C823 Field Experience Task Hourly rounding to prevent patient falls in Hospital Setting

Chapter 1: Introduction Problem Statement 

Falls among patients is the most frequently reported safety incidents in my healthcare organization. The inpatient units report a significant number of patient falls each year and despite the use of different strategies the problem still persists. The elderly population is observed to be most affected by this issue with falls reported during admission and subsequent care in the wards. The main problem is adherence to the set guidelines on fall prevention in the facility.

The majority of falls in hospitals are no true accidents, but a combination of intrinsic and extrinsic factors related to the patient’s behavior. For example, the healthcare organization encourages mobility among patients, especially during prolonged hospitalization. However, the exercise can cause patient falls which can harm the patient further. The main cause of falls in this facility is the lack of a stepwise multidisciplinary approach to falls prevention. The nursing team is observed to assume more responsibility to monitor patients when all members of the healthcare team should be involved.

Most healthcare organizations focus on age as the risk factor for falls leaving other gaps unresolved. In my institution, the majority of falls observed are related to early mobility and lack of proper guidance for the population at risk. For example, the elderly population with chronic conditions find it difficult to move around the hospital and most experience falls even beside their hospital beds. Other risk factors that cause the adverse outcome include cognitive impairment, patients recovering from anesthesia, and the female gender. Despite the use of standardized assessment and intervention tools, falls are still occurring in the hospital setting

 Problem Background

The causes of patient falls in the facility can be classified into intrinsic and extrinsic factors. Most patients experiencing patient falls in the institution are those from theatre who have not yet recovered from anesthesia. Most of them wake up while they are confused making it difficult to move around. Last year, almost 50% of the patients who experienced falls in the facility were those in the surgical and medical units. Another cause of falls in the institution is poor monitoring of patients, especially at night. The nursing team report for the probable causes of falls indicated that lack of adequate staffing at night contributed to more falls. Additionally, the fall rate has increased since the COVID19 outbreak due to the limited availability of relatives to take care of the patients as per the hospital rules.

Falls in healthcare institutions can result from the use of medications and patient conditions especially for the elderly. Medications such as narcotics and sedatives can cause dizziness which can result in patient falls (Guirguis-Blake et al., 2018). Lack of enough education to the patients can make it difficult to understand the effects of these drugs leading to falls. Statistics in the hospital also indicate that medical conditions such as dementia result in patient falls due to frequent movement and lack of precaution when using washrooms. In another hospital medical unit, it was observed that lack of wet floor signs frequently resulted in slips and falls.

Healthcare organizations are moving towards the use of multidisciplinary approaches to promote patient safety and security. Lack of teamwork and good relationships between nurses and other healthcare professionals can be a contributing factor to patient falls in the facility. The nurses are the only team in the institution giving priority to the issue of patient falls. An educational program will greatly serve to inform other healthcare professionals of the importance of fall prevention. The issues with fall prevention in the institution exist because clear guidelines on the role of each healthcare team do not exist. There is also a lack of attention to fall prevention due to a lack of enough information about the importance of preventing falls in the facility.

Practice Change, Quality Improvement, or Innovation

The use of evidence-based practices in healthcare today is a practice that has improved the quality of care given to patients.  The purpose of this project is to propose an evidence-based practice (EBP) change focusing on the role of nurses in preventing patient falls. There I recommend intentional hourly rounding for a solution in the prevention of patient falls in the organization.  Intentional hourly rounding (IHR) is an organized practice where nurses preform standard evaluations concentrating on addressing the (4 P’s) patient’s pain, personal needs, positioning and placement of items in the room (Barry, 2017). Educating staff on the structured elements to evaluate during IHR will be the initial goal for all nursing staff.  This EBP study showed that implementing IHR helped the patient feel safer, less cut off from people, and helped the nurse meet the patient’s needs (Barry, 2017).  Additionally, IHR has been discovered to decrease patient falls and overall outcome as well as boost staff and patient satisfaction (Flowers et al., 2016).

Rationale for the Practice Change, Quality Improvement, or Innovation

It is a known fact among healthcare professionals that falls in the hospital are a serious concern and preventing patient falls is of the utmost priorities.  The effects of patient falls can range from minor complications to major health concerns like fractures or even death. There is a need to address the issue of patient falls because it affects the quality of patient care in many ways. Firstly, patient falls cause prolonged hospitalization which can be costly to patients. Prolonged hospitalization also means patients lose trust in the organization on matters of safety and recovery from disease. The end result is poor patient satisfaction and reduced revenue due to low patient turnover. The healthcare organization needs to address the issue of patient falls because it is their responsibility to ensure safety. Sometimes the organization can be sued due to negligence in ensuring the safety of patients while receiving healthcare. For example, lack of a wet floor sign in the wards can cause a fall that can seriously harm the patient. On this grounds, any adverse outcome means the hospital will have to take responsibility including treating the individual.

 Chapter 2: Review of the Literature

Credible Sources

The literature review was obtained from articles obtained from Google web search and databases that consist of peer-reviewed articles from 2016 through 2021. The retrieval of these articles were obtained by several key term searches that included, but not limited to fall prevention, hourly rounding, intentional rounding, hospital setting, risk of falls, and inpatient falls.  A full and complete review of the articles is accessible in the credible sources table, Appendix A.

Best Practices

Intentional hourly rounding is a protection mechanism to safeguard patients and prevent falls while attending to the patient’s needs (East et al., 2020). Prior to implementing any quality improvement (QI) plan, training of the staff in teamwork, safety and fall prevention measures for intentional hourly rounding was found to improve project outcome (Morgan et al., 2017).   In reviewing the literature one review found that providing a nurse presence with purposeful hourly rounding patient felt less vulnerable and safer (East et al., 2020).  The hourly rounding approach to prevent patient falls will consist of an evaluation of the patient’s needs and the 4 P’s (Barry, 2017).   This approach will allow nurses to attend to needs of the patient in a more structured format to minimize patient falls.

Evidence Summary

The Burden of Patient Falls

Patient falls have has become a safety issue amongst healthcare providers and gain national attention.    The World Health Organization (WHO) explains that the occurrence of adverse events is one of the top 10 leading causes of disability and death in the world (World Health Organization, 2019). There are a multitude of factors associated with the incidence of patient falls these include but not limited to medications, poor vision or lighting, lower extremity weakness, and untidy room (Morris & O’Riordan 2017). In a report produced by the Agency for Healthcare Quality and Research (AHRQ), it is estimated that each year around one million patients fall in the United States (Agency for Healthcare Quality and Research, 2018). These falls increase hospital stays, can cause irreversible damage to patients and decrease reimbursement to the hospital from insurance companies. It is projected that patient falls result in $50 billion each year in medical cost (Florence et al., 2018). Providing nurses the training and education will lead to better understanding of IR and will result in more favorable outcome for the patient (Daniels, 2016). Having this knowledge will promote the regular routine in implementing it in the patient’s everyday care.

Risk Factors for Falls in Hospital

The problem of patient falls in the hospital can be caused by intrinsic and extrinsic patient factors. One study documents that patient falls are associated with factors like age, male sex, prior history of fall, gait instability, confusion, and neuro-cardiovascular instability (Najafpour et al., 2019). Some extrinsic factors may be not answering call lights promptly, wet floors, and poor lighting. Therefore, IR has become a widely accepted approach to making sure that the needs of the patient are not overlooked (Morgan et al., 2017).

Strategies for Fall Prevention

Evidence to guide falls prevention in healthcare is limited due to the lack of clear approaches to the healthcare issue. However, studies have tried to propose solutions to the prevention of falls. A study conducted in Baltimore Maryland LTC reported that hourly rounding is important in identifying the needs of the patients including the 4P’s of patient’s care which reduces falls (Linehan & Linehan, 2018).  Morgan et al., recommends nurse-driven IR protocols in order to develop positive outcomes (2017). Forming an environment of safety into the hospital setting and rounding are key features of reducing falls (Linehan, & Linehan, 2018).  IR not only prevented falls by connecting with the patient more often, but decreased call light use, and created greater patient satisfaction (Ryan et al., 2019).  Additional, IR has been defined as a straightforward answer to difficult challenges (Sims et al., 2019). During these rounds patients would be asked about their pain, if they needed to go to the bathroom, help reposition the patient if needed, and make sure call light or other items were in reach. Doing these small tasks at each rounding would help in preventing falls.

Recommended Practice Change, Quality Improvement, or Innovation

There is a lot of pressure for hospital’s to implement protocols or strategies to prevent patient falls. Research has revealed that hourly rounding prevents patient falls. Therefore, my recommendation is to implement intentional hourly rounding. In addition to the IHR, I recommend that nurses receive training and education on hourly rounding and how to incorporate the 4P’s (pain, potty, positioning, and possessions) in a caring and easy-going manner.  This approach to fall prevention is sensible, well-organized, and provides a safer environment for patients.

Chapter 3: Implementation

Description of Steps

Discussion of Changes

Discussion of Barriers

Explanation of overcoming barriers.

Identification of Interprofessional Relationships

Discussion of Relationships

 Chapter 4: Post Capstone Project Considerations

Discussion of Successes

How successes will inform future projects.

Aspects that Did Not Go Well

Understanding what did not go well

Explanation of How Gap was Bridged

Supporting the Plan

Resources for Post-Implementation

 

Chapter 5: Reflection

 

Integration of MSN Program Outcomes

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References

Agency for Healthcare Quality and Research. (2018). Preventing patient falls: Overview. Retrieved from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/overview.html#Problem

Barry, K. (2017). How intentional rounding and red pegs are the key to an excellent patient experience at Mediclinic Panorama. Professional Nursing Today, 21(4), 57–59.

Daniels, J. (2016). Purposeful and timely nursing rounds: a best practice implementation project. JBI Database of Systematic Reviews and Implementation Reports, 14, 248-267. https://doi.org/10.11124/jbisrir-2016-2537

East, L., Targett, D., Yeates, H., Ryan, E., Quiddington, L., & Woods, C. (2020). Nurse and patient satisfaction with intentional rounding in a rural Australian setting. Journal of Clinical Nursing, 29(7–8), 1365–1371. https://doi.org/10.1111/jocn.15180

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693-698. https://doi.org/10.1111/jgs.15304

Flowers, K., Wright, K., Langdon, R., McIlwrath, M., Wainwright, C., & Johnson, M. (2016). Intentional rounding: facilitators, benefits and barriers. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 25(9–10), 1346.

Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018). Interventions to prevent falls in older adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 319(16), 1705-1716. DOI: 10.1001/jama.2017.21962

Linehan, J., & Linehan, J. (2018). Fall prevention in long term care using purposeful hourly rounding. Journal of the American Medical Directors Association, 19(3), B17. https://doi.org/10.1016/j.jamda.2017.12.056

Morgan, L., Flynn, L., Robertson, E., New, S., Forde, J. C., & McCulloch, P. (2017). Intentional Rounding: a staff-led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 26(1–2), 115–124. https://doi.org/10.1111/jocn.13401

Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical Medicine (London, England), 17(4), 360–362. https://doi.org/10.7861/clinmedicine.17-4-360

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

Ryan, L., Jackson, D., Woods, C., & Usher, K. (2019). Intentional rounding – An integrative     literature review. Journal of Advanced Nursing (John Wiley & Sons, Inc.), 75(6), 1151–1161

World Health Organization. (2019). Patent safety. Retrieved from https://www.who.int/news-room/fact-sheets/detail/patient-safety

 

Appendix A

Credible Sources

 

Author(s) (Formatted as in-text citation)	Database (CINAHL, EBSCO, Cochrane, Pro-Quest)	Peer-Reviewed (Yes/No)	Applicability   (Yes/No)	Evidence Grade (Strength/ Hierarchy)	Appraisal (Brief summary of findings; how findings inform your project?)	Inclusion   (Yes/No)
Agency for Healthcare Quality and Research (2018)	Google Web Search	No	Yes	Level 1 Evidence Based Practice Guidelines	The website draws attention to a guide to help develop, implement, and sustain a fall prevention program.	Yes
Barrett et al. (2017)	WGU Library	yes	NO	Level 1 Systematic Review	Research conducted on the perception of nurses and patient care techs on a protocol of regular scheduled toileting to prevent patient falls.	No
Christiansen et al. (2018)	WGU Library	Yes	Yes	Level 1 Systematic Review	The barriers to nurses and patients when implementing intentional rounding protocol.	No
Daniels (2016)	WGU Library	Yes	Yes	Level 1 Systematic Review	Purposeful and routine rounding to provide safety measures, care needs, and prevent sentential events is best practice to deal with issues beforehand.	Yes
East et al. (2020)	WGU Library	Yes	Yes	Level 4 Non-experimental Designs (cross sectional )	Intentional rounding is a way for nurses to frequently be available to address patients’ needs and prevent falls.	Yes
Flowers et al. (2016)	WGU Library	Yes	Yes	Level 6 Qualitative Research Study	Intentional hourly rounding not only helps to address patient needs but also family needs.	Yes
Florence et al. (2018)	WGU Library	No	Yes	Level 3 Quasi-experimental designs	Medical cost for lethal and non-lethal injuries cost billions of dollars each year.	Yes
Guirguis-Blake et al. (2018)	WGU Library	Yes	Yes	Level 1 Meta-analyses	Evidence showed that interventions such as multifactorial assessment and treatment of patients, exercise therapy, and Vitamin D supplements reduce risk of patient falls.	Yes
Hopewell et al. (2020)	WGU Library	Yes	No	Level 1 Meta-Analysis	Multifactorial interventions may reduce the risk of people suffering one or more falls.	No
Johnston and Magnan (2019)	WGU Library	Yes	Yes	Level 1 Systematic Review	How monitoring nurses compliance with using a fall prevention checklist help to improve patient safety.	No
Katana et al. (2018)	WGU Library	Yes	No	Level 2 Randomized control trial	The article suggest programmed exercises be applied as part of physical therapy to reduce fall risk in the elderly patient.	No
Lee and Hayter (2019)	Pro-Quest	Yes	No	Level 6 Single Qualitative Studies	Multifactorial interventions showed a slight reduction in falls when compared to just routine care.	No
Linehan and Linehan (2018)	ProQuest	Yes	Yes	Level 1 Systematic Review	Hourly rounding is important in identifying the needs of the patients including the position of patients which reduces falls.	Yes
Morgan et al. (2017)	WGU Library	Yes	Yes	Level 1 EBP Guidelines	Training of staff in teamwork and quality improvement measures for IR can be effective in reducing falls.	Yes
Morris and O’Riordan (2017)	NCBI	Yes	Yes	Level 1 Systematic Review	Proper screening can prevent falls 20 to 30% of the time in hospital settings, through the use of screening measures.	Yes
Najafpour et al. (2019)	WGU Library	Yes	Yes	Level 2 Randomized control  study	Falls amongst the elderly increased due to patient and   environmental influences.	Yes
Nicolas et al. (2016)	WGU Library	Yes	Yes	Level 1 Systemic Review	By using targeted solution tools (hourly rounding, patient and family brochures on safety and read and sign a contract on patient risk) can reduce falls and improve patient safety.	Yes
Nuckols (2017)	WGU Library	Yes	No	Level 6 Qualitative Study	How integrating hourly rounding to prevent falls may be cost effective and beneficial.	No
Pond (2017)	WGU Library	Yes	No	Level 1 EBP Guidelines	Implementing a bundle approach reduces falls and promotes best practice results.	No
Pirschel (2016)	WGU Library	Yes	No	Level 1 EBP Guidelines	In order to create an atmosphere of safety it requires continuous education.	No
Roberts et al. (2020)	WGU Library	Yes	No	Level 2 Randomized control  study	Conducting 20-min Intentional rounding decreased falls in the elderly care institutions.	No
Russell Taing and Roy (2017)	WGU Library	Yes	No	Qualitative Research	Among the elderly that live at home modifications and physical activity can prevent falls.	No
Ryan et al. (2019)	WGU Library	Yes	Yes	Level 1 Integrated Review	This analysis concentrated mostly on how IR affected the patient’s safety, the physical health, and patient interaction and satisfaction with nursing staff.	Yes
Schuchman and Graziano (2020)	Web Search Springer Link	No	No	Level 1 EBP Guidelines	Evidence suggests that most falls can be prevented if timely identification of risk factors is done and prompt action is taken.	No
Sun et al. (2020)	WGU Library	Yes	NO	Level 6 Qualitative Research Study	Hourly rounding and bedside reporting may call for vigorous and continued interventions to be beneficial.	No
Sims et al. (2018)	WGU Library	Yes	Yes	Level 1 Systematic Review	IR appears to be a suitable to meet certain goals but    to achieve particular goals.  However, less suitable for other goals.	Yes
Spano-Szekely et al. (2019)	WGU Library	Yes	No	Level 1 Evidence Based Practice Guidelines	A proven guideline for fall prevention approaches, these included risk assessment, purposeful hourly rounding, and video monitoring.	No
Stone et al.  (2020)	WGU Library	Yes	Yes	Level 6 Qualitative Study	The pros and cons of a checklist for hourly rounding in the emergency department setting.	No
Walsh et al. (2018)	WGU Library	Yes	No	Level 1 Systematic Review	The trends of fall prevention protocols and how bundling of fall prevention tools may have long term benefits.	No
World Health Organization (2019)	Google Web Search	No	Yes	Level 1 EBP Guidelines	Patient safety is important in providing outstanding patient care.	Yes

Appendix B

Organization Approval Letter

Appendix C

Preceptor Agreement Form