University of St Augustine for Health Sciences

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Student Scholarly Projects Student Research

Fall 11-30-2020

Reducing Patient Falls Through Purposeful Hourly Rounding

Amanda Savage
University of St. Augustine for Health Sciences, [email protected]

DOI: https://doi.org/10.46409/sr.UOZB3951

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Recommended Citation
Savage, A. (2020). Reducing Patient Falls Through Purposeful Hourly Rounding. [Doctoral project,
University of St Augustine for Health Sciences]. SOAR @ USA: Student Scholarly Projects Collection.
https://doi.org/10.46409/sr.UOZB3951

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REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 1

Reducing Patient Falls Through Purposeful Hourly Rounding

Amanda L. Savage M.Ed., BSN, RN

School of Nursing, University of St. Augustine for Health Sciences

This Manuscript Partially Fulfills the Requirements for the

Doctor of Nursing Practice Program and is Approved by:

Sarah Cartwright, DNP, MSN-PH, RN-BC, CAPA

Deborah Saber PhD, RN, CCRN-K

Deborah Sanford MBA, MSN, RN

November 30, 2020

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 2
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 3

Abstract

Practice Problem: Falls significantly affect patients, resulting in temporary or permanent harm,

even death. In a large acute care facility, patient falls increased from 444 in 2016 to 556 falls in

2019.

PICOT: In an adult inpatient hospital setting, does purposeful hourly rounding (PHR), compared

to no rounding, reduce patient falls over a period of 30 days during the same time period from

the previous year?

Evidence: Of the 360 articles reviewed, 12 articles, varying from evidence levels two (1), level

three (4), and level five (7), supported PHR as effective in reducing harm from falls in adult

hospital settings. The majority of this lower level evidence supported implementation of PHR as

a pilot.

Intervention: PHR, shown to improve fall rates using the proper application of tools,

specifically the Studer Group Purposeful Hourly Rounding LogSM (2020a), was implemented to

decrease falls over a period of 30 days during the same period from the previous year, without

the previously used bedside sitters.

Outcome: The falls rate for the baseline period was 4.11 falls per 1,000 occupied bed days; and

5.07 falls per 1,000 occupied bed days for the implementation period. The incidence rate ratios

of the falls rate between baseline and implementation was 0.81 (x2(1) = 0.140, p = 0.708; 95%

CI = [0.27, 2.42]).

Conclusion: In this EBP change project, PHR did not result in a decrease in patient falls;

however, the potential ramifications from the clinical significance of PHR should be considered.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 4

Reducing Patient Falls Through Purposeful Hourly Rounding

According to the Joint Commission (2015), falls with serious injury resulting in severe or

permanent harm are consistently among the top 10 sentinel events reported in health care

facilities (Fridman, 2019). Falls are defined as a patient's unplanned descent to the floor or other

lower surface with or without injury or even death and are consistent problems that significantly

affect patient care in hospitals across the country (Bouldin et al., 2013; Hitcho et al., 2004;

Najafpour et al., 2019). Even with the use of bedside sitters, the hospital for this Evidence-Based

Practice (EBP) change project, being a 411-bed acute care facility, had 444 falls in 2016 that

increased to 556 in 2019, which included 143 falls with injury (Eastern Maine Medical Center

[EMMC], 2020). Najafpour et al. (2019) discussed a direct correlation between falls and poor

outcomes, increased cost of care, a longer length of stay, and permanent harm such as death.

With the number of falls increasing in this organization, an intervention such as PHR was

indicated to address this major patient safety issue.

The purpose of this paper is to describe the Doctor of Nursing Practice (DNP) scholarly

EBP change project that examined whether PHR, the process of intentionally checking on

patients at regular intervals to meet their needs proactively, impacted the reduction of patient

falls (Hutchings et al., 2013). It provides reviews of evidence-based literature with Ronald

Lippett's model for change and the Johns Hopkins Nursing Evidence Based Practice model

(JHNEBP) as a framework for the EBP change project's implementation, on which the practice

recommendation to pilot PHR is based (Dang & Dearholt, 2017). This EBP change project

consists of a description of PHR, implementation, data analyses, findings, evaluation results,

implications, as well as plans for dissemination.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 5

Significance of the Practice Problem

Falls are a significant issue globally, nationally, regionally, and locally. For example,

patients in Australia experienced 1,330 falls and 418 falls injuries from 27,026 hospital

admissions, yielding 3.6% of patients involved in at least one fall and 1.2% in at least one fall

with injury (Morello, 2015). In 2018, hospitals in the United States reported approximately

700,000 to 1,000,000 patient falls annually, with up to half resulting in injury (Radecki et al.,

2018). These numbers mirror the global trend as patients in adult medical and surgical units have

fall rates at 3.56 times per 1000 patient days, with 26.1% of falls resulting in patient injuries

(Walsh et al., 2018). In the state of Maine, there were 556,092 falls in 2017. The hospital for this

EBP reported 95,565 (Maine Health Data Organization, 2013). Zhao et al. (2019) points out an

association between advanced ages, inpatient falls, and falls with injury, which is a concern in

Maine due to its large older population. The median age in Maine is 45.1 years, the oldest in the

country, and 20.6% of the population is over the age of 65 (United States Census Bureau, 2019).

Fifty percent of inpatient falls, occur in patients who are 60 years of age or older, notably,

patients over the age of 80 are at the highest risk for falls and falls with injury (Zhao et al.,

2019).

The national standard and expectation for patients in healthcare facilities established the

goal of zero harm (Joint Commission Center for Transforming Healthcare, 2019). As of October

1, 2008, the Centers for Medicare and Medicaid Service (CMS) deemed falls "never events,"

meaning they should never occur during a patient's hospitalization (Bouldin et al., 2013). CMS

refused to pay for associated health care costs if the patient had experienced a fall while

hospitalized, and as a result, falls have become an enormous hospital expense. There is an

increase in hospital charges by approximately $4,200 in patients who have sustained a fall
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 6

compared to those who did not, due to increased use of resources and hospital length of stay

(Hinks, 2015). The Joint Commission (2020) estimated the cost of a fall with injury at $14,000

per patient, and the Agency for Healthcare Research and Quality (AHRQ) (2020a) estimated the

cost of a fall at $12,965 per patient. By 2020, the annual direct and indirect cost of fall injuries is

projected to exceed $54 billion across the country (Hinks, 2015).

Evidence shows that inpatient falls and falls with injury are complicated phenomena

involving multiple factors that can be intrinsic to the patient, such as age, physical or mental

condition, and extrinsic or environmental factors (Zhao et al., 2019). Lack of knowledge of a

patient's fall risk, such as what occurs when a fall risk assessment is not completed, is an

extrinsic factor that puts the patient at risk (AHRQ, 2013). Another example of an extrinsic risk

factor is a high patient-to-staff ratio, which obviates effective PHR. As staffing shortages

worsen, rounding occurs less frequently, adversely affecting health care quality and patient

safety (Clarke & Donaldson, 2008; Olrich et al., 2012).

Seventy-nine percent of falls take place in patient rooms (Tzeng & Ying, 2008).

Structured PHR, using an interdisciplinary care team and including specific nursing actions, aims

to meet patient needs proactively, thereby decreasing falls (Olrich et al., 2012; Radecki et al.,

2018). In seven hospitals throughout the country, that participated in a study using pilot units to

reduce patient falls, purposeful rounding reduced falls by 62% over a 1-year period (The Health

Research & Educational Trust, 2018). The Institute for Healthcare Improvement (n.d.) endorsed

PHR as the best way to not only reduce call lights and fall injuries but also to increase patient

quality of care and satisfaction (Daniels, 2016).

In 2019, the hospital for this EBP change project reported 556 falls of which 143 falls

were with injury (EMMC, 2020). On the medical-surgical unit, there were 67 falls reported with
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 7

17 reported injuries, which cost the organization $934,851 for this unit alone (EMMC, 2020).

Literature shows that patient falls increase suffering through risk of injury, longer length of stay,

pain, distress, and loss of confidence, independence, or even life (Hiyama, 2017). The site of this

EBP change project, like all healthcare organizations, has the ethical obligation to reduce

preventable hospital-acquired conditions, such as falls, reducing the physical, psychosocial, and

financial burden to the patient and the community (AHRQ, 2019).

PICOT Question

The PICOT question is a clinical question relevant to a problem at hand, phrased with the

mnemonic device "PICOT" to facilitate the search for an answer (Richardson et al., 1995). For

the current EBP change project, the PICOT question is: "In an adult inpatient hospital setting (P),

does purposeful hourly rounding (I), compared to no rounding (C), reduce patient falls (O) over a

period of 30 days from the previous year (T)?"

The target patient population was specific to adult patients over 18 years of age who were

admitted to the medical-surgical unit. Excluded from this EBP change project were all patients

under the age of 18, and any patients noted for suicidal ideation who required a bedside sitter.

A PHR strategy, developed by Studer Group (2020b), was used as an intervention for

patient falls, which includes eight rounding behaviors:

1. Use opening key words to reduce anxiety.

2. Perform scheduled tasks.

3. Address the 3 P's: pain, potty, and position.

4. Assess additional comfort needs.

5. Conduct an environmental assessment.

6. Ask (before leaving the patient), "Is there anything else I can do for you? I have time."
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 8

7. Tell each patient when you will be back.

8. Document the round on the patient chart.

Patients who received PHR were compared to patients who received no rounding the prior year

within a 30-day period. The outcome, which the EBP change project aimed to accomplish, was a

reduction in patient falls via PHR within this given time.

Evidence-Based Practice Framework and Change Theory

Ronald Lippitt's change theory and the JHNEBP model were used to develop and

implement this EBP change project. Described as a practical guide for the bedside nurse to use

the best evidence to make care decisions, the JHNEBP Practice Question, Evidence, Translation

(PET) model’s permissions were accepted and used as a framework to implement this EBP

change project (Dang & Dearholt, 2017; Schaffer et al., 2012) (see Appendices A and B). In the

process of PHR, using the PET model as a guide, nurses thought critically as they asked

questions and applied evidence to care for their patients while adjusting their environments to

reduce patient falls. As Wyant (2017) maintains, the JHNEBP model is a comprehensive

clinician-focused model, allowing the rapid and appropriate application of current EBP practices

addressing all essential components of the EBP process (Schaffer et al., 2012). Ronald Lippitt's

change theory has seven phases: diagnose the problem, assess motivational/capacity for change,

assess the change agent's motivation and resources, select a progressive change objective, choose

the appropriate role of the change agent, maintain change, and terminate the helping relationship

(Mitchell, 2013). This aligns with the language of the nursing diagnosis process: assessment,

planning, implementation, and evaluation. Lippitt's work is known to be more detailed, which

helps generate change at the bedside. Lippitt's theory, alongside a democratic style of leadership,

is a popular, effective combination (Mitchell, 2013). Good communication is a prominent feature

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 9

of every phase of the change process, and almost all project managers cite it as fundamental to

effective implementation (Robb, 2004). Strong, open communication across teams strengthens

the chance of firmly embedding change by supporting the development of therapeutic

relationships and removing barriers (Murphy, 2006). Attempts to implement planned change face

numerous barriers, but using a framework, such as Lippitt's, proactively rather than

retrospectively can help eliminate some of the potential problems, and address and act on others

(Mitchell, 2013). Unique to nursing, is the skill of observational assessment of the clinical

environment, meaning collect data to answer questions that could not be answered through other

methods to enhance patient healing (Kelley & Brandon, 2012). Even with the use of bedside

sitters, patient falls were trending upward at this EBP change project site. Therefore, the use of

Lippitt's change theory and the idea of bringing in an external change agent to put a plan in place

to effect change with the implementation of PHR were utilized to reduce patient falls. The

intervention of PHR included frequent patient assessment, as well as addressing patient needs

such as hygiene, toileting, comfort, and access to food/drink.

Evidence Search Strategy

A thorough systematic review of nursing and health-related literature from 2010-2019

was conducted. Keywords used in search of literature included: hourly rounding, purposeful

rounding, rounds, falls, fall prevention, adult patients, acute care, acute setting, sitters, and

companions. The search phrases included: nursing+ falls, inpatient + adults, hourly + rounding,

quality + improvement, and safe + patient care. Assessed literature comprised of English

language, peer-reviewed journals via search methods in the PubMed, ProQuest, Medline,

CIINAHL, OVID, and Google Scholar databases.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 10

Evidence Search Results and Evaluation

A review of 360 articles was performed resulting in 12 retained (see Appendix C). The

studies exhibited design variation to include systematic and narratives reviews, empirical studies,

mixed methodology research, qualitative studies, and expert opinions. These remaining items

were reviewed further for their level of evidence and quality of the study.

All matched articles were organized based on adult inpatient falls, falls with injury,

hourly rounding, and the use of sitters, which was also the inclusion criteria for this evidence

search. Exclusion criteria were the following: articles in outpatient practices, pediatrics,

ambulatory services, and the use of bedside sitters with documented suicidal ideation. This

available knowledge assisted in building the answer to the PICOT question: "In an adult

inpatient hospital setting, does purposeful hourly rounding, compared to no rounding, reduce the

patient falls over a period of 30 days during the same time period from the previous year?"

When synthesized, the amassed literature supported PHR as an effective strategy for

reducing harm through falls in the adult inpatient hospital setting. With the use of an evidence-

based practice rounding tool, proper application, education on PHR, and surveillance of

adherence to rounding practice, a decrease in falls was purported to be evident.

The Johns Hopkins Nursing Evidence-Based Practice Quality Grading Tool (2020) was

used to review the 12 articles for levels of evidence I through VI and quality ratings A through

C. The hierarchy of evidence grade varied between levels I to VI, based on the strength of the

methodological quality of design, validity, and application to patient care. The strength of the

evidence was found relevant. One article with evidence level I had a high-quality grade,

consistent results for the sufficient sample size, and the recommendations were consistent based

on other literature reviews. There were four articles with evidence level III ranging from quality
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 11

grades A, B, and C, comprised of systematic reviews or quasi-experimental studies categorized

as high, good, or low quality (see Appendix D). The remaining seven articles were evidence

level V with quality grades A and B. These were based on experiential and non-research

evidence and had high or good EPB improvement methods (see Figure 1).

Themes

The evidence on PHR was gathered and synthesized related to the medical-surgical adult

inpatients and how PHR reduced falls. Also included, were information and data regarding

bedside sitters to reduce falls, since the EBP practice site had used sitters during the previous

year. The themes expressed in the synthesis table (see Appendix E) were assessed using four

queries:

1. Does the literature support stand-alone documentation to standardize and prevent

harm related to falls?

2. Does the literature support competency-based hardwiring (use of a process to ingrain

systems and tools) for fall prevention? (Studer Group, 2007)

3. Does the literature support the best practice bundle to prevent injury related to falls?

4. Does the literature support hardwiring change in the implementation of PHR?

The studies reviewed, whose settings were mainly large urban hospitals with trial

implementation over a few months, met inclusion criteria of being relevant in terms of nursing

practice relationship, strategic rounding, adoption rates, potential barriers to practice change, and

evidence of successful implementation. The net resulting 12 articles proffer many similarities,

differences, and controversies, summarized within each of the four themes as follows.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 12

Stand-Alone Documentation to Standardize and Prevent Harm Related to Falls

Radecki et al. (2018) supports that fall assessments need to shift from clinical-centric to

patient-centric. Moving from strictly focusing on filling out the assessment tool, looking at lab

values, medication changes, and diagnosis, focusing on understanding patient perspectives and

developing strategies in partnership with them. Silva and Hain (2017) believe that using each fall

risk factor number as an action plan is irrelevant. Positive outcomes were found with the addition

of a seven item practice fall prevention plan, which consisted of organizational support for a fall

prevention program, fall risk evaluation on admission, risk assessment to identify risk factors,

communication of risk factors, observation and surveillance, auditing, continuous learning, and

working toward improvement (Spano-Szekely et al., 2018).

Competency-Based Hardwiring for Fall Prevention

Empowering staff and providing education, consistency, auditing, and follow-through are

critical to hardwiring a fall prevention process. Education on a multidimensional fall prevention

program utilizing an incremental approach, fall prevention screening tools, PHR, and fall

bundles, all decrease fall numbers (Silva & Hain, 2017; Walsh et al., 2018). PHR alone, showed

results in fall reduction and positive clinical outcomes, through improved patient perception of

staff responsiveness, call light reduction, and improved patient satisfaction (Mitchell et al.,

2014).

Best Practice Bundle to Prevent Injury Related to Falls

Three articles showed similarities in best practice through bundling standardization of fall

prevention practices including safety huddles, PHR, fall risk scale, individual care plans, and

post fall debriefing. Fridman (2019) expressed a clear relationship between delirium, toileting,

high-risk prescription medications, and ambulation impairment with a high risk of falls. The
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 13

implementation of PHR including use of bundles, which is time spent with patients, policies, and

processes, enabling a safe environment that supports fall prevention.

Significant contributing barriers to PHR are lack of education, consistency, and staffing.

Mitchell et al. (2014) found that PHR and patient perceptions of staff responsiveness improved

patient satisfaction and positively impacted patient outcomes, including falls. Inadequate staffing

challenges nursing staff in the implementation of appropriate fall prevention interventions (Zhao

et al., 2019). The intentional presence of nursing staff during PHR, rather than addition of fall

risks, fall prevention, post fall huddles, rounding, and presence of a sitter, translated into a

decrease in falls and other quality metrics (Adams & Kaplow, 2013).

Hardwiring Change in the Implementation of Purposeful Hourly Rounding

The majority of reviewed articles showed evidence regarding hardwiring change in order

to gain buy-in and drive the wanted outcome. Hicks (2015) revealed literature reviews that

indicate that structured PHR encourages positive patient outcomes, including decreased fall

rates. When faced with the need to find a solution to a fall-related problem, PHR is frequently

practiced. Olrich et al. (2012) yielded a clinically significant reduction in falls with PHR by

nursing teams who work collaboratively through increased compliance with safe patient

outcomes. Barrett et al. (2017) found effective care planning between the groups by utilizing a

targeted strategy to increase the understanding of patients that are high risk for falls. When a

multifaceted fall prevention program was employed over 11.5 years, the result was a 27.7%

reduction in falls. Structured PHR aims to proactively meet patients' needs, however, no one

exact method has proven to consistently decrease falls (Radecki et al., 2018).
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 14

Practice Recommendations

The increased financial, physical, and social costs that result from patient falls have made

reducing their numbers a major priority for healthcare organizations (Najafpour et al., 2019).

Results of the literature search showed moderate strength evidence suggesting that effective PHR

can promote patient safety by decreasing falls and improving patients' perceptions of nurse

responsiveness, leading to higher satisfaction scores, especially when used with the bundled

approach of an evidence-based practice rounding strategy and Studer Group Purposeful Hourly

Rounding LogSM (Mitchell et al., 2014; Studer Group, 2020a) (see Appendix F). Success requires

the permissions (see Appendix F) and proper application of the tools, education on PHR, and

surveillance of adherence to rounding practice (see Figure 2). No study attested that PHR alone

is the best method for decreasing falls; however, the literature demonstrated support for its use

(Studer Group, 2020b) (see Appendices C and D). Results of the literature evaluation for this

EBP change project showed lower levels of evidence in 7 of 12 articles reviewed (see Figure 1).

According to the Johns Hopkins Level of Evidence Tool (2020) rather than a systems-wide

change, lower levels of evidence recommend a pilot study of an intervention.

Consistent with the synthesis of evidence, the practice recommendation was to pilot PHR

using the Studer Group Purposeful Hourly Rounding LogSM (2020a) on the medical-surgical

floor of this large acute care facility to decrease the number of inpatient falls. Education with

implementation of PHR and the Studer Group Purposeful Hourly Rounding LogSM (2020a) were

used to standardize rounding and hold the staff responsible to the expectations of addressing the

eight rounding behaviors with the patients.

There were threats to internal validity of the EBP change project, such as, the short

timeframe, that is, only a 30-day comparison of falls from 2019 to 2020. Other factors affecting
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 15

internal validity included: COVID-19's effects on the patient population, staff call outs that

compromised nurse-to-patient ratios, patients' admitting diagnosis, number of inpatients at the

time of the intervention, and staff adherence to the rounding logs. The short, 30-day evaluation

period resulted in a limited data analysis and the low daily patient volume also presented

limitations.

Project Setting

The practice setting is a Level II trauma, rural teaching community hospital, which

services multiple communities throughout the state with an average daily census of 360 patients

per day. Part of nine hospitals, it provides integrated care for patients of all ages seeking

emergency, medical-surgical, oncology, neurology, women's health, and palliative care. The

staffing ratio is typically five patients to one registered nurse (RN) depending on patient acuity,

and the certified nursing assistant (CNA) can care for up to 12 patients.

Prior to the implementation of the EBP change project, the staff worked collaboratively

to prevent falls among patients at risk, by using an electronic scoring rubric to request a bedside

sitter to be assigned by a house manager. However, this process had not led to a reduction in

falls, but rather, falls were on the rise. In 2016, there were 444 falls or 4.01 per patient days

compared to 2019 with 556 falls or 4.72 per patient days (EMMC, 2020). The benchmark for

healthcare facilities is 3.4 falls per 1000 patient days (AHRQ, 2020b). Establishing an

organizational need for the implementation of this PHR project was essential to the stakeholders,

the organization, and to quality care.

Organizational Culture

The practice setting is passionate about safe, quality patient care, as evidenced by its

vision to become a national leader in healthcare excellence, which aligns with its mission to
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 16

embrace the values of integrity, respect, compassion, and accountability (Northern Light Health,

2020). It is a cause and effect organization, responding to areas of need with immediate attention.

For example, the Centers for Medicare and Medicaid Services requires all hospitals in the United

States to provide patient surveys to each patient. A low Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS) score on patient satisfaction surveys, caused the

organization to focus on that immediate area of need at that time.

Facilitators

The practice setting comprised a fair and just culture that improves patient safety by

empowering employees to proactively monitor the workplace and participate in safety efforts

(Boysen, 2013). With the support of advanced practice organizational leaders, who utilize

proactive EBP within this just culture, the organization is held accountable while focusing on

risk, system design, human behavior, and patient safety (Boysen, 2013).

Stakeholders

Key stakeholders in the PHR project included patients, who benefited from safe care; the

organization, which benefited financially from decreased falls with injury and length of hospital

stays; and staff, particularly nurses, who benefited from the improved communication with

patients and family, potentially impacting job satisfaction and retention.

Sustainability

Once the project data were analyzed and disseminated, the project would be sustained

through ongoing education across the organization, which included the steps outlined in the

process of PHR with staff and leaders. Plans included collaborating with the Evidence-based

Practice Council (EBPC) and the Performance Improvement/Project Management team to

standardize the project to the care continuum by adding PHR to everyday work, opposed to an
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 17

add-on to routine clinical care. The goal of this EBP change project is to achieve sustainable

change that would become the "new way of working" (Silver et al., 2016, p. 3).

Strength, Weakness, Opportunity, Threat Analysis

A Strength, Weakness, Opportunity, and Threat (SWOT) analysis is a strategic planning

mechanism that can take large quantities of data within these four areas and organize them into

specific concerns (Phadermrod et al., 2019; Walden, 2018). For this project, some of the

strengths were: high-quality, safe patient care focus, large facility, skilled team members, new

innovative leadership, a strong culture of safety, and fall prevention in place. Weaknesses noted

were: inpatient falls below metric baseline, lower quadrille scores of patient experience

HCAHPS surveys, high acuity on floors, high staff call-outs and turn over, lack of education on

fall prevention and PHR.

Opportunities and threats are external to the organization, but can provide openings to

advantage of opportunities and protect against threats. Some opportunities included:

reimbursement, patient satisfaction, leaders to revisit PHR, community growth, building

relationships with interdisciplinary care providers to work more collaboratively to eliminate

potential fall risk factors, and staff benefiting from additional education. Threats were: financial

stability, patient flow, acuity of patients, staffing challenges, age of inpatient population in the

community, and an increase in comorbidities, delirium, alcoholism, and drug use (see Appendix

G).

Project Overview

The mission and vision of this EBP change project coincided with the mission of the

organization to provide safe, quality patient care. This is based on the objective of

implementation of PHR with the support from the EBP best practice tool, Studer Group
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 18

Purposeful Hourly Rounding LogSM (2020a). Just as the medical center is a "cause and effect"

organization and strives to address areas of immediate needs, the EBP change project aimed to

address fall rates that were trending upward.

This EBP change project's short-term objectives were to increase transparent patient-

nurse communication on quality metrics already in place at the organization and to provide

educational events about PHR to staff, measured as pre- and post-tests (see Appendix H). The

long-term objective was to decrease the amount of patient falls, using a pilot to implement PHR.

Unintended Consequences and Missing Data

With EBP change projects, there are unintended consequences and even missing data.

One area of concern of unintended consequences was the sample size. During the 30-day trial,

the unit had an average daily census below the standard census of 52 patients. This was assumed

to be due to COVID-19, which caused the general population to shelter in place rather than seek

optional medical care. Unit staffing caused unintended consequences. Frequently, the unit was

staffed below the census of 52, equating to nursing and nursing tech assignments larger than

usual. This caused challenges to the support of PHR and added risk to patient safety since nurse-

to-patient ratios influence many patient outcomes, most markedly in-hospital mortality (Driscoll

et al., 2018).

Missing data occurred. Rounding sheets had been thrown out. Errors in the

documentation included patient room numbers. Missing data and incorrect information on the

PHR sheets added risk that the change results would be skewed. Possible limitations on data

collection could have occurred in the quality of data, manual documentation from staff, what was

defined as a fall, and whether it was reported.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 19

The plan to compare fall rates from pre-intervention to post-intervention created

summative data; however, there was a subjective measure of adherence to the Studer Group

Purposeful Hourly Rounding LogSM (2020a). While it was expected that all staff would work

hard and comply with PHR, there were limitations on the fidelity of employees. For example,

equating the staff signature on the rounding sheet confirmed that the patient's needs were

addressed upon entering the room, which was reliant on the veracity of staff members.

Project Plan (Method)

Descriptions of the Approach and Methods Employed

The JHNEBP model forms the framework for the EBP change project (Dang & Dearholt,

2017). After acquiring permissions (see Appendix A), the PET management guide (see Appendix

B) facilitated PHR's implementation. The first step identified the practice questions that helped

to develop and refine the EBP question: "In the adult inpatient hospital

setting, does PHR reduce falls during a determined time period?". Falls were analyzed on the

medical-surgical unit, key stakeholders identified, and pre fall data obtained and evaluated before

the EBP method was implemented.

The second step focused on the evidence. The Johns Hopkins Nursing Evidence-Based

Practice Quality Grading Tool (2020) was used to review the 12 articles for levels of evidence I

through VI and quality ratings A through C. The hierarchy of evidence grade varied between

levels I to VI, based on the strength of the methodological quality of design, validity, and

application to patient care. If the lower level of evidence in seven or 12 articles suggested a

recommendation of a pilot rather than a systems change project.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 20

The final step was translation, where a plan was created, and the implementation to pilot

PHR using the Studer Group Purposeful Hour Rounding Log SM (2020a) was completed. Results

were evaluated, shared with stakeholders, and findings were further disseminated.

Method for Understanding Variation of Data

Methods for understanding the variation of data involved statistical analysis utilizing

SPSS 24 software (Field, 2018). Pre- and post- assessment surveys were needed for quantitative

analysis, and a chi-square statistical test was used. Quantitative data were collected at 0-, 15-,

and 30- days, as outlined, utilizing an unpaired t-test. Tableau, software that allows the ability to

exploit the best data visualizations concepts and techniques, was used to disseminate information

(Terhaar & Taylor, 2018) (see Appendix I).

Barriers

Barriers during the implementation of the EBP change project were new leadership, lack

of consistent staffing, inconsistency in the volume of patients, and longer lengths of inpatient

stays. New leaders, who find the barriers overwhelming, may become too stressed to provide

support for bedside nurses, and although bedside nurses understood the importance of EBP

change, the lack of support and increased expectations resulted in a decreased ability to fulfill

patients' needs.

Ethical Considerations

Aspects relating to ethics of this EBP change project included: data storage, privacy, and

safety of vulnerable populations. Ethical codes of conduct, such as Nursing Codes of Ethical

Conduct espoused by the American Nurses Association, were observed and utilized (Zahedi et

al, 2013). This EBP change project incorporated Studer Group Purposeful Hourly RoundingSM
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 21

(2020a) to increase patient surveillance and assistance, which helped mitigate risk and safety

issues.

Budget

The cost savings associated with PHR is significant due to the potential increase in

satisfaction scores, insurance reimbursement due to better quality numbers, and the cost of a fall

to the organization. This EBP change project did not receive any specific grants or funding.

Table 1 displays the direct and indirect expenses along with the net revenue. This amount of

savings was significant to the organization.

Evaluation Results

This EBP change project evaluated the effectiveness of PHR on the reduction of patient

falls. The evaluation used formative and summative evaluation strategies and quantitative data

analysis to measure pre- and post-intervention outcomes, which ensured that the patients' needs

were met every hour.

Formative Evaluation

Staff who worked on the medical-surgical unit received a pretest before educational

events to assess their knowledge of how PHR affected the reduction of falls. Those who worked

on the unit were assigned a PHR education competency module (see Appendices H, J, and K),

followed by unit huddles, lunch and learns, and question and answer sessions to bridge

educational gaps. Staff participation in PHR was identified by their adherence to the Studer

Group Hourly RoundingSM eight rounding behaviors (2020b) and filling out the Studer Group

Purposeful Hourly Rounding LogSM (2020a).

Staff received education regarding actions to take during PHR, such as scripting and

attending to patients' immediate personal needs, how to fill out the Studer Group Purposeful
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 22

Hourly Rounding LogSM (2020a), and the benefits of PHR. Education particular to float staff was

provided to maintain consistency throughout the units. During leadership rounding, unit

leadership round throughout the week to model the behavior of rounding, the efficiency of

rounding, and identify any areas of opportunity for change. Once the pre-education was given,

the go-live date for PHR implementation was initiated.

Summative Evaluation

The interdisciplinary team of leadership: the project manager, executive leadership

support, staff, clinical and non-clinical staff, and IT team initiated the EBP practice change;

collected primary data which were stored on a secure drive, and physical data in a locked file

cabinet on the unit, only accessible to the project manager; and evaluated for success (see

Appendix L). PHR was documented by staff using the Studer Group Purposeful Hourly

Rounding LogSM (2020a) (see Appendix M) and assessed daily with the use of the Studer Group

Purposeful Hourly RoundingSM Daily Count (2020a) (see Appendix N). Inpatient fall rates and

the focus of the evaluation were documented and calculated. Daily analysis was completed using

the cause and effect diagram and a check sheet (see Appendix O and Appendix P), respectively,

which provided a method to identify prevalence of and reasons for falls on the medical-surgical

unit. Next, the frequency of patient checks was examined on the check sheet. This information

provided an understanding of patients' needs in relation to their safety at the bedside, the need to

round in order to monitor cause and effect, and the need to keep staff accountable for the

improved quality outcomes when rounding occurred.

The Approach Used to Establish Observed Outcomes through the Intervention

The effectiveness of using a valid and reliable tool coupled with fall risks assessment and

post fall huddles has been supported in the literature to decrease falls (King et al., 2018). The
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 23

information gained from the two assessment tools, advanced the need for the development of a

plan for this EBP change project as it brought attention to the areas of need and people who

could help drive the change. The information from the tools provided only a snapshot but served

as indicators of the need the organization was not meeting. The cause and effect diagram gave

way to brainstorming the areas of people, environment, materials, methods, and equipment that

the organization needed to address to decrease falls successfully.

Recruitment of Participants and Data

Participants were inpatients on the medical-surgical unit with exclusion criteria of

patients who had a sitter due to suicidal ideation and any patients under the age of 18. On

admission, all patients were educated about PHR. A sign was posted in all rooms to inform the

patients and families of the practice. Staff wore buttons, which sparked conversation and their

dedication to PHR (see Appendix Q). Nursing staff utilized the bedside whiteboard to increase

communication and address any specific questions. The results were shared throughout the

organization. The interdisciplinary team of leadership, the project manager, executive leadership

support, staff, clinical and non-clinical staff, and IT team, initiated the practice change, collected

data, and evaluated for success (see Appendix R).

Data Collection and Data Analysis

Patient clinical and demographic characteristics data were collected through review of

falls huddle reports and compared to an electronic report from the medical record documentation.

They were utilized for analysis on patients who had fallen or had fallen sustaining injuries. The

demographic data consisted of (a) age; (b) room number; (b) gender; (c) activated bed alarm; (d)

fall risk socks; (e) confusion; (f) documentation of fall risk; (g) the time of day/night if they had
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 24

fallen. Data were collected at 0000 daily of the house-wide census, unit census, and any falls

noted at 0-, 15-, and 30- days.

The medical-surgical unit fall rates from the same time frame one year prior to

implementation were analyzed to evaluate the impact of PHR. Each day, data were collected

from the hard copy Studer Group Purposeful Hourly Rounding LogSM (2020a), which measured

the compliance of rounding. The tool was reviewed 30 days after the education and

implementation of the new rounding process. Each week, the Studer Group Purposeful Hourly

Rounding Daily Count SM (2020a) was evaluated for compliance. The collected data, which

would determine the EBP change project's success, were put into an SPSS and Excel spreadsheet

and analyzed for the following:

1. The effect of the PHR on falls rates using the recommended calculation by the AHRQ

(2020a) which is, taking the total occupied beds and dividing the number of falls for

that month into that number: This calculation is: falls per patient days. Falls and falls

with injury rates are calculated per 1,000 occupied bed days. The fall data were

collected and stored from the Electronic Medical Record (EMR) and RL Solutions

Risk software, an electronic incident reporting system used at the institution.

Example: 3(falls)/879 (occupied bed days) = 0.034x 1000= 3.4 fall rate per 1000

occupied bed days.

2. Compliance with PHR as documented on the Studer Group Purposeful Hourly

Rounding Daily Count SM Tool (2020a) and measured as a percentage. Twenty rounds

were expected to be completed in 24 hours; compared to the number actually done.

Example: 19 (actual documented rounds)/ 20 (rounds that should be done = 95%

compliance.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 25

3. Comparison of descriptive analyses of demographic and clinical characteristics

collected on patients with falls and falls with injuries. To compare group differences,

chi square and unpaired t-tests were used. A p value was set at < 0.5.

Percentage differences were used to calculate change in falls rate from pre- to post- PHR

implementation. Data were imported into and analyzed using SPSS version 24 (Field, 2018).

Frequency tables and descriptive statistics summarized characteristics of patient falls.

Descriptive statistics were computed for percentage of the Studer Group Purposeful Hourly

Rounding Log (2020a) compliance during the study period. Figures such as bar charts and line

charts were created using Microsoft Excel. The rate of falls per 1000 occupied bed days for the

baseline period of June 22 to July 21, 2019 and the implementation period of June 22 to July 21,

2020, was compared using incidence rate ratio and 95% confidence intervals (CI) (Giles et al.,

2006; Rosner, 2011; Sahai & Khurshid, 1996). For any tests, a p value less than 0.05 was

considered significant.

Evaluation

There are many measures and benchmarks associated with PHR. The primary categories

of measures are the outcome, process, balancing, finance, and sustainability. In this EBP change

project, the primary outcome was to decrease inpatient falls. This metric was measured by the

number of patients per 1000 patient days noted by the National Database of Nursing Quality

Indicators benchmark, which was 3.4 falls per 1000 patient days (AHRQ, 2020b). Other

measures identified were the raw number of patients rounded on, patients who had a fall risk

charted, patients who had fall risk interventions in place, the number of post falls huddles for

patients who had fallen, the number of documented post falls huddles, the number of weekly
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 26

shifts adequately staffed to cover the average daily census of 52 beds, and the total payroll and

cost savings for the organization.

There was feasibility, which was an option to compare the process measure of falls as it

helped to improve safe quality patient care at 0-, 15-, and 30- days and determined if the planned

change was implemented as intended. Fidelity was encouraged through the education portion of

this EBP change project to improve staff buy-in and accountability, specifically by the presence

of fall champions and the collaborative effort of sharing the EBP change project that was

underway with patients through postings in rooms, staff buttons, and on whiteboards (see

Appendices Q and S).

Demographics of Patients Falls

There were a total of five patients, three females and two males, who fell a total of seven

times on the medical-surgical unit during the implementation period from June 22 to July 21,

2020. Of the seven patient falls, two had refused and three had agreed to have fall risk

interventions. There were no falls with injury as shown in Table 2, which presents the

characteristics of patient falls. Nearly 60% of the patients who had fallen had activated the bed

alarm. The data shows 71.4% of patient falls had fall risks socks and 85.7% had documented

confusion. There was 100% compliance of the documentation of fall risk for all patients, 71.4%

of post falls huddles were completed.

The frequency counts of the diagnosis of patient falls are presented in Figure 3, and the

time of falls are presented in Figure 4. Three patient falls occurred around noon; two occurred in

the evening after 1900; one occurred in the early morning at 0425; and one occurred in the

afternoon at 1447.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 27

The Studer Group Purposeful Hourly Rounding Log

On each day of the study intervention, the numbers of PHR documented and the number

of PHRs expected were recorded in the Studer Group Purposeful Hourly Rounding LogSM

(2020a). The percentage of PHR compliance was computed as 100% *(number of PHR

documented)/(number of PHR expected). The summary statistics of these measures, daily

number of PHR documented, daily number of PHR expected, and daily percentage of PHR

compliance are presented in Table 3.

The average daily number of PHR documented was 592.13 (SD = 117.93) and the

average daily number of PHR expected was 794.37 (SD = 114.87). The average daily percentage

of PHR compliance was 74.16% (SD = 8.55). Figure 5 further presents a line chart for the daily

percentage of PHR compliance. The daily percentage of PHR compliance over the 30-day study

period appears stable.

Falls Rate Assessment

Falls per 1000 occupied bed days were computed for two periods: baseline period of June

22 to July 21, 2019, and implementation period of June 22 to July 21, 2020. For the baseline

period, there were six falls and 1459 occupied bed days; for the implementation period, there

were seven falls and 1382 occupied bed days. Thus, the falls rate for baseline period was 4.11

falls per 1000 occupied bed days (95% CI = [1.85, 9.15]). The falls rate for implementation

period was 5.07 falls per 1000 occupied bed days (95% CI = [2.42, 10.62]) (see Table 4). The

incidence rate ratio of the falls rate between baseline and implementation was 0.81 (χ2(1) =

0.140, p = 0.708; 95% CI = [0.27, 2.42]), indicating that there was no statistically significant

difference in fall rates between the baseline period and the implementation period. These results

were compared to the findings from other publications.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 28

Missing Data Details and Data Storage

A carefully scripted plan for any missing data was utilized. All falls were checked against

the EMR and RL Solutions used at the institution. Electronic data were stored on a secure drive

and physical data in a locked file cabinet on the unit, accessible only to the project manager. To

ensure privacy, the falls data were collected in a de-identified manner and stored with the use of

a password-protected computer and distributed in aggregate. Compliance with PHR was

documented on the Studer Group Purposeful Hourly Rounding Daily Count SM (2020a).

Statistical and Clinical Significance

Statistical significance indicates the reliability of study results (Ranganathan et al., 2015).

This study did not have statistical significance. Despite the implementation of PHR, the number

of patient falls did not decrease compared to the year prior 30 day period. However, the sample

size (unit census), on which statistical significance depends, varied daily from 40 to 52.

While there are established, traditionally accepted values for statistical significance

testing, this is lacking for evaluating clinical significance (Fethney, 2010, as cited in

Ranganathan et al., 2015). More often than not, it is the judgment of the clinician, and the

patient, which decides whether a result is clinically significant (Ranganathan et al., 2015). This

study is clinically significant because of its impact on clinical practice. The outcomes led to a

better understanding of hospital falls on the medical-surgical unit, why falls happen, and the use

of PHR as a possible strategy to prevent them. There were also added benefits of PHR that are

not measured in this EBP change project, such as increased patient-nursing staff communication,

which potentially impacts patient satisfaction scores and how patients view their care.

With PHR being known as a fall prevention, patient safety intervention, and a goal of

preventing additional harm to patients while in the hospital, this EBP change project was
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 29

identified as clinically significant. Preventing falls means protecting against fall-related longer

hospital stays, which are costly and potentially harmful. Through the rigorous process required

by the University of St. Augustine for Health Sciences and the EBP change project site, this EBP

change project was designed so that processes and outcomes were evaluated to guide practice

and policy and provide a foundation for future practice scholarship (American Association of

Colleges of Nursing, 2020).

Protection of Human Rights

Protection of rights was ensured through the review of this EBP change project both pre-

initiation and ongoing. The EBPC reviewed the EBP change project proposal and determined the

appropriate nature of the project. All information collected as part of evaluating the impact of

this EBP change project from the providers involved was described in the aggregate only and did

not include any potential identifiers. Each staff member who participated in this EBP change

project remained anonymous.

Limitations

There were limits to the generalizability of the work. Limitations that had been

considered thus far supporting PHR included the sample size and staffing levels. The impact for

this EBP change project helped to decrease fall rates on this medical-surgical unit and had the

ability to show improvement in other areas such as, length of stay, early ambulation, call light

usage, patient satisfaction, and staff retention. Through the evidence presented in this scholarly

EBP change project the implication of PHR was useful, sustainable, clinically significant, and

essential.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 30

Impact

This EBP change project was clinically significant because of its impact on clinical

practice. It helped bring light to this significant safety issue and how bedside nursing can

positively impact patient falls. The outcomes led to a better understanding of the types of and

reasons for hospital falls on the medical-surgical unit and PHR as a possible prevention strategy.

Staff identified ways to alter their care and adapt to future implications for safe quality care. In

addition, there was a clear focus on the nursing team and the patient to create collaborative

relationships and work toward the same goal.

The added benefits of PHR that were not measured in this EBP change project was the

noted improvement of patient-nursing staff communication, which potentially has a positive

impact on patient satisfaction scores, as effective communication subsequently affects how

patients view their care. Nurses recognized that the protection from falls translated into

safeguarding against fall-related longer hospital stays, which are both costly and potentially

harmful.

The EBP change project had an impact on the organization as it was determined there

was a large number of projects being implemented simultaneously. Due to this determination,

projects are to be vetted through the EBPC for consistency, timelines, and ongoing evaluation of

effectiveness and follow up. Falls were highlighted as a hot spot, and the need was identified to

form a team of process improvement and practice managers to work on sustainably of PHR.

With a substantial focus on the lessons learned, the next steps include a robust education plan,

documentation in "now time" in the EMR, and a proactive care approach to address this practice

problem and potential project replication.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 31

Plans for Dissemination

The plan for dissemination, which is the process of sharing findings with stakeholders

and wider audiences, is essential for uptake. Through acceptance and the use of findings, the

success and sustainability will be on target for long term utilization. Presenting the EBP change

project's findings to stakeholders, executive leaders, managers, and both clinical and non-clinical

staff via poster presentation and through visual aids, handouts, and interactive discussions is an

essential component of dissemination. The EBP change project's findings and impact of the

project were presented identifying the differences between observed and anticipated outcomes,

which included the influence of context, cost, strategic tradeoffs, and opportunity costs. By

showcasing the hard work being done, the results of the EBP change project, and the plans for

continuing to work on safe and quality patient outcomes to stakeholders and leadership and the

importance of ongoing adjustments and continued work of PHR, decreased falls and improved

patient outcomes is anticipated.

The organization supported this mode of delivery and encouraged sharing the findings

internally and externally. One possible venue for this EBP change project is a regional chapter of

Sigma Theta Tau International Honor Society of Nursing, where a poster presentation would

allow for sharing of information to a broad audience that supports EBP change.

Plans to submit to peer-reviewed nursing journals that appeal to bedside nurses and

nursing leaders are underway, such as The Journal of Nursing Practice Applications & Reviews

of Research (JNPARR), the official international, peer-reviewed publication of the Philippine

Nurses Association of America, accepts DNP EBP change projects for publication as written, but

cut down to a 20 page limit. Similar to an article published in Nursing Management about PHR

in 2015, a query will be sent to the journal editor to ask whether there would be interest in an
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 32

article on factors that enhance the success of PHR. Submission to The Scholarship and Open

Access Repository will occur after peer review and approval.

Conclusion

Patient falls are consistent problems that have a significant impact on patent care in

hospitals across the country, leading to injury or even death (Najafpour et al., 2019). In keeping

with the literature, which supports PHR as one successful strategy to reduce inpatient falls, this

EBP change project was implemented as a pilot to compare the impact of PHR, using the Studer

Group's Purposeful Hourly Rounding ToolSM (2020a). This EBP change project was

implemented in a large acute care facility over a period of 30 days during the same time period

from the previous year. The results revealed no statistical significance between baseline falls

rates and implementation on this medical-surgical unit. In fact, falls rose from 4.11 to 5.07 per

1000 occupied bed days. Although PHR with the use of the Studer Group Purposeful Hourly

Rounding LogSM (2020a) did not result in a decrease in patient falls, the interpretation of the

results of this EBP change project should take into account the clinical significance by looking at

the impact of improved patient care rather than p values and statistical significance. The clinical

significance and whether the intervention made a real difference to patients' lives should be

considered, even when subjectively interpreted. PHR has clinical significance in patients' lives

through increased touch points that improve their perception of staff responsiveness, which

yields positive patient outcomes. Other ramifications of the clinical significance from this EBP

change project's intervention included increased patient-nursing staff communication, patient

satisfaction scores, and decreased call light usage, and hospital lengths of stay.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 33

References

Adams, J., & Kaplow, B. (2013). A sitter reduction program in an acute health care system.

Nursing Economic, 31(2), 83-89.

http://husson.idm.oclc.org/login?url=https://www.proquest.com/docview/1347609778?ac

countid=27496

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals.

https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk3.html#3-3

Agency for Healthcare Research and Quality. (2019). Estimating the additional hospital

inpatient cost and mortality associated with selected hospital-acquired conditions.

https://www.ahrq.gov/hai/pfp/haccost2017.html

Agency for Healthcare Research and Quality. (2020a). Falls. https://psnet.ahrq.gov/primer/falls

Agency for Healthcare Research and Quality. (2020b). How do you measure fall rates

and fall prevention practices?

https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html

American Association of Colleges of Nursing (2020). Doctorate of nursing practice

(DNP) tool kit. www.aacnnursing.org/DNP/Tool-Kit

Barrett, M., Vizgirda, V., & Zhou, Y. (2017). Registered nurse and patient care technician

perceptions of toileting patients at high fall risk. Medical Surgical Nursing, 26(5), 317-

323.

https://www.thefreelibrary.com/Registered+Nurse+and+Patient+Care+Technician+Perce

ptions+of+Toileting...-a0514512712
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 34

Bouldin, L., Andresen, M., Dunton, E., Simon, M., Waters, M., Liu, M., Daniels, M.

J., Mion, C., & Shorr, I. (2013). Falls among adult patients hospitalized in the United

States: Prevalence and trends. Journal of Patient Safety, 9(1), 13–17.

https://doi.org/10.1097/pts.0b013e3182699b64

Boysen, P. G., (2013). Just culture: A foundation for balanced accountability and patient

safety. The Ochsner Journal, 13(3), 400–406.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/

Clarke, S., & Donaldson, N. (2008). Patient safety and quality: An evidence-based

handbook for nurses. Agency for Healthcare Research, 4(25), 1-4.

www.ncbi.nlm.nih.gov\books\NBK2676\

Dang & Dearholt, S. (2017). Johns Hopkins nursing evidence-based practice: Model and

guidelines (3rd. ed.). Sigma Theta Tau International

Daniels, J. (2016). Purposeful and timely nursing rounds: A best practice implementation

project. JBI Database of Systematic Reviews and Implementation Reports, 14(1). 248-

267. https://doi.org/10.11124/jbisrir-2016-2537

Driscoll, A., Grant, M., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwaldt, D., Mckee, G.,

Munyombwe, T., & Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-

sensitive patient outcomes in acute specialist units: A systematic review and meta-

analysis. European Journal of Cardiovascular Nursing, 17(1), 6–22.

https://doi.org/10.1177%2F1474515117721561

Eastern Maine Medical Center. (2020, March). Quality Dashboard.

http://www.intranet.emmc.org/
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 35

Field, A. (2018). Discovering statistics using IBM SPSS statistics: North American edition. (5th

ed.). SAGE Publications.

Fridman, V. (2019). Redesigning fall prevention program in acute care: Building on

evidence. Clinical Geriatric Medicine, 35(1), 265-271.

https://doi.org/10.1016/j.cger.2019.01.006

Giles, L. C., Bolch, D., Rouvray, R., McErlean, B., Whitehead, C. H., Phillips, P. A., & Crotty,

M. (2006). Can volunteer companions prevent falls among inpatients? A feasibility study

using a pre-post comparative design. BMC geriatrics, 6(1), 11.

https://doi.org/10.1186/1471-2318-6-11

Health Research & Educational Trust. (2018). Falls with injury change package.

Chicago, IL: Health Research & Educational Trust. https://www.wha.org/Quality-

Patient-Safety/Partners-for-Patients/Shared-

Resources/Falls/FALLS_ChangePackage_2015-HRET

Hinks, C. (2015). Can rounding reduce patient falls in acute care? An integrative

literature review. Medical Surgical Nursing, 24(1), 51-55.

https://pubmed.ncbi.nlm.nih.gov/26306357/

Hitcho, E., Krauss, J., Birge, S., Claiborne-Dunagan, W., Fischer, I., Johnson, S., Nast, A.,

Costantinou, E., & Fraser, J. (2004). Characteristics and circumstances of falls in a

hospital setting: A prospective analysis. Journal of General Internal Medicine, 19(7),

732–739. https://doi.org/10.1111/j.1525-1497.2004.30387.x

Hiyama, A. (2017). Relationship between ethical issues in fall prevention care and nurses'

characteristics. International Journal of Nursing, 4(2), 22-28.

https://doi.org/10.15640/ijn.v4n2a3
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 36

Hutchings, M., Ward, P., & Bloodwork, K. (2013). Caring around the clock: A new approach to

intentional rounding. Nursing Management. 20(5), 24-30.

http://www.doi.org/10.7748/nm2013.09.20.5.24.e1075

Institute for Healthcare Improvement. (n.d.). IHI improvement resource tools.

http://www.ihi.org/resources/Pages/Tools/Patient-Safety-Essentials-

Toolkit.aspx?gclid=EAIaIQobChMImIuO68Pm7AIVGbbICh3cAwAQEAAYASACEgK

UGvD_BwE

Joint Commission. (2015, September 28). Preventing falls and fall-related injuries.in health care

facilities. Sentinel event alert (55), 1-5. https://www.jointcommission.org/-

/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-

library/sea_55pdf.pdf?db=web&hash=53EE3CDCBD00C29C89B781C4F4CFA1D7

Joint Commission (2020). Sentinel event. www.jointcommission.org/en/resources/patient-safety-

topics/sentinel-event/

Joint Commission Center for Transforming Healthcare. (2019). Targeted solution tools for

preventing falls. www.centerfortransforminghealthcare.org/what-we-offer/targeted-

solutions-tool/preventing-falls-tst

Kelley, T. & Brandon, D. (2012). Development of an observational tool to measure nurses'

information needs. International Congress on Nursing Informatics, 6(1), 23-27.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799094/

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention

on nurses and care of fall risk patients. The Gerontologist, 58(2), 331–340.

https://doi.org/10.1093/geront/gnw156
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 37

Maine Health Data Organization (2013). Hospital quality data.

https://mhdo.maine.gov/quality_data.htm

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing

Management, 20(1), 32-7. http://doi.org/10.7748/nm2013.04.20.1.32.e1013

Mitchell, M., Lavenberg, J., Trotta, R., & Umscheid, C. (2014). Hourly rounding to improve

nursing responsiveness: A systematic review. Journal Nursing Administration, 44(9),

462-472. https://doi.org/10.1097/nna.0000000000000101

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G., the PRISMA Group. (2009, July 21).

Preferred reporting items for systematic reviews and meta-analyses: The PRISMA

Statement. PLoS Med 6(7): e1000097. https://doi.org/10.1371/journal.pmed.1000097

Morello, R. (2015). The extra resource burden of in-hospital falls: A cost of falls

study. Medical Journal of Australia, 11(2), 367. https://doi.org/10.5694/mja15.00296

Murphy, F. (2006). Using change in nursing practice: a case study approach. Nursing

Management. 13(2), 22-25. https://www.deepdyve.com/lp/royal-college-of-nursing-

rcn/using-change-in-nursing-practice-a-case-study-approach-4PXWW6qc6q

Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital in-

patients: A prospective nested case control study. International Journal of Health Policy

and Management. 8(5), 300–306. https://doi.org/10.15171/ijhpm.2019.11

Northern Light Health. (2020). About us. https://northernlighthealth.org/About-Us

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study.

Medical Surgical Nursing, 21(1), 1-5.

https://www.researchgate.net/publication/223961466_Hourly_rounding_A_replication_st

udy
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 38

Phadermrod, B., Crowder, R., & Wills, G. (2019). Importance- performance analysis-based

SWOT analysis. International Journal of Information Management. 44(1), 194-203.

http://doi.org/10.1016/j.ijinfomgt.2016.03.009

Radecki, B., Reynolds, S., & Kara, A. (2018). Inpatient fall prevention from the patient's

perspective: A qualitative study. Applied Nursing Research, 43(1), 114-119.

https://doi.org/10.1016/j.apnr.2018.08.001

Ranganathan, P., Pramesh, C. S., & Buyse, M. (2015). Common pitfalls in statistical analysis:

Clinical versus statistical significance. Perspectives in clinical research, 6(3), 169–170.

https://doi.org/10.4103/2229-3485.159943

Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. A. (1995). The well-built

clinical question: A key to evidence-based decision. ACP Journal Club.

https://mclibrary.duke.edu/sites/mclibrary.duke.edu/files/public/guides/richardson.pdf

Robb, M. (2004). Changing methods of communication. Nursing Management. 10(9), 32-35.

https://journals.rcni.com/doi/abs/10.7748/nm2004.02.10.9.32.c1963

Rosner, B. (2011). Fundamentals of biostatistics. Brooks/Cole.

Sahai, H., & Khurshid, A. (1996). Statistics in epidemiology: Methods, techniques, and

applications. CRC Press, Inc.

Schaffer, M., Sandau, K., & Diedrick, L. (2012). Evidence-based practice models for

organizational change: overview and practical applications. Journal of Advanced

Nursing, 69(5), 1197-1209. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-

2648.2012.06122.x
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 39

Silva, K. & Hain, P. (2017). Fall prevention: Breaking apart the cookie-cutter approach. Medical

Surgical Nursing, 26(3), 198-213.

https://www.thefreelibrary.com/Fall+prevention%3a+breaking+apart+the+cookie+cutter

+approach.-a0502001247

Silver, S., McQuillan, R., Harel, Z., Weizman, A., Thomas, A., Nesrallah, G., Bell, C., Chan, C.,

& Chertow, G. (2016). How to sustain change and support continuous quality

improvement. Clinical Journal of the American Society of Nephrology, 11(5) 916-

924; DOI: https://doi.org/10.2215/CJN.11501015

Spano-Szekely, L., Winkler, A., Walters, C., Dealmeida, S., Brandt, K., Williamson, M., Blum,

C., Gaster, L., & Wright, F. (2019). Individualized fall prevention program in an acute

care setting: An evidence-based practice improvement. Journal of Nursing Care Quality,

34(2), 127-132. http://doi.org/10.1097/NCQ.0000000000000344

Studer Group. (2007). Hourly rounding supplement Best practice: Sacred Heart Hospital

Pensacola Florida.

www.mc.vanderbilt.edu/root/pdfs/nursing/hourly_rounding_supplementstuder_group.pdf

Studer Group. (2020a). Hourly Rounding.

https://www.studergroup.com/resources/healthcare-tools/hourly-rounding

Studer Group. (2020b). Hourly Rounding on patients delivers quality outcomes and makes the

job easier. www.studergroup.com/hardwired-results/hardwired-results-07/improve-

clinical-outcomes-with-hourly-rounding

Terhaar, M. F., & Taylor, L. A. (2018). Best practices for submission to the Institutional Review

Board. In M. L. Sylvia. Clinical analytics and data management for the DNP (2nd ed).

Springer Publishing Company.

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 40

The Johns Hopkins Hospital/Johns Hopkins University. (2020). Hopkins Nursing Evidence

Based Practice Appendix C: Level and Quality Grade.

https://www.hopkinsmedicine.org/evidence-based

practice/_docs/appendix_c_evidence_level_quality_guide.pdf

Tzeng, H., & Ying, C. (2008). Nurses' solution to prevent inpatient falls in hospital

patient rooms. Nurse Economy, 26(3), 179-187.

https://pubmed.ncbi.nlm.nih.gov/18616056/

United States Census Bureau. (2019). Quick facts Maine. www.census.gov/quickfacts/ME

Walden, S. (2018). Strategic healthcare management: Planning and execution (2nd ed.). Health

Administration Press.

Walsh, C., Liang, L., Grogan, T., Coles, C., McNair, N., & Nuckols, T. (2018). Temporal trends

in fall rates with the implementation of a multifaceted fall prevention program:

Persistence pays off. The Joint Commission Journal on Quality and Patient Safety, 44(1),

75-83. https://doi.org/10.1016/j.jcjq.2017.08.009

Wyant, T. (2017). Adopt an evidence-based practice model to facilitate practice change.

ONS Voice, 11(21), 1-2. https://voice.ons.org/news-and-views/adopt-an-evidence-based-

practice-model-to-facilitate-practice-change

Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., Parsapour, A., Maddah, S.,

Cheraghi, M., Mirzabeigi, G., Larijani, B., & Dastgerdi, M. (2013). The code of ethics for

nurses. Iranian Journal of Public Health, 42(1), 1–8.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712593/
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 41

Zhao, Y., Bott, M., He, J., Kim, H., Park, S., & Dunton, N. (2019). Evidence on falls and

injurious fall prevention interventions in acute care hospitals. The Journal of Nursing

Administration, 49(2), 86-92. http://10.1097/NNA.0000000000000715

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 42

Table 1

Budget

EXPENSES REVENUE

Direct Billing 0.00

Student Salary and benefits 0.00 Grants 0.00

Supplies and Services $100.00 Institutional budget support 0.00

(laminating and copying)

Snacks for Lunch and Learn $200.00 Reduction of 2.2 FTE Sitter per ($72,000.00)

year

Staff Training (one hour) 0.00 Reduction of Falls by 1 fall ($13,953.00)

Cost of Fall with injury $139,530.00 Reduction of Patient Experience ($92,840.00)

(13,953x10) (22%) Value Based Purchasing

Indirect

Overhead 0.00

Total Expenses $139830.00

Net Balance $178793.00 Total Revenue -$38,963.00

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 43

Table 2

Characteristics of Patient Falls

No Yes

Falls with injury 7 (100) 0

Activated bed alarm 3 (42.9) 4 (57.1)

Fall risk socks 2 (28.6) 5 (71.4)

Confusion 1 (14.3) 6 (85.7)

Documentation of fall risk 0 7 (100)

Post falls huddle 2 (28.6) 5 (71.4)

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 44

Table 3

Summary Statistics of PHR

M SD Min Max

# PHR documented 592.13 117.93 313 805

# PHR expected 794.37 114.87 555 1014

% of PHR compliance 74.16 8.55 54.91 88.17

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 45

Table 4

Falls per 1000 Occupied Bed Days

Number of falls Occupied bed days Fall rate [95% CI]

B 6 1459 4.11 [1.85, 9.15] falls per 1000 occupied bed days

I 7 1382 5.07 [2.42, 10.62] falls per 1000 occupied bed days

Note. B = baseline period and I = implementation period. Fall rate = (Number of falls/Occupied

bed days)*1000.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 46

Figure 1

Adapted PRIMSA Methodology

Note: Adapted from The PRISMA Statement and the PRISMA Explanation and

Elaboration document are distributed under the terms of the Creative Commons

Attribution License, which permits unrestricted use, distribution, and reproduction in any

medium, provided the original author and source are credited (PRIMSA, 2020).

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G., the PRISMA Group. (2009, July 21).

Preferred reporting items for systematic reviews and meta-analyses: The PRISMA

Statement. PLoS Med 6(7): e1000097. https://doi.org/10.1371/journal.pmed.1000097

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 47

Figure 2

Practice Recommendation for Decreasing Falls

Adherence to Studer Group

rounding Purposeful
practice Hourly
Rounding

Proper application
and education
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 48

Figure 3

Diagnosis
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 49

Figure 4

Fall Time
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 50

Figure 5

Daily percentage of PHR compliance

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 51

Appendix A

Accepted Permission From Johns Hopkins to use Nursing Evidence Based Practice Model
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 52

Appendix B

JHEBP Model PET Management Guide

Through the use of Johns Hopkins Nursing Evidence-Based Practice the PET management guide facilitated the
EBP change project through the steps below.

PRACTICE QUESTION
Step 1: Recruit interprofessional team
Step 2: Define the problem
Step 3: Develop and refine the EBP question
Step 4: Identify stakeholders
Step 5: Determine responsibility for project leadership
Step 6: Schedule team meetings

EVIDENCE
Step 7: Conduct internal and external search for evidence
Step 8: Appraise the level and quality of each piece of evidence
Step 9: Summarize the individual evidence
Step 10: Synthesize overall strength and quality of evidence
Step 11: Develop recommendations for change based on evidence synthesis

TRANSLATION
Step 12: Determine fit, feasibility, and appropriateness of recommendation(s) for translation path
Step 13: Create an action plan
Step 14: Secure support and resources to implement an action plan
Step 15: Implement an action plan
Step 16: Evaluate outcomes
Step 17: Report outcomes to stakeholders
Step 18: Identify next steps
Step 19: Disseminate findings

Dang & Dearholt, S. (2017). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd. ed.).
Sigma Theta Tau International
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 53

Appendix C

Summary of Primary Evidence

Design, Sample Intervention Usefulness

Citation Level Theoretica Outcome Results
Sample Comparison l Definition Key Findings
Quality size Foundatio
Grade n
Olrich, T., Kalman, M., & Nigolian, C. (2012). Evidence 506 bed PHR Not Falls rate PHR by nursing
Hourly rounding: A replication study. Level 2 teaching vs. no disclosed 3.37/1000 to personnel
Medical Surgical Nursing, 21(1), 1-5. hospital. intervention by author 2.61/1000 positively impacts
https://www.researchgate.net/publication/2239614 Quality 1 year 23% three variables:
66_Hourly_rounding_A_replication_study A 4.418 reduction in patient fall rates,
patients falls was call light usage,
clinically and patient
significant satisfaction.
not
statistically
significant (p
= 0.672)
Radecki, B., Reynolds, S., & Kara, A. (2018). Evidence 12 patients Interviews Not Three Fall assessment
Inpatient fall prevention from the patient's Level 3 mean age patients disclosed themes: How needs to shift
perspective: A qualitative study. Applied Nursing 65.2 perspective of by author I see myself, from clinician -
Research, 43(1), 114-119. Quality their own fall how I see the centric to patient-
https://doi.org/10.1016/j.apnr.2018.08.001 C risk of the fall interventions, centric.
prevention and how I see Structured
intervention teamwork Rounding, which
implemented by 90% believed includes specific
staff they shared nursing actions,
the same aims to meet
prevention patients' needs
plan as the proactively
nurse.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 54

through 1 or 2
hourly rounds.
Hodgson, L. (1012). Hourly rounding in a high Evidence 51 patients Rounding logs Not No patient 25 patient logs
dependency unit. Nursing Standard, 27(8), 35-40. Level 5 for assignment disclosed falls during documented for
https://search.proquest.com/docview/1130216113? of two patients by author trial (also no PHR.
accountid=158603 Quality falls two Inconclusive on
B months falls with
before trial or implementation
after trial)
Trepanier, S., & Hilsenbeck, J. (2014). A hospital Evidence 50 Interdisciplinary Not Decrease in An EBP
system approach at decreasing falls with injuries Level 5 hospitals team initiated a disclosed anticipated standardized fall
and cost. Nursing Economics, 32(2), 135-141. 12 month standardized fall by author falls by year prevention
http://search.ebscohost.com/login.aspx?direct=true Quality of prevention 2 72% and program resulted
&db= A implementa program decrease in in a decrease in
heh&AN=96936044&site=eds-live tion falls by anticipated falls
58.3%. with injuries
Potential cost
avoidance
reduction of
$776,064

Silva, K. & Hain, P. (2017). Fall prevention: Evidence 408 beds Fall prevention PSDA 69% of Fall risk numbers
Breaking apart the cookie-cutter approach. Level 5 on 13 adult using screening Model unassisted seem to be
Medical Surgical Nursing, 26(3), 198-213. med tools, PHR, fall falls in irrelevant
https://www.thefreelibrary.com/Fall+prevention% Quality surgical bundle (yellow patients 18- Action plan to
3a+breaking+apart+the+cookie+cutter+approach.- B rehab units socks, bracelet, 64. each risk factor
a0502001247 own shoes, Common Patient specific
signs, bed/chair cause 33% initiative
alarm, self- muscle Empower staff,
releasing belt, weakness, facilitate
1:1 observer, fall loss of immediate
video in several balance 24%, debrief.
languages) and altered
mental status
24%,
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 55

slipped/trippe
d 19%.
40% of falls
happened
from 12-7pm
Barrett, M., Vizgirda, V., & Zhou, Y. Evidence 4 hospital RN perception Not Significant Effective care
(2017).Registered nurse and patient care technician Level 3 health of Toileting disclosed differences planning between
perceptions of toileting patients at high fall risk. system regimen for high by author were found RN and PCT is a
Medical Surgical Nursing, 26(5), 317-323. Quality 221 RN risk fall patients between RN targeted strategy
https://www.thefreelibrary.com/Registered+Nurse B 186 PCT and PCTs in that may increase
+and+Patient+Care+Technician+Perceptions+of+ identification the understating
Toileting...-a0514512712 of patient of needs of
characteristic patients at high
s associated risk for falls.
with risk of Toileting is
toileting- important
related falls component of fall
(pt. mobility, reduction
toileting program on
habits, med medical surgical
use, med patients.
conditions,
and schedule
for toileting
pts with
AMS, waking
patients for
toileting,
routine
toileting, and
diapers as
alterative
toileting
strategy.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 56

Walsh, C., Liang, L., Grogan, T., Coles, C., Evidence 466 bed Fall committee, Not Falls rate Multidimensional
McNair, N., & Nuckols, T. (2018). Temporal Level 3 academic flagged high risk disclosed reduced from fall prevention
trends in fall rates with the implementation of a center patients, by author 3.07 to 2.22 program
multifaceted fall prevention program: Persistence Quality improved all per 1,000 incremental
pays off. The Joint Commission Journal on Quality A reporting, patient falls a approach and
and Patient Safety, 44(1), 75-83. increased 27.7% persistence pay
https://doi.org/10.1016/j.jcjq.2017.08.009 scrutiny of falls, reduction in off
instituted PHR, 11.5 years
reorganized
leadership
system,
standardized fall
prevention
equipment,
routinely
investigated root
cause, mitigated
fall risk during
PHR, educated
patients on falls,
taught nurse to
think critically
about risk.
Jong, L., Kitchen, S., Foo, Z., & Hill, A. (2017). Evidence 31 Exploring COM-B is 90% of sitters Sitters have
Exploring fall prevention capabilities, barriers and Level 3 participants barriers and a health felt confident limited capability
training needs among patient's sitters in a hospital completed training needed behavior in their role, regarding fall
settings: A pilot survey. Geriatric Nursing, 39(1), Quality survey for patient sitters change 91% of falls prevention
263-270. B as a fall framework were pt.
https://www.sciencedirect.com/science/article/pii/S prevention related
0197457217302434?via%3Dihub strategy. 64% said
sitter capacity
was limited
84% of sitters
would like
further
training.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 57

Adams, J., & Kaplow, B. (2013). A sitter reduction Evidence 6 month Decrease sitters Not Decrease Presence of sitters
program in an acute health care system. Level 5 period without disclosed sitter use 50% did not decrease
Nursing Economic, 31(2), 83-89. impacting fall by author in one fiscal falls.
http://husson.idm.oclc.org/login?url=https://www. Quality rates year. Savings It was intentional
proquest.com/docview/1347609778?accountid=27 B of 1.2 million presence of
496 in annual nursing staff
savings (PHR) that was
without successful in the
negatively reduction of sitter
impacting fall use
rates
Fridman, V. (2019). Redesigning fall prevention Evidence 13.3% of PHR as a PSDA Fall A clear
program in acute care: Building on evidence. Level 5 participants meaningful task Model prevention is relationship
Clinical Geriatric Medicine, 35(1), 265-271. addressed to decrease falls complicated between
https://doi.org/10.1016/j.cger.2019.01.006 Quality toileting and careful deliriums, patient
B planning, toileting needs,
implementati high-risk
ons and prescriptions
evaluations medications,
are required ambulation, and
for successful impairment
nursing increase in the
practice number of patient
change. falls.
Rachh, P., Wilkins, G., Capodilupo, T., Kilroy, S., Evidence 950 bed Patient observer Not CAM Practice change
Schinder, M., Repper-Delisi, J. (2016). Level 5 academic hours decreased disclosed positive included the
Redesigning the patient observer model to achieve center, pilot 46% in by author patients ability to hold the
increased efficiency and staff engagement on a Quality 27 bed utilization. Fall patient falls rate
surgical trauma inpatient unit. The Joint B adult rates remained steady
Commission Journal on Quality and Patient inpatient unchanged. Staff
Safety, 42(2), 77-85. surgical satisfaction
https://www.sciencedirect.com/science/article/abs/ trauma unit increased from
pii/S155372501642009X 9-72% with
patient observer
model.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 58

Spano-Szekely, L et al. (2019). Individualized fall Evidence 54% CPG identified 7 EBPI Implementati Added video
prevention program in an acute care setting: An Level 5 reduction practices for model. on proves, monitoring.
evidence-based practice improvement. Journal of in falls effective fall PDSA feedback Debriefing key to
Nursing Care Quality, 34(2), 127-132. Quality from 2.51 prevention: cycle from staff, sustainability
http://doi.org/10.1097/NCQ.0000000000000344 A falls per organizational and learning
1000 support for a fall from real
patients to prevention time debriefs
1.15 fall program, reinforce
per 100 evaluation of the learning and
patient. pat on admission sustainability.
72% for fall risk, risk
reduction assessment to
in sitters identify risk
usage = factors,
84,000 communicate
annual risk factors,
savings observation and
noted. surveillance,
auditing,
continuously
learning, and
improvement.
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 59

Appendix D

Summary of Systematic Reviews (SR)

Citation Quality Question Search Strategy Inclusion/ Data Key Findings Usefulness/Recommen
Grade Exclusion Criteria Extractio dation/
n and Implications
Analysis
Hicks, D. (2015). Can Quality PHR nursing+ falls, Inclusion fall Systematic 14 studies were Promising effects of
Rounding reduce A inpatient + adults, prevention program Review analyzed to identify PHR decrease fall rates
patient falls in acute hourly + rounding, and PHR utilized patters, similarities,
care? An integrative quality + and differences
literature review. improvement, and safe
Medical Surgical + patient care
Nursing, 24(1), 51-55.
https://search.proquest.
com/openview/7891afc
5d54f14c1e75dacf0181
55793/1/advanced
Zhao, Y., Bott, M., He, Quality Staffing nursing+ falls, Inclusion fall Systematic CMS and Medicaid Without adequate
J., Kim, H, Park, S., & A and PHR inpatient + adults, prevention program Review services no longer staffing, it is
Dunton, N. (2019). hourly + rounding, and PHR. Also reimburses hospitals challenging for nursing
Evidence on falls and quality + addresses adequate for treatment of staff to implement
injurious fall improvement, and safe staffing preventable injuries, appropriate fall
prevention + patient care including fall- prevention
interventions in acute related injuries. interventions to prevent
care hospitals. The Hospitals will pay falls and injurious falls.
Journal of Nursing the extra cost for
Administration, 49(2), these falls and
86-92. hospitals in revenue
http://10.1097/NNA.00 losses.
00000000000715

Mitchell, M., Quality PHR nursing+ falls, Included PHR and Systematic Positively impact Improves pt.
Lavenberg, J., Trotta, A inpatient + adults, nurse responsiveness Review patient outcomes perception, of staff
R., & Umscheid, C. hourly + rounding, responsiveness, reduces
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 60

Citation Quality Question Search Strategy Inclusion/ Data Key Findings Usefulness/Recommen
Grade Exclusion Criteria Extractio dation/
n and Implications
Analysis
(2014). Hourly quality + call light and improves
rounding to improve improvement, and safe patient satisfaction
nursing responsiveness: + patient care scores.
A systematic review.
Journal Nursing
Administration, 44(9),
462-472.
https://doi.org/10.1097/
nna.000000000000010
1
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 61

Appendix E

Synthesis Matrix

Bundle
Staff
Hourly Hardwire (fall risk, Fall Rounding Medi- Video
Toileting Empower- Sitters
Rounding Change rounding, Risk Logs cation Monitoring
ment
debrief)

Olrich, T., Kalman, M., & Nigolian, C.

X X
(2012)

Radecki, B., Reynolds, S., & Kara, A. (2018) X X X

Hodgson, L. (2012) X X X X

Trepanier, S., & Hilsenbeck, J. (2014) X X X

Silva, K. & Hain, P. (2017) X X X X

Barrett, M., Vizgirda, V., & Zhou, Y. (2017) X X X

Walsh, C., Liang, L., Grogan, T., Coles, C.,

X X X
McNair, N., & Nuckols, T. (2018)

Jong, L., Kitchen, S., Foo, Z., & Hill, A.

X X
(2017)

Adams, J., & Kaplow, R. (2013) X X X

Fridman, V. (2019) X X X X

Rachh, P., Wilkins, G., Capodilupo, T.,

Kilroy, S., Schinder, M., & Repper-Delisi, J. X X
(2016)

Spano-Szekely, L. et al. (2019) X X X

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 62

Appendix F

Accepted Permission from Studer Group to Use Tools

REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 63

Appendix G

SWOT Analysis
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 64

Appendix H

Pre- and Post- Education on Purposeful Hourly Rounding

 REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 65

Appendix I

Gantt Chart

Design (Plan) Phase

Initial Design Project Manager (author) 1/10/20 1/20/20
Literature Review Project Manager 1/20/20 1/30/30
ERPC Approval Project Manager 5/18/20 5/30/20
Seek Executive Stakeholder Approval
CNO (Executive Liaison) 2/20/20 4/25/20
at NL EMMC
Organizational Gap and SWOT
Project Manager 2/25/20 3/1/20
Analysis
Establish Hour Rounding Protocol and
AVP of Med/Surgical 2/25/20 3/1/20
Necessary Documentation
Meet with USA Faculty Project Manager 1/10/20 4/25/20
Implementation (Do) Phase
Educate the medical surgical unit and
Nurse Manager (NM) and Assistant Nurse
Disseminate Project 6/1/20 6/7/20
Manager (ANM)
Information
Select Fall Champions RN and CNA 6/1/20 6/1/20
Identify benchmarks for falls Project Manager 6/1/20 6/1/20
Begin pilot project Project Manager 6/1/20 6/1/20
Implementation of PHR
NM & ANM 6/1/20 6/1/20
and charting
Removal of bedside sitters NM & ANM 6/1/20 6/1/20
Evaluation (Study) Phase
Post on Bulletin Board first month
implementation audits (falls, falls with NM & ANM 7/1/20 7/6/20
injuries)
Meeting with Staff at 15 days Project Manager 7/1/20
 REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 66

15 day of implementation audits NM 6/1/20 6/5/20

Meeting with Staff at 30 days Project Manager 7/1/20
Compare data and predictions Project Manager 7/1/20 7/1/20
Process Measures: How many patients
Project Manager 7/1/20 7/1/20
fall
Contextual Measures: Daily staffing
Project Manager 7/1/20 7/1/20
ratios
Contextual Measures: Average daily
Project Manager 7/1/20 7/1/20
census
Contextual Measures: Average age of
Project Manager 7/1/20 7/1/20
the patient
Dissemination (Act) Phase
Data analysis and apply to outcomes Project Manager & Data/IT Informatics RN 8/1/20 9/1/20
Complete DNP Project Project Manager 9/1/20 9/2/20
Disseminate applied data to the
AVP, CNO, & Project Manager 9/5/20 10/1/20
organization
Look at areas to improve Project Manager 1/10/20 9/1/20
Look to implement project housewide CNO 9/1/20 9/1/20
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 67

Appendix J

ICARE Pretest Score

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Appendix K

ICARE Posttest Score

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Appendix L

Action Plan
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 70

Appendix M

Data Collection Tool for Evaluation: Daily Hourly Rounding Log

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Appendix N

Daily Count
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Appendix O

Cause and Effect Diagram

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Appendix P

Check Sheet
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Appendix Q

Staff Buttons and Badge Reminders

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Appendix R

Evaluation
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 76
REDUCING PATIENT FALLS THROUGH HOURLY ROUNDING 77

Appendix S

EBP Staff Communication Board