcare Providers and Systems-HCAHPS scores) to nursing unit staff |
12/9/19 (2 weeks) |
12/20/19 |
-PR support team -Clinical advisor -Clinical nurse specialist (EBP expert) -Unit manager -Nursing unit staff (nurses, PCTs/PCAs) |
|
-Prepare presentation (research evidence, outcomes of project-trial run, and cost benefits) to present to hospital management to establish practice hospital wide |
1/6/20 (2 weeks)
-break from 12/20/19- 1/6/20 due to holidays, vacations |
1/17/20 |
-PR support team (including team leader) -Clinical advisor -Clinical nurse specialist (EBP expert) -Nursing management |
section 4
Plan for Evaluation
Research supports that the evidence-based practice of purposeful rounding can result in a reduced rate of falls. This section will discuss and provide valuable information regarding the baseline data for the 4South Orthopedic/Neurology unit and the outcome indicators (Table 3) that will be utilized to evaluate the success of the proposed purposeful rounding project. Baseline Data
Collecting baseline data prior to the PR trial run is required to accurately compare the effects of implementing consistent purposeful rounding. The baseline data that will be collected before the trial run will include the fall incidence rate which is the number of patients who fall during their hospital stay on the 4South Orthopedic/Neurology unit per 1,000 occupied bed days. Using this method of incidence rates takes into consideration how empty or full the unit was at any given time when a fall occurred rather than simply the sheer number of falls. The outcome data will be measured this same way to stay consistent and to show the effectiveness of the PR project.
On the 4South unit, the patient fall incidence is currently being tracked by completing post-fall huddle forms and turning them into the unit manager as well as completing an incident report. These forms are reviewed by the unit manager and shared with the quality improvement team and clinical nurse specialists who focus on fall prevention. A “call to action” form is developed which summarizes the post-fall huddle form and is reviewed in shift change huddle for at least a week after the fall has occurred to reflect on the fall to prevent future falls. The information from the post-fall huddle forms and incident reports are logged and used to generate a monthly report of fall incidence.
The fall incidence data that was collected the last six months prior to the PR trial run will be used as baseline data for the PR trial run on the 4South unit. This data will be obtained from the monthly report of fall incidence that is developed from the post-fall huddle forms and incidence reports. This same method of data collection will be used during implementation of the six-month PR trial run to maintain consistency.
Another outcome indicator that will be tracked for the PR project is the number of call lights that occur on the 4South unit. Currently, there is no baseline data available because the call light system that is used does not have a record that keeps track of how many times the call light buttons are pushed. With the call light system that is currently used, the only way to track the number of call lights that occur is to manually record and tally them as they occur. This could be done before and after implementing the PR project to evaluate whether purposeful rounding can be effective at reducing the number of call lights.
Lastly, patient satisfaction survey scores (HCAHPS) are another outcome indicator that will be focused on. Currently, the HCAHPS scores are available for unit managers to review and share with the nursing staff. The HCAHPS scores are kept track of so that improvements can be made, and nursing staff are aware of what they can do to increase the scores and improve the overall quality of patient care they provide. The HCAHPS scores can be reviewed and recorded each month for six months before and after implementing the PR project to evaluate whether purposeful rounding can be effective at increasing the patient satisfaction scores (HCAHPS). Compliance Data
Each week during the PR trial run, the PR team lead will review the data being collected which includes the incidence rate of falls, number of call lights, and HCAHPS scores. The purposeful rounding logs will be reviewed and evaluated to ensure they are being completed correctly and accurately. These rounding logs will reflect the compliance of the purposeful rounding that is being done and highlight the 4Ps. If it is found that the rounding logs are not being completed correctly, accurately, or if not completed at all, then the PR team lead will meet determine who the nursing staff member(s) was and discuss it with them. The PR team lead can then openly discuss with the individual(s) the barriers to completing the rounding log and determine if the rounding is getting done at all even if the log is not being completed. Finding out why the purposeful rounding was not performed is important so that the areas needing changes made can be pinpointed. Interpretation of Data
During the six-month PR trial run, monthly fall incidence rates will continue to be gathered by completing the post-fall huddle forms and incident reports with additional help from the PR support team. After implementation of the PR trial run on 4South, the baseline pre-implementation fall rates can be compared to the post-implementation fall rates. With the help of the Clinical Nurse Specialist (EBP expert) and Quality Improvement representatives, interpretations of the PR project data can be made. This comparison of baseline and post-implementation data will determine if implementing purposeful rounding is effective at decreasing fall rates in hospitalized adult patients with impaired mobility. The project outcome indicators include:
· Within six months of implementing the PR trial run, the fall incidence rate will decrease by 20% on the 4South Orthopedic/Neurology unit
· Within six months of implementing the PR trial run, the number of call lights will decrease by 25% on the 4South Orthopedic/Neurology unit
· Within six months of implementing the PR trial run, the patient satisfaction survey scores (HCAHPS) will increase by 20% for patients who stayed on the 4South Orthopedic/Neurology unit
Table 3
EBP Evaluation Plan
|
Outcome(s) |
Measures/Measurement |
Data Collection Process/Time of Collection/Person Responsible |
|
1. Fall incidence rate
· Within six months of implementing the PR trial run, the fall incidence rate will decrease by 20% on the 4South Orthopedic/Neurology unit
|
Measurement Definition: Fall incidence rate is the number of patients who fall during their hospital stay on the 4South Orthopedic/Neurology unit per 1,000 occupied bed days
The calculation is: Fall incidence rate= (number of patients who fell in a month) / (number of occupied bed days for a month) x 1,000
-Using this method takes into consideration how empty or full the 4South unit is at any given time
Baseline Incidence: A six-month review of fall incidence data will be assessed (from 4South unit) prior to launching the PR trial run. This information is currently being documented by completing a post-fall huddle form and incident report. The unit manager, quality improvement, and clinical nurse specialists generate a monthly fall incidence report.
Outcome Data Measurement: During the PR trial run, a six-month audit of monthly fall incidence will be compiled based on the monthly fall incidence report.
The baseline pre-PR project data will be compared to the pre-PR project data through the creation of a comparison chart. This will allow analysis to be performed to determine if the fall incidence rate has decreased as a result of the new purposeful rounding practice. This information will be presented to hospital management and will be used to determine if the PR project should be applied to the entire hospital.
|
Data Collection Process: The process to determine fall rate data during the 4South unit PR trial run is as follows: 1.) The unit nurses will complete a post-fall huddle form and an incident report when a patient fall occurs. 2.) Unit manager will review post-fall huddle form and incident report. 3.) Quality Improvement (QI) and Clinical Nurse Specialists (CNS) will review post-fall huddle form and incident report. They will create a “call to action” form to summarize the fall and share with unit nurses who will discuss at each shift change huddle for at least a week after the fall. 4.) QI and CNS will generate a monthly fall incidence report.
Time of Collection: During the six-month unit PR trial run (June 2019-December 2019), monthly reports will be generated from the collection of post-fall huddle forms and incident reporting indicating the patient falls information
Person(s) Responsible: PR support team members will be responsible for collecting and monitoring the fall incidence data: -Nursing staff- will complete post-fall huddle form when a fall occurs and complete an incident report -Unit manager/PR team lead- will monitor the PR project and ensure interventions (4Ps, logging) are being implemented properly -Quality improvement team and clinical nurse specialist will monitor monthly fall rates and produce monthly report |
|
2. Number of call lights
· Within six months of implementing the PR trial run, the number of call lights will decrease by 25% on the 4South Orthopedic/Neurology unit
|
Measurement Definition: Number of call lights is the number of times the call light button is pushed on the 4South Orthopedic/Neurology unit
Baseline Data Measurement: The number of call lights that occur on 4South will be recorded for six months prior to the beginning of the PR trial run. A staff member will need to accurately record/tally how many call lights occur during this six-month time frame.
Outcome Data Measurement: During the PR trial run, a six-month audit of the number of call lights each month will be compiled based on the tally count recorded each month.
The baseline pre-PR project data will be compared to the pre-PR project data through the creation of a comparison chart. This will allow analysis to be performed to determine if the number of call lights decreased as a result of the new purposeful rounding practice. This information will be presented to hospital management and will be used to determine if the PR project should be applied to the entire hospital. |
Data Collection Process: The process to determine call light usage rate data during the 4South unit PR trial run includes staff members (PR support team members, volunteers, champions, etc.). They will record/tally the number of call lights that occur on the 4South unit.
Time of Collection: During the six-month unit PR trial run (June 2019- December 2019), monthly reports will be generated from the tally counts recorded by staff each month.
Person(s) Responsible: -PR support team member volunteers, champions- will record/tally call lights as they occur and compile data for each month for six months |
|
3. Patient satisfaction survey scores (HCAHPS)
· Within six months of implementing the PR trial run, the patient satisfaction survey scores (HCAHPS) will increase by 20% for patients who stayed on the 4South Orthopedic/Neurology unit
|
Measurement Definition: Patient satisfaction survey scores (HCAHPS) is the percentage level of overall satisfaction patients rate their hospital stay on the 4South Orthopedic/Neurology unit
Baseline Data Measurement: The HCAHPS scores for patients who were on the 4South unit will be recorded for six months prior to the beginning of the PR trial run.
Outcome Data Measurement: During the PR trial run, a six-month audit of the HCAHPS scores will be compiled and recorded each month.
The baseline pre-PR project data will be compared to the pre-PR project data through the creation of a comparison chart. This will allow analysis to be performed to determine if the HCAHPS score increased as a result of the new purposeful rounding practice. This information will be presented to hospital management and will be used to determine if the PR project should be applied to the entire hospital.
|
Data Collection Process: The process to determine patient satisfaction survey scores data during the 4South unit PR trial run involves obtaining the HCAHPS scores each month during the trial run.
Time of Collection: During the six-month unit PR trial run (June 2019- December 2019), HCAHPS scores will be viewed and recorded. Person(s) Responsible: PR support team members will be responsible for obtaining and reviewing HCAHPS scores. -Unit manager/PR team lead/Quality improvement team will review HCAHPS scores and share with staff
|
section 5
Conclusions, Recommendations and Implications
The following section will outline the conclusions, recommendations, and implications for the evidence-based practice proposal to implement routine purposeful rounding.
Conclusions
Patient falls continue to be a patient safety issue in healthcare facilities, such as hospitals, regardless of the various fall prevention interventions that are implemented. Falls are associated with several negative patient outcomes including extended hospital stay, injury, death, anxiety, and decreased satisfaction as well as increased financial costs.
A review of research and evidence suggests that consistent purposeful hourly rounding while implementing the 4Ps (pain, potty, position, possessions) can reduce the incidence of falls that occur in hospitals. Purposeful hourly rounding is a suggested technique to address patient needs while enhancing their safety and overall healthcare experience.
Recommendations/Implications
With the 4South Orthopedic/Neurology unit having the highest incidence rate of falls in the entire Hospital, it is appropriate that an increased focus on fall prevention is initiated. This evidence-based practice proposal suggests the implementation of a more consistent and routine purposeful hourly rounding practice to reduce the incidence rate of falls on the 4South unit. For this to be successful, it is crucial that a multidisciplinary PR (purposeful rounding) support team be created. After approval, development, and organization of the new and improved purposeful rounding practice by the PR support team, a trial run will be done on the 4South unit. There will be specific outcome measures for the 4South unit trial run which include: 1.) a reduced fall incidence rate, 2.) a decrease in the number of call lights, and 3.) an increase in the patient satisfaction survey scores (HCAHPS). Through these outcome measures, the plan is to increase the overall safety and quality of patient care on the 4South unit and potentially throughout the entire hospital.
Patient falls are a significant patient safety and quality of patient care indicator that continue to be a challenge for healthcare facilities. To make a difference in the lives of patients, change must occur, no matter the barriers that exist. Through this evidence-based practice proposal involving implementation of a more routine purposeful rounding program, Hospital A would be supporting their vision of “the best care, designed for you”. By creating a project that is evidence-based and patient-centered, that vision is represented and can offer an overall better quality of life for patients.
References
Agency for Healthcare Research & Quality. (2018). Preventing falls in hospitals: A toolkit for improving quality of care. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
Avanecean, D., Calliste, D., Contreras, T., Lim, Y., & Fitzpatrick, A. (2017). Effectiveness of patient-centered interventions on falls in the acute care setting compared to usual care: a systematic review. JBI Database of Systematic Reviewed and Implementation Reports, 15(12), 3006-3048. Retrieved from http://ovidsp.tx.ovid.com.pnw.idm.oclc.org/sp-3.32.1b/ovidweb.cgi?&S=GMNKFPAGOKDDNLLENCDKNAJCPPHJAA00&Link+Set=S.sh.18%7c4%7csl_190
Daniels, J. (2016). Purposeful and timely nursing rounds: A best practice implementation project. JBI Database of Systematic Reviewed and Implementation Reports, 14(1), 248-267. doi:10.11124/jbisrir-2016-2537 Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. MEDSURG Nursing, 24(1), 51–55.
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Hopp, L. & Rittenmeyer, L. (2012). Introduction to evidence-based practice: A practical guide for nursing. Philadelphia: F.A. Davis Company.
Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
Mitchell, M., Lavenburg, J., Trotta, R., & Umscheid, C. (2014). Hourly rounding to improve nursing responsiveness: A systematic review. The Journal of Nursing Administration, 44(9), 464-472. doi:10.1097/NNA.0000000000000101
Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. MEDSURG Nursing, 21(1), 23-36. Retrieved from http://web.a.ebscohost.com.pnw.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=7&sid=8d02109b-34c1-46f3-aae7-0435f8f7cbae%40sdc-v-sessmgr01
The Joanna Briggs Institute. (2017). Falls prevention strategies: Acute in-hospital setting. Retrieved from Joanna Briggs Institute EBP Resources website: http://joannabriggslibrary.org/
The Joanna Briggs Institute. (2016). Nursing rounds: Clinician information. Retrieved from http://ovidsp.tx.ovid.com.pnw.idm.oclc.org/sp-3.32.1b/ovidweb.cgi?&S=ICFKFPMCOPDDNLMMNCDKKDOBJKFIAA00&Link+Set=S.sh.18%7c1%7csl_190
The Joint Commission. (2015). Sentinel event alert 55: Preventing falls and fall-related injuries in health care facilities. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_55.pdf
