Hourly Rounding to Prevent Patient Fall

Approval and Support

Patient falls have been a thorny issue in all medical facilities, especially geriatric facilities. Different plans or interventions have been formulated and implemented to try and reduce patient falls. Nurses have been at the center of implementing these policies which have either wholly or partially failed to lead to patient dissatisfaction and more harm. The Medicare announced that from 2008, it will no longer be paying for preventable errors in health facilities which include injuries from falls (Brooks, 2007). The implementation of this regulation and the inefficiencies of previous fall prevention regulations have pushed the healthcare stakeholders to come up with better interventions to curb falls in hospitals.  Hourly rounding has proved to be one of the best modern fall prevention interventions in the modern era. The intervention involves a proactive approach where nurses and assistant nurses address and anticipate the needs of patients. This paper will discuss the implementation process of an hourly rounding intervention. 

     The organization has to seek approval before implementing the hourly rounding plan. Approval occurs in two levels, informal and formal. Informal approval emanates from support and participation from the peers. The proposer(s) of the hourly rounding intervention should rally support from peers and even members of the management who believe in the course and are willing to support it, this will speed up the process for pushing for the necessary formal approvals. Fellow nurses and other stakeholders can be made to understand how the intervention works, how it has been successful in other institutions and proof that it is an evidence-based nursing practice. Support from the administration has a significant impact on the success and influence of the intervention in the facility. Some of the stakeholders that can provide support include individuals with vested interest in the subject of fall prevention, patient population, and staffing pool. Informal approvals can be obtained through leadership buy-in, staff participation, physician involvement and staff participation.

     After the informal approval, the proposal can now seek for formal approval. The most important approval body is the Institution Review Board (IRB) which is tasked with protecting the patients and institution that will be involved in a project or research. The hourly rounding intervention includes humans and therefore physical, mental and emotional risks have to be assessed before the intervention is approved. The institution has to send a complete proposal copy to the IRB will all the procedures and measures that will mitigate any risks involved. The primary mandate of IRB is to protect the rights of human subjects and resolve any ethical issues in the project. Some of the important considerations before the IRB submission are training and obtaining Human Subject Protection Certification (HSP). The peer and administrative support plays a primary role in pushing for the formal approval by the IRB.

Problem Statement 

Many problems are present in the fall prevention interventions applied in medical facilities. There are four important standards that an intervention must meet for it to be efficient. These standards are clinical, economic, ethical and legal aspects. Most of the fall prevention plans meet either one or two of the aspects and failing to meet of all the four dimensions. Some of these interventions used to prevent falls that may result in injury lack empirical evidence. For instance, home modification and training have been widely used to reduce falls, but there is no empirical evidence they reduce injuries as a result of falls (Balzer et al., 2012). A majority of the research carried out on these interventions either lack internal validity or have clinical heterogeneity which prevents definitive interpretation of the data results. 

    The economic aspect is in important consideration bearing in mind of the soaring healthcare costs. Despite the facilities mandated to care for their preventable error costs after withdrawal by Medicare, the healthcare facilities are faced with the challenge of cost containment and reduction strategies. Implementation of fall prevention interventions that are costly leads to inefficiencies due to lack of financial commitment to the course. Organizations are likely to reject entirely or implement fall prevention interventions that are expensive. The interventions implemented have a low return on investment (ROI) because after many resources are dedicated to fall prevention strategies, injuries from falls are still high. 

     Subjective considerations of patients need for fall prevention are not taken into perspective by medical facilities in formulation fall prevention strategies. Most of the intervention measures have been restraint measures that are not effective in the prevention of falls as others are degrading human dignity. Some patients do not require physical restraints to prevent their fall because all they need is more attention to their needs. It is a legal risk in differentiating general life risk and fall risk in formulation and implementation of fall prevention interventions (Balzer et al., 2012). 

Proposed Solution

The implementation of the hourly rounding intervention is the best solution to the fall preventions in healthcare facilities. The first important step is training the nurses and their assistants in hourly rounding before starting the project. After the nurses are well trained in the program, a pilot study can be launched in different departments because it is essential for the change process. The pilot study can be conducted over a period of 6 months in different departments to determine the potential barriers to change that might be faced in implementing the program to the whole organization (Melnyk & Fineout-Overholt, 2011). Baseline data can be collected from the pilot study in the different departments that will assist in the implementation of an institution-wide rollout. The data is collected and documented in hourly rounding documentation log, fall record, weekly hourly rounding meeting agenda. The most commonly used hourly rounding is the nurses making hourly rounds to every patient during the day and in every two hours during the night. The effectiveness of the program can be improved through teamwork, proper coordination and excellent communication with the patients. The nurses should be in a position to predict or anticipate the needs of the patients. 

    In hourly rounding, the 4 Ps of pain, position, potty and possessions should be addressed. In the hourly rounding, the nurses should always identify how the pain of their patients which helps to anticipate their needs. The nurses are supposed to determine the position of their patients by assessing if they are comfortable or not. The bathrooms are considered the most important room in any house because of their essential function; therefore it is the nurse to ensure the patients’ bathroom needs are well-taken care. The last thing the nurses need to provide is the placement of items in the patient’s reach or proximity. The nurse can inquire from the patient if they need any of the facilities in the room such as telephone, water-pitcher, trash can, etc. needs to be moved near their reach. Observation of the 4 Ps makes work easier for the nurses and also the patients. 

Rationale for Selection

Hourly rounding approach is evidence-based practice because it has been proven to reduce patient falls, reduction of patients’ use of lights/bells, reduction in pressure ulcers, a decline in skin breakdowns, and increase in patient’s ratings (Gardner et al., 2009; Tea et al., 2008). The previous research and evidence generated on hourly rounding prevention have supported the intervention as a viable strategy. There is more to inefficiencies than nurses training, proper systems and consistency. The economic aspect plays a crucial role in implementing a fall prevention strategy. Hourly rounding is a low-cost approach that is mainly dependent on the commitment of the nurses and the management rather than availability of material resources. Hourly rounding strategy can be implemented with readily available resources in an institution with the most valuable resources being human and time. 

     Despite being an evidence-based practice, hourly rounding involves the patients in the implementation process. The intervention cannot be a success without the engagement of the patients. The nurses get constant feedback from the patients on the hourly rounding. There is a continuous monitoring of the patients leaving little or no chance to lack of attendance. The patients are treated with more dignity due to the socio-ethical nature of the intervention. The frequent presence of nurses does not only ensure that the physical needs of the patients are met but also their emotional needs. Human contact in the medical field plays a critical role towards relief and assurance; this is opposed to fall prevention interventions that physically restrain patients. 

Evidence from Review of Literature

At the point when bells are going continually, medical attendants may get to be strained to answer them in a convenient way. This can negatively affect the safety of the patient, for instance, if a patient at danger of falls chooses not to sit tight for help getting to the restroom or acquiring a thing from over the room. Adjusting can reestablish the bell to its status as a life saver, as opposed to permitting it to wind up a consistent disturbance.

Another regular strategy is utilizing whiteboards as a part of every patient bed to help with more engaged attendance. Attendants can compose their particular names or the name of the nurse who is planned to make rounds, alongside an indication of what time rounds will next happen (Brosey & March, 2015). They can likewise scribble down the time that prescribed drugs are next planned for, and any concerns the patient has, to make sure they are tended to reliably in the hourly rounding; this may be a note that the patient is inclined to fill on something that is bothering them.

Implementation Logistics

The program will be implemented over an extended period in phases. This could take approximately 6-8 months to implement. The implementation process will be carried out in stages. The first phase is hiring a resource champion; this can be done three months before implementing the program. The duty of the resource champion is to train the patient attendants or nurses and assist in the implementation process. The second phase is the implementation where the execution begins on the findings and recommendations from the pilot study. The third step is data collection and analysis where the resource champion analyzes the progress of the program and documents the processes and problems. The documentation logs in the third phase are used in quality control. The fourth phase is the evaluation of data where correlation is identified between fall prevention and hourly rounding. This information should be presented to the senior management to inform decision making. The last phase is the corrective action where changes are made as documented from previous observation and evaluations. 

     The applicable implementation costs include resource nurse, training costs, and printing costs. The responsibility of resource nurse is training, auditing and assisting in the implementation process. The cost of the resource nurse will average $80,000 per year. The nurses will be trained on how to execute the hourly rounding program which will not go for more than three months with the nurses trained on an average 2 hours in a day. The cost of training a nurse is $10/hr. The last cost is for printing materials such as welcome cards, pillow cards, and pocket cards. 

Resources

In the implementation of hourly rounding, the most valuable resource is the human resource. The nurses and their assistance will be at the center of the program because they are the ones to carry the hourly round. The resource nurse will be responsible for oversight and auditing of the implementation process. The assessment tools will be documentation logs where the resource nurse fills relevant data on the progress of the implementation process. The nurses and patients will be interviewed to supplement the documentation log as an assessment tool. The last resource will be the hourly rounding toolkit. The kit contains promotion flyers, patient information cards, documentation logs, pillow cards, pocket cards, and competency checklist.

 

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