FALLS FALLS FALLS

Using Evidence-Based Nursing Rounds to Improve Patient Outcomes

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clinical nurse specialist led to the development of an evidenced-based approach to reduce falls. A review of the literature was performed, and one study was found that validated the use of frequent nursing rounds as a strategy to decrease falls and call light use (Meade, Bursell, & Ketelsen, 2006). The interventions proposed in this study seemed to provide a feasible solution to the problem of falls. Hourly nurse rounding is an example of a protec- tive strategy to reduce accidental and anticipated falls (Morse, 2002). The Madigan Nursing Research Department was consulted to help design and implement the program. The decision was made to replicate the study interventions from Meade and colleagues (2006) with a pilot project on the telemetry ward.

A timeline was created to guide program implementation with goal dates for specific interventions. Data collection of nurse call bell usage was initiated first using a con- venient check sheet placed adjacent to the call monitor. The staff anno- tated the time a call was received and the nature of the call by check- ing one of six categories, such as assistance getting to the bathroom, need for medication, need for a nurse, and other care issues. This report was tabulated daily and entered into a database to capture the number, type, and time of nurse calls in a 24-hour period to provide a sense of the demand the call bell system placed on the nursing staff.

demonstrate that Army hospitals meet the same standards by which civilian facilities are judged. Within MAMC, this is demonstrated by an intense focus on graduate medical education and registered nurse advanced skills training courses as noted by 19 residency programs, 8 fellowship programs, one of four 16- week Army critical care nursing programs, a clinical site for nurse anesthetist training, and a 16-week operating room nursing course.

In continued efforts to maintain high standards of patient care at MAMC, the Joint Commission’s 2008 National Patient Safety Goals were reviewed formally. This review was part of the systematic ap- proach to improving health care in the critical care arena and the con- tinued pursuit of an evidence-based health care methodology. Reducing the risk of harm resulting from falls (Goal #9) became the focus of the Critical Care Section for the step- down telemetry unit. This unit was identified to have greater than 75% patient movement and a high turnover rate of nursing staff. The number of patient falls in the last year was the impetus for selecting this goal. Also, potential implemen- tation of measures to decrease the fall rate were examined.

Pilot Project In the first quarter of 2007, an

increase in patient falls was noted in this busy unit. A discussion by the critical care supervisor and the

Madigan Army Medical Center(MAMC) is a 204-bed, level two trauma center responsible for care of soldiers and their beneficiaries. Located near Tacoma, WA, on Fort Lewis, this medical center serves more than 120,000 beneficiaries for primary and tertiary care in the region, and is the largest Army Medical Center on the West Coast of the continental United States. Although military hospitals are not required to have Joint Commission reviews, the facility gladly wel- comes surveyors and scores very highly with each periodic review. The ability to compare military services to civilian health care net- works by Joint Commission reviews allows the military health care sys- tem to demonstrate high standards of patient care and delivery meth- ods. Additionally, such reviews

MAJ Brian Weisgram, MSN, RN, CCRN, CNS, is a Major, Army Nurse Corps, and was the Critical Care Clinical Nurse Specialist, Madigan Army Medical Center, Fort Lewis, WA, at the time this article was written. He is currently Head Nurse, Intensive Care Unit, Evans Army Community Hospital, Fort Carson, CO.

COL Susan Raymond, MSN, RN, ACNP, is a Colonel Army Nurse Corps, and was the Chief Critical Care Service, Madigan Army Medical Center, Fort Lewis, WA, at the time of this article was written. She is currently Chief Nurse, 86th Combat Support Hospital, Baghdad, Iraq.

Disclaimer: The opinions and views expressed in this article are those of the author and do not necessarily rep- resent those of the U.S. Army Nurse Corps, nor those of the U.S. Department of Defense.

Brian Weisgram Susan Raymond

Note: Military nursing offers unique practice opportunities. Share your perspec- tives on your practice as a nurse in the Armed Forces with the readers of MED- SURG Nursing by submitting a manuscript in consideration for this column. Questions and submissions can be directed to the Editor, Dottie Roberts, at [email protected].

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The rounding process and the Meade et al. (2006) article were dis- cussed with the staff during multi- ple sensing sessions prior to imple- menting the program. Champions of the program were identified to facil- itate the implementation process, and to encourage their peers and co-workers to support the program.

The Nursing Rounds Program consisted of the nurse or designee performing a 12-step process relat- ed to the systematic approach to patient care that is typically taught in nursing education. This emphasis on a patient-centered, organized approach to providing attentive nursing care demonstrated the abil- ity to reduce the potential for harm from falls and enhance patient satis- faction. During these rounds, nurses performed the 12-step patient-nurse interaction (see Table 1), including evaluations of pain, toileting needs, positioning, and access to call light, telephone, tissues, and trash can. The program consisted of hourly rounding between 8:00 a.m. and

10:00 p.m., and rounding every 2 hours between 10:00 p.m. and 8:00 a.m. A verbal agreement was made with the patient to have a staff mem- ber return every 1-2 hours.

Outcomes The outcomes that were being

monitored during this program included patient falls, call light use, adherence to the 12-step hourly rounds program, and patient satis-

faction. The preliminary results of the program demonstrated 84%- 96% nursing adherence to the 12- step hourly rounds program. Patient call light use decreased from a high of 120 to 20 calls in a 24-hour period. Staff observed that when one RN’s adherence to the rounding program decreased by 50%, there was an immediate jump in the call light use from 20 to 69 calls over one 24-hour period. This spontaneously prompted self-policing from the other nursing personnel on the unit. Overall, this evidence-based 12-step hourly rounds program has initially decreased patient call light use by 23%. Although more data need to be gathered, fewer falls also have occurred in the first 30 days of the program.

The project team has devised a timeline to continue evaluating this program for its long-term effects on call light use, patient satisfaction, and patient safety. Based on the suc- cessful results to date, the 12-step hourly rounds program has been expanded to additional medical-sur- gical units within the facility. If the program is effective overall, the goal is to propose implementation of this program throughout the facility as an operational systems change in accordance with the Joint Com- mission’s National Patient Safety Goal #9.

References Meade, C.M., Bursell, A.L., & Ketelsen, L.

(2006). Effects of nursing rounds on patients’ call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70.

Morse, J.M. (2002). Enhancing the safety of hospitalization by reducing patient falls. American Journal of Infection Control, 30, 376-380.

Table 1. 12-Step Nursing Rounds Chart

Q1 Hour 0800 to 2200 & Q2 Hours 2200-0800

The following items will be checked and performed for each patient. • Upon entering the room, tell the patient you are there to do your rounds. • During the evaluation, also assess the patient’s mental status including

location/orientation.

1 Assess patient pain levels using a pain assessment scale. If needed, con- tact an RN immediately for pain relief so the patient does not have to use the call light.

2 Put medication as needed on RN’s scheduled list of things to do for patients and offer the dose when due.

3 Offer toileting assistance.

4 Ensure patient’s ID band is on and verify the patient’s identity by name and birthday. Verify the easy ID band is on.

5 Make sure the call light is within the patient’s reach.

6 Put the telephone within the patient’s reach.

7 Put the bedside table next to the bed.

8 Put the tissue box and water within the patient’s reach.

9 Put the garbage can next to the bed.

10 Assess the patient’s position and position comfort. Ask if patient needs to be repositioned and is comfortable.

11 Prior to leaving the room, ask, “Is there anything I can do for you before I leave? I have time while I am here in your room.”

12 Tell the patient that a member of the nursing staff will be back in the room making nursing rounds in an hour (or in 2 hours during the night).

Source: Modified from Meade, Bursell, & Ketelsen, 2006.

Visit the AHRQ Patient Safety Network Web Site AHRQ’s national Web site — the AHRQ Patient

Safety Network, or AHRQ PSNet — continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety.

The Web site includes summaries of tools and find- ings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site’s unique “My PSNet” feature.

To visit the AHRQ PSNet Web site, go to http://psnet.ahrq.gov/