Hourly rounding by nursing staff helps to proactively manage patient needs and minimize the number of unscheduled calls from patients. The focus of this study was to determine if an increased emphasis on hourly rounding had an effect on call bell usage on an oncology unit. Patient call bell usage requests, such as asking for water or repositioning, and the total number of all alarms, such as bed exit alarms and lavatory assist alarms, decreased. Subsequent patient satisfaction surveys showed an increase in patient perception of how quickly help was received.
AT A GLANCE
- Proactive hourly rounding decreased call bell usage and total alarms in this project.
- There were no significant differences in bed exit and lavatory assist alarms pre- and postintervention.
- Patients’ perceptions of prompt responses to their needs increased, as demonstrated on patient satisfaction surveys.
The development of strategic initiatives to enhance the quality of services delivered to patients stems from reimbursement guidelines from the Centers for Medicare and Medicaid Services (CMS) and their link to patient experience and satisfaction. The Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey provides a real-time performance scorecard as a measure of a patient’s experience (CMS, 2019). Using data from a hospital-wide tracking system, the authors of this article examined patients’ call bell usage and alarm frequency and looked for correlations with patients’ HCAHPS survey responses.
Based on reports examining the effectiveness of hourly rounding, also known as intentional rounding, differing criteria for determining effectiveness were used with mixed results. Associations among hourly rounding and patient satisfaction (Bragg et al., 2016), staff satisfaction (Flowers et al., 2016), fall rates (Morgan et al., 2017), and call bell usage (Olrich et al., 2012) were studied.
The project was conducted on a 15-bed adult inpatient unit at a National Cancer Institute–designated comprehensive cancer center. The majority of patients on the unit have a hematologic malignancy, and other patients have solid tumor diagnoses.
The call bell system used throughout the hospital provides each unit with monthly data from each patient room, including the type of alarm or call (e.g., emergency, bed alarm, lavatory assist, routine call). Staff locators, clip-on devices that track staff members throughout the inpatient unit, were used to monitor compliance with the hourly rounding guidelines. Weekly data reports are compiled to assess frequency and duration of time spent in each patient’s room. Patient rounds were to be conducted hourly during waking hours and every two hours during sleeping hours.
In June 2018, staff were educated on the project’s intervention, which was to proactively round according to minimum guidelines. All members of the unit’s nursing staff were informed about the project, the expectations, and the goals to improve patient satisfactions scores, reduce patient falls, and reduce call bell usage. Education about the project was provided to nurses during staff meetings and through emails. Signs reinforcing the rounding guidelines were placed in staff areas around the unit, including in the nurses’ station, medication rooms, and staff break room. The hourly staff rounding education focused on the 5 P’s: assessing the patients’ potty needs, pain, position, possessions, and pumps (see Figure 1).
Data collection for this project began on April 1, 2018, and weekly reports were collected through September 30, 2018. Data were split into pre- and postintervention categories. Preintervention data included patient call bell reports from April 1, 2018, through June 30, 2018. Postintervention data included reports generated from July 1, 2018, through September 30, 2018. Pre- and postintervention mean values and standard deviations were calculated for each type of alarm; each set included 13 weekly reports. Differences between pre- and postintervention values were compared using two-sample, equal-variance, one-tailed t tests; p values less than 0.05 were considered significant.
Mean values, standard deviations, and p values for each type of call and for total alarm were calculated for the pre- and postintervention datasets (see Table 1). No statistically significant differences were observed between bed exit alarms and lavatory assist alarms. Bed exit alarms averaged 49 (SD = 33) alarms per week, ranging from 3 to 111 alarms during any one-week preintervention period; weekly postintervention bed exit alarms averaged 19 (SD = 13) alarms per week, ranging from 0 to 46 alarms per week (p = 0.1). Lavatory assist alarms during the preintervention period averaged 6 (SD = 4) alarms per week, ranging from 0 to 12 alarms in any single week; postintervention lavatory assist alarms averaged 5 (SD = 5) (p = 0.6) alarms per week, ranging from 0 to 14 alarms in a single week.
Statistically significant decreases in call bell usage and the total number of all alarms were observed between the pre- and postintervention periods. Total alarms averaged 706 (SD = 140) alarms per week preintervention, ranging from 475 to 927 alarms per week. The average decreased to 507 (SD = 81) (p = 0.001) calls per week postintervention, ranging from 379 to 638. The number of patient call bells decreased from 608 (SD = 107) calls per week preintervention, ranging from 453 to 755 per week, to 472 (SD = 72) (p = 0.003) calls per week postintervention, ranging from 352 to 593 per week.
Respondents to patient satisfaction surveys reported increases in the perception that they always received help as soon as they needed it; those responses increased from 56% (n = 25) preintervention to 64.3% (n = 16) postintervention, a positive change of 8.3%. Positive responses increased 22.5% in a small group of patients who needed help with bedpans or getting to the toilet, from 37.5% (n = 8) preintervention to 60% (n = 5) postintervention. However, questions about nursing communication decreased slightly postintervention with regard to the percentage of respondents who were always satisfied. For example, a question about nurses treating patients with courtesy and respect decreased from 96.3% preintervention to 93.8% postintervention, a question about nurses listening carefully decreased from 85.2% to 81.3%, and a question about nurses explaining things in a way that was easy to understand decreased from 92.6% to 87.5%.
A larger percentage of patients who needed help getting to or from the bathroom reported always receiving help when needed; however, the sample size of patients who needed such help is smaller than that of all the patients using their call bell. Therefore, this observation will require additional analysis.
This project focused on the effects of hourly rounding on call bell usage. Total alarms were 28% lower, and call bell usage was 22% lower in the postintervention data set. That difference translates into 14 fewer total alarms, including 10 fewer call bells per 12-hour shift. There were no significant differences in bed exit and lavatory assist alarms from pre- to post-intervention because the total numbers of these alarms were lower on average and had wider week-to-week distributions. These limitations may be overcome with a longer study to allow for the collection of more data.
The authors’ data indicate that increased emphasis and staff education on hourly rounding reduces patients’ use of call bells. Additional data analysis will determine if decreased call bell usage correlates with decreased fall rates. As with bed exit alarms and lavatory assist alarms, the number of falls that occurred during the project time frame were too low for meaningful statistical analysis. Similarly, the observed increase in patient satisfaction scores, specifically in getting toileting help, needs to be more thoroughly studied. In answering the question if the hourly rounding decreased call bell usage on this unit, many more questions were raised. Future projects will focus on whether these hourly rounding guidelines are being followed, the effect on patient fall rates, and effects on staff and patient satisfaction.
The effectiveness of hourly rounding on call bell usage was the subject of this study. Methods used to measure the effectiveness of the intervention were described. Reinforcing staff adherence to hourly rounding guidelines resulted in statistically significant decreases in patients’ call bell usage and total alarms. Further study will be needed to more thoroughly address the observed increase in patient satisfaction scores.
About the Author(s)
Barry C. Johnson, PhD, BSN, RN, was, at the time of this writing, a staff nurse and Laurie Bryant, RN, MSN, OCN®, APRN-CNS, is a clinical nurse specialist, both in the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital in Baltimore, MD. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Bryant can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
Bragg, L., Bugajski, A., Marchese, M., Caldwell, R., Houle, L., Thompson, R., . . . Lengerich, A. (2016). How do patients perceive hourly rounding? Nursing Management, 47(11), 11–13.
Centers for Medicare and Medicaid Services. (2019, October 15). HCAHPS: Patients’ perspectives of care survey. https://go.cms.gov/2WLtSVn
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