Effect of Structured Frequent Nursing Rounds on Patient Satisfaction, Safety, and Call Light Usage Aimee Cloyd, ASN,RN Nurse Supervisor Leisa Kelly, MS, APRN, CEN Clinical Nurse Specialist Objective • To relate the effects of a structured rounding program to patient outcomes. Evidence Based Practice Support for the Project • A research study was published in AJN in 2006 describing the results of a multi-facility research study to measure the effectiveness of frequent nursing rounds • This research study supported the EBP we implemented at our institution Background Information • Press Ganey measures patient satisfaction on a random group of patients discharged from our facility • Patient satisfaction within the medical division consistently ranged below the 90th percentile • Patient falls were higher than the national benchmark • Staff viewed call light usage as an ongoing interruption into our day • The Medicine Division saw this research study as a potential solution to improve outcomes EBP Team • The divisional director, nurse managers, and members of the unit based council worked together with the CNS to develop the model for the project • Processes discussed in the original study design were replicated Development of the Call Light Log • Call light log had been used previous to this project; however, the purpose of the call was changed from a write in box to a check box to provide categorical data • • • • Included patient room number Call back time Whether the need was met Purpose of the call Development of the Rounding Log • A rounding log was developed to act as a visual reminder to staff • Staff was to initial each time they entered the room • Log was duplicated, and later laminated for durability Development of the Rounds Request Form • A rounds request form was develop to communicate patient needs to the nurse when the CNA or CSR rounded • Non-licensed personnel documented the patient need on a form • Communicated to the nurse at the end of their rounding session Development of the Scripting and the Process • Nurses rounded on the odd hour (Assessments at 7AM/PM; meds 9 AM/PM) • Non-licensed personnel rounded on the even hour • Rounds scheduled hourly from 7AM-10PM • Every other hour from 12MN to 6AM • Scripts and observations for rounding developed Actions to be Taken by Nursing Staff Members During Rounding • • • • • • • • • • • • Determine patient’s pain level Put medication as needed on the nurses scheduled list Offer toileting assistance Determine the patient’s position and position comfort Make sure the call light is within the patient’s reach Place the telephone within the patient’s reach Place the TV remote/bed light switch within the patient’s reach Place the bedside table next to the bed Place the Kleenex box and water within the patient’s reach Place the garbage can next to the bed Ask: “Is there anything I can do for you before I leave? I have time while I am here in the room.” Tell the patient that a member of the nursing staff will be back in the room in one hour to round and check on them again. Implementation of the Pilot • Initially the process was implemented on the North Tower • A ceremony highlighting the Lake’s nurse theorist, Jean Watson, kicked off the rounding project • Hospital administration, service line administrators, managers and staff nurses attended the ceremony • For the first month all was well Effect of Hourly Rounding on Clinical Outcomes • No effect on call light usage • No effect on patient falls • Improvement in patient satisfaction measures • Pain Management: Pain controlled • Loyalty: Recommend the facility to others • Care and Concern • Personal Needs Call Light Usage 1200 1000 1128 1046 Manual Log Executone 920 969 800 600 621 2006 2007 533 519 419 400 200 0 March April May June Call Light Data • An attempt to obtain objective call light data was explored • Data from the Executone System was obtained, but staff did not concur to its accuracy • Call lights used for non-patient requests • System changed from 2006 to 2007 • After several months, call light data was no longer considered as an outcome Falls Per 1000 Patient Days 10 9 8 7 6 5 4 3 2 1 0 9.1 6.6 4.3 2.2 Mar 4.5 2.2 April 4.4 2.3 May 4.16 2.26 June July 2006 2007 Patient Satisfaction Nursing Core Indicators: Attention to Personal Needs 100 81.3 75 80 70 92.9 91.7 90.6 90 87.5 85.3 78.6 70.6 75 73.1 80 76.8 83.3 8081.8 77.1 87.5 87.5 80 60 50 2006 2007 40 30 20 10 0 March May July September November Patient Satisfaction Nursing Core Indicators: Response to Concerns 100 90 88.9 83.3 80 70 90 83.9 75 71.7 70.8 73.1 76.9 79.3 76.8 76.6 79.2 81.7 81.8 89.7 85.7 85.7 67.9 65 60 2006 50 2007 40 30 20 10 0 March May July September November Patient Satisfaction Nursing Core Indicators: Loyalty 100 90 85.4 84.4 80 70 81.3 79.2 85.7 88.3 89.1 85 85.1 90 82.1 80.3 80 89.6 83.9 92.5 89.7 85.7 78.3 66.7 60 2006 2007 50 40 30 20 10 0 March May July September November Patient Satisfaction Nursing Core Indicators: Pain Management 100 90 87.5 86.1 80 91.1 82.1 75 70 84.1 95.5 85.9 83.3 80.9 82.7 91.7 87.5 86.8 82.5 81.8 83.3 72.5 68.3 70 60 50 2006 2007 40 30 20 10 0 March May July September November Pre-Post Comparisons: Pilot Unit Year 1 to year 2 Outcome t Loyalty .182 287 346 .859 Personal Needs .692 294 349 .504 Pain .328 260 324 .749 Care and Concern .072 264 313 .944 N 06-07 N 07-08 p Effects of the Pilot • There was initial buy-in, however staff soon began to question “When was the pilot going away?” • Initial gains realized were not held • Consistent outcome measures were difficult to obtain • Falls are only as accurate as reported • Call light usage was only as accurate as documented Other Units Believed it Would Work • The medical unit on the south tower wanted to give the process a try • They were challenged to maintain consistent patient satisfaction scores and saw the process as an opportunity • The unit was eager to show that teamwork can improve patient satisfaction scores • Several of the nurses were in school, had read the article, and wanted to implement it Patient Satisfaction Nursing Core Indicators: Attention to Personal Needs 100 90 80 91.3 81.8 84.6 84.485.5 88 83.3 89.1 85.9 90.7 80.6 83.3 80 72.5 70 60 2006 50 2007 40 30 20 10 0 June August October December Patient Satisfaction Nursing Core Indicators: Response to Concerns 100 90 80 90 82.9 80.4 87.5 82.4 85.2 80.9 86.4 83.9 86.5 80.8 86.4 72.4 70 66.9 60 2006 50 2007 40 30 20 10 0 June August October December Patient Satisfaction Nursing Core Indicators: Loyalty 100 90 80 88.5 92.3 79.6 87.5 83.8 89.5 93.3 89.1 81.3 93.5 84.7 85 80.3 70.2 70 60 2006 2007 50 40 30 20 10 0 June August October December Patient Satisfaction Nursing Core Indicators: Pain Management 100 90 80 93.2 86.8 82.9 84.182.4 85.9 81.7 88.5 84.8 84.485 85.7 76.4 70 63.5 60 2006 2007 50 40 30 20 10 0 June August October December Pre-Post Comparisons Outcome t Loyalty 1.819 280 277 .046* Personal Needs 2.464 273 277 .031* Pain 1.523 238 246 .156 Care and 2.212 Concern 247 234 .049* N 06-07 N 07-08 p Comparative Analysis Between the Groups Outcome F N p Personal NeedsPre .272 567 .607 Personal NeedsPost 4.524 626 .045* Pain-Pre .192 498 .665 Pain-Post 1.226 570 .280 Care and ConcernPre 1.057 511 .315 Care and ConcernPost 4.032 547 .047* Loyalty-Pre 1.048 567 .317 Loyalty-Post 17.921 623 <.001** What was the difference? Our CNA Star • • • • • We have stars in our team – CNA’s, PCA’s, and CSR’s – were all important factors in the success of this project We believed that it would work We personalized the process and wanted it to be a success Our scores have stayed consistent, it is how we provide care now The paradigm shift occurred What Were Our Challenges? • Initial buy-in was tough, but the patient satisfaction scores increased, our staff was sold on the project. • Staff was hesitant to say “We’ll be back in an hour,” worried that no one would return. • We like to succeed and we incorporated hourly rounding into our daily routine. • We were pushed to take down the papers, but our manager felt that they were visual reminders. Questions????