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Hourly Rounding in the Emergency Department: How to Accelerate Results
EVIDENCE-BASED PRACTICE
HOURLY ROUNDING IN THE EMERGENCY DEPARTMENT: HOW TO ACCELERATE RESULTS Author: Stephanie J. Baker, RN, CEN, MBA, Gulf Breeze, FL Section Editor: Nancy McGowan, RN, PhD
hen a woman died in the ED lobby of a Los Angeles hospital several years ago because she could not obtain timely care, it made national news. On that day, Americans around the country wondered how this could happen in the US health care system today. They wondered if it could happen to them. However, consider this: If every emergency department in the country implemented hourly rounding in their treatment and reception areas, such an event would be highly unlikely. Hourly rounding on patients in the emergency department is an evidence-based leadership practice that effectively addresses the top 3 priorities of all ED patients1: pain, plan of care, and delays (PPD). ED patients want to have their pain controlled, they want staff and physicians to keep them informed about their plan of care, and they want to be kept informed about delays. The key to really accelerating clinical, service, and financial gains from hourly rounding is validating staff accountability through leader rounding on patients, hardwiring the use of rounding logs (Figure 1), and providing real-time feedback to staff.
W
experience, performed scheduled tasks, addressed PPD, assessed comfort needs, conducted an environmental assessment, used closing key words, explained when someone would return, and documented the round on the log or chart. The study showed that hourly rounding reduced the number of patients who left without being seen by 23.4%, decreased the number of patients who left against medical advice by 22.6%, reduced the number of falls by 54.5%, reduced call light usage by 34.7%, and reduced the number of families and patients who approached the nursing station by 39.5%. Patient satisfaction also increased between 5 and 20 mean points in all areas measured. Parkwest Medical Center in Knoxville, Tennessee, which sees 48,000 ED patients per year, has found that since they hardwired hourly rounding in 2007, falls are very infrequent in the emergency department. “It’s also virtually eliminated the need for the nurse call system,” notes Darrell Brackett EMT-P, MBA, and director of Parkwest’s emergency department. “Patients no longer use the call light because their needs have been addressed.”
Evidence for Hourly Rounding in Emergency Department
How to Get Started
Because 51% of inpatients come from the emergency department and they typically judge their inpatient experience based on their ED experience, Studer Group (Gulf Breeze, FL) tested the impact of 8 rounding behaviors in 32 emergency departments in 2006.2 ED nurses used opening key words to introduce their skill set and
Stephanie J. Baker, Member, ENA Chapter 228, is Coach, Account Leader, and National Speaker, Studer Group, Gulf Breeze, FL. For correspondence, write: Stephanie J. Baker, RN, CEN, MBA, Studer Group, 913 Gulf Breeze Pkwy, Gulf Breeze, FL 32561; E-mail: stephanie. [email protected]. J Emerg Nurs 2012;38:69-72. Available online 5 December 2011. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.09.013
January 2012
VOLUME 38 • ISSUE 1
Hourly rounding provides an opportunity to reward, recognize, and connect the practice of the behavior to wins and opportunities for better patient safety, clinical quality, and saving time. Before beginning hourly rounding, you will need to decide who will round on patients. In the ED reception area, for example, the triage nurse owns the process, but organizations use charge nurses, registration clerks, security, chaplains, case managers, ancillary staff from other departments, and even senior leaders to help round. It is a team sport! In addition, ask leaders to round on patients to verify that staff are rounding on them. It is an important feedback mechanism to ensure that staff are using the rounding behaviors consistently and effectively. (For example, a leader might say, “Our goal is to manage your pain effectively. Did your nurse reassess your pain level after giving your medication?” or “Did your nurse update you on how long the procedure would take?”). At Parkwest’s emergency department, 100% of patients who received leader rounding in the emergency department have scored their nurses
WWW.JENONLINE.ORG
69
EVIDENCE-BASED PRACTICE/Baker
Hospital_______________________________ Date _________ Inform patient of PLAN OF CARE, inquire about PAIN and inform of any DELAYS (PPD) TIME PERIOD
INITIALS OF PERSON ROUNDING
TIME OF ROUNDING VISIT
COMMENTS
6-7 AM 7-8 AM 8-9 AM 9-10 AM 10-11 AM 11-12 AM 12-1 PM 1-2 PM 2-3 PM
Role model and practice. By role modeling, you show that none of this is new. It is just better. What is not right about checking patients for pain and updating them on their plan of care? Hourly rounding just asks staff to be more prescriptive. In addition, after you train staff, ask them to do a written self-assessment on everything from how they introduce themselves and address PPD to how they perform tasks and document their rounding. Then have an evaluator assess them as well. (Download a sample competency assessment at www.studergroup.com/excellenceintheed.)
3-4 PM 4-5 PM
Validating and Accelerating Results
5-6 PM 6-7 PM 7-8 PM 8-9 PM 9-10 PM 10-11 pm 11-12 PM 12-1 AM 1-2 AM 2-3 AM 3-4 AM 4-5 AM 5-6 AM LOGS WILL BE GIVEN TO NURSE MANAGER DAILY AND REVIEWED DAILY FOR ACCOUNTABILITY.
Key= E to denote room is empty
FIGURE 1 Sample ED hourly rounding log. 5 To download a full-size version of this sample, go to the “Excellence in the Emergency Department” resource page at www.studergroup.com/excellenceintheed.
as “excellent” on their patient satisfaction surveys since November 2010. It is important to remember, however, that rounding hourly in the emergency department is not the first tactic to use. Successful organizations only introduce hourly rounding after they have hardwired leader rounding on staff and patients. (You must engage employees first before you ask them to engage). Studer Group also recommends implementing post-visit phone calls to patients before hourly rounding, because these calls offer an opportunity to validate whether hourly rounding occurred.3 Train Your Staff
Formalized staff training and competency assessment (Figure 2) are key to success. When you train your staff, focus on what the 8 rounding behaviors look like—how they impact pain, plan of care, and duration—and why they need to do them. Be clear about your expectations.
70
JOURNAL OF EMERGENCY NURSING
The best way to ensure that you obtain fast and solid results from hourly rounding on patients is to use a 24hour rounding log to ensure rounding is taking place hourly (Figure 1). The log should be used both in the ED reception area and in treatment rooms. Keep the log in the treatment room as patients come and go. When rounding, if the room is empty, staff can write “room empty.” That way, when leaders review the log, they do not think that someone has forgotten to round or document the round. This validates that each assigned individual is actually rounding, so you can ensure that rounding takes place consistently for 100% compliance. Share your findings from reviewing the logs with staff daily so that everyone can adjust and respond to the new information. The community emergency department at Baylor Regional Medical Center in Grapevine, Texas—which sees 50,000 patients annually—reduced its rate of patients who left without being seen from 6% to 2%, for a return on investment of $480,000. (It should be noted that this calculation is based on seeing an additional 2,000 patients per year at an average treat-and-release rate of $240 per patient.) The tactics used were leader rounding, hourly rounding, and key words.4 Kris Powell, RN, MSN, CEN, NEA-BC, currently Director of Emergency Services at Baylor University Medical Center, was a participant in Studer Group’s 2006 original hourly rounding pilot study when she was Director of Emergency Services at Baylor Regional Medical Center (the results of which were discussed earlier). She hardwired and accelerated results by placing the hourly rounding log (Figure 1) for leaders on the back of the charge nurse shift report to ensure consistent leader rounding. “Charge nurses, managers, and directors were all expected to round,” she explains. “At the end of shift, an administrative assistant tallied and audited them so we can send reports back to supervisors on how many patients were rounded upon.”
VOLUME 38 • ISSUE 1
January 2012
Baker/EVIDENCE-BASED PRACTICE
FIGURE 2 Sample hourly rounding competency checklist.5 To download a full-size version of this sample, go to the “Excellence in the Emergency Department” resource page at www.studergroup.com/excellenceintheed.
Her top tip to accelerate results? “Leaders need to schedule hourly rounding on patients into their day to ensure it gets done. Consistent visibility to both patients and staff sends a clear message that addressing patients’ top concerns are our top priority.” Another key way to accelerate results is to create a monthly dashboard to track, measure, and report back on trends, opportunities, and the financial impact of hourly rounding in the emergency department so that everyone understands the important difference it is making in your organization. (Download a sample at www.studergroup. com/excellenceintheed.) Conclusion
Hardwire It
Once staff are consistently rounding, use these tips to ensure that everyone is 100% compliant and rounding in a standardized way for continuous improvement:
• Validate behaviors through information learned from lea-
There is no question that hourly rounding improves patient care. You will see it for yourself. Your emergency department will enjoy more positive word of mouth as a result of hourly rounding. Moreover, you too will enjoy a new reality: one that is safer, quieter, and more efficient. I have had dozens of ED leaders tell me that they never thought they would get their staff to make hourly rounds.
January 2012
Yet, once staff saw the benefits, they got on board quickly and would never consider going back. Once a nurse goes into a patient’s treatment room during hourly rounds and finds a patient not breathing or climbing over a bed rail, he or she will be a believer for life. Hourly rounds keep patients safe. Once staff know a better way to provide patient care, their values dictate that they do it!
VOLUME 38 • ISSUE 1
der rounding on staff, patients, and discharge phone calls.
• Review rounding logs daily to ensure staff compliance with documentation.
• Review results that leaders have harvested at daily stand-up meetings or “huddles.”
• Report results monthly to staff, physicians, and senior leaders. Use the dashboard for hourly rounding in
WWW.JENONLINE.ORG
71
EVIDENCE-BASED PRACTICE/Baker
the emergency department at www.studergroup.com/ excellenceintheed. • Use individualized coaching during monthly one-onone sessions with employees as needed. • Reward and recognize without restraint!
3. Baker SJ. Post-visit phone calls save lives, improve clinical outcomes, and reduce readmissions. J Emerg Nurs. 2010;36(3):256-9. 4. Baker SJ. Key words: a prescriptive approach to reducing patient anxiety and improving safety. J Emerg Nurs. 2011;37(6):571-4. 5. Baker SJ. Hourly rounding with individualized patient care in the ED. In: Excellence in the Emergency Department: How to Get Results. Gulf Breeze, FL: Firestarter Publishing; 2009. p. 138.
REFERENCES 1. Pulse Report 2010 Emergency Department: Patient Perspectives on American Health Care. South Bend, IN: Press Ganey Associates; 2010:4. 2. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70.
72
JOURNAL OF EMERGENCY NURSING
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD [email protected]
VOLUME 38 • ISSUE 1
January 2012
HOURLY ROUNDING IN THE EMERGENCY DEPARTMENT: HOW TO ACCELERATE RESULTS Author: Stephanie J. Baker, RN, CEN, MBA, Gulf Breeze, FL Section Editor: Nancy McGowan, RN, PhD
hen a woman died in the ED lobby of a Los Angeles hospital several years ago because she could not obtain timely care, it made national news. On that day, Americans around the country wondered how this could happen in the US health care system today. They wondered if it could happen to them. However, consider this: If every emergency department in the country implemented hourly rounding in their treatment and reception areas, such an event would be highly unlikely. Hourly rounding on patients in the emergency department is an evidence-based leadership practice that effectively addresses the top 3 priorities of all ED patients1: pain, plan of care, and delays (PPD). ED patients want to have their pain controlled, they want staff and physicians to keep them informed about their plan of care, and they want to be kept informed about delays. The key to really accelerating clinical, service, and financial gains from hourly rounding is validating staff accountability through leader rounding on patients, hardwiring the use of rounding logs (Figure 1), and providing real-time feedback to staff.
W
experience, performed scheduled tasks, addressed PPD, assessed comfort needs, conducted an environmental assessment, used closing key words, explained when someone would return, and documented the round on the log or chart. The study showed that hourly rounding reduced the number of patients who left without being seen by 23.4%, decreased the number of patients who left against medical advice by 22.6%, reduced the number of falls by 54.5%, reduced call light usage by 34.7%, and reduced the number of families and patients who approached the nursing station by 39.5%. Patient satisfaction also increased between 5 and 20 mean points in all areas measured. Parkwest Medical Center in Knoxville, Tennessee, which sees 48,000 ED patients per year, has found that since they hardwired hourly rounding in 2007, falls are very infrequent in the emergency department. “It’s also virtually eliminated the need for the nurse call system,” notes Darrell Brackett EMT-P, MBA, and director of Parkwest’s emergency department. “Patients no longer use the call light because their needs have been addressed.”
Evidence for Hourly Rounding in Emergency Department
How to Get Started
Because 51% of inpatients come from the emergency department and they typically judge their inpatient experience based on their ED experience, Studer Group (Gulf Breeze, FL) tested the impact of 8 rounding behaviors in 32 emergency departments in 2006.2 ED nurses used opening key words to introduce their skill set and
Stephanie J. Baker, Member, ENA Chapter 228, is Coach, Account Leader, and National Speaker, Studer Group, Gulf Breeze, FL. For correspondence, write: Stephanie J. Baker, RN, CEN, MBA, Studer Group, 913 Gulf Breeze Pkwy, Gulf Breeze, FL 32561; E-mail: stephanie. [email protected]. J Emerg Nurs 2012;38:69-72. Available online 5 December 2011. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.09.013
January 2012
VOLUME 38 • ISSUE 1
Hourly rounding provides an opportunity to reward, recognize, and connect the practice of the behavior to wins and opportunities for better patient safety, clinical quality, and saving time. Before beginning hourly rounding, you will need to decide who will round on patients. In the ED reception area, for example, the triage nurse owns the process, but organizations use charge nurses, registration clerks, security, chaplains, case managers, ancillary staff from other departments, and even senior leaders to help round. It is a team sport! In addition, ask leaders to round on patients to verify that staff are rounding on them. It is an important feedback mechanism to ensure that staff are using the rounding behaviors consistently and effectively. (For example, a leader might say, “Our goal is to manage your pain effectively. Did your nurse reassess your pain level after giving your medication?” or “Did your nurse update you on how long the procedure would take?”). At Parkwest’s emergency department, 100% of patients who received leader rounding in the emergency department have scored their nurses
WWW.JENONLINE.ORG
69
EVIDENCE-BASED PRACTICE/Baker
Hospital_______________________________ Date _________ Inform patient of PLAN OF CARE, inquire about PAIN and inform of any DELAYS (PPD) TIME PERIOD
INITIALS OF PERSON ROUNDING
TIME OF ROUNDING VISIT
COMMENTS
6-7 AM 7-8 AM 8-9 AM 9-10 AM 10-11 AM 11-12 AM 12-1 PM 1-2 PM 2-3 PM
Role model and practice. By role modeling, you show that none of this is new. It is just better. What is not right about checking patients for pain and updating them on their plan of care? Hourly rounding just asks staff to be more prescriptive. In addition, after you train staff, ask them to do a written self-assessment on everything from how they introduce themselves and address PPD to how they perform tasks and document their rounding. Then have an evaluator assess them as well. (Download a sample competency assessment at www.studergroup.com/excellenceintheed.)
3-4 PM 4-5 PM
Validating and Accelerating Results
5-6 PM 6-7 PM 7-8 PM 8-9 PM 9-10 PM 10-11 pm 11-12 PM 12-1 AM 1-2 AM 2-3 AM 3-4 AM 4-5 AM 5-6 AM LOGS WILL BE GIVEN TO NURSE MANAGER DAILY AND REVIEWED DAILY FOR ACCOUNTABILITY.
Key= E to denote room is empty
FIGURE 1 Sample ED hourly rounding log. 5 To download a full-size version of this sample, go to the “Excellence in the Emergency Department” resource page at www.studergroup.com/excellenceintheed.
as “excellent” on their patient satisfaction surveys since November 2010. It is important to remember, however, that rounding hourly in the emergency department is not the first tactic to use. Successful organizations only introduce hourly rounding after they have hardwired leader rounding on staff and patients. (You must engage employees first before you ask them to engage). Studer Group also recommends implementing post-visit phone calls to patients before hourly rounding, because these calls offer an opportunity to validate whether hourly rounding occurred.3 Train Your Staff
Formalized staff training and competency assessment (Figure 2) are key to success. When you train your staff, focus on what the 8 rounding behaviors look like—how they impact pain, plan of care, and duration—and why they need to do them. Be clear about your expectations.
70
JOURNAL OF EMERGENCY NURSING
The best way to ensure that you obtain fast and solid results from hourly rounding on patients is to use a 24hour rounding log to ensure rounding is taking place hourly (Figure 1). The log should be used both in the ED reception area and in treatment rooms. Keep the log in the treatment room as patients come and go. When rounding, if the room is empty, staff can write “room empty.” That way, when leaders review the log, they do not think that someone has forgotten to round or document the round. This validates that each assigned individual is actually rounding, so you can ensure that rounding takes place consistently for 100% compliance. Share your findings from reviewing the logs with staff daily so that everyone can adjust and respond to the new information. The community emergency department at Baylor Regional Medical Center in Grapevine, Texas—which sees 50,000 patients annually—reduced its rate of patients who left without being seen from 6% to 2%, for a return on investment of $480,000. (It should be noted that this calculation is based on seeing an additional 2,000 patients per year at an average treat-and-release rate of $240 per patient.) The tactics used were leader rounding, hourly rounding, and key words.4 Kris Powell, RN, MSN, CEN, NEA-BC, currently Director of Emergency Services at Baylor University Medical Center, was a participant in Studer Group’s 2006 original hourly rounding pilot study when she was Director of Emergency Services at Baylor Regional Medical Center (the results of which were discussed earlier). She hardwired and accelerated results by placing the hourly rounding log (Figure 1) for leaders on the back of the charge nurse shift report to ensure consistent leader rounding. “Charge nurses, managers, and directors were all expected to round,” she explains. “At the end of shift, an administrative assistant tallied and audited them so we can send reports back to supervisors on how many patients were rounded upon.”
VOLUME 38 • ISSUE 1
January 2012
Baker/EVIDENCE-BASED PRACTICE
FIGURE 2 Sample hourly rounding competency checklist.5 To download a full-size version of this sample, go to the “Excellence in the Emergency Department” resource page at www.studergroup.com/excellenceintheed.
Her top tip to accelerate results? “Leaders need to schedule hourly rounding on patients into their day to ensure it gets done. Consistent visibility to both patients and staff sends a clear message that addressing patients’ top concerns are our top priority.” Another key way to accelerate results is to create a monthly dashboard to track, measure, and report back on trends, opportunities, and the financial impact of hourly rounding in the emergency department so that everyone understands the important difference it is making in your organization. (Download a sample at www.studergroup. com/excellenceintheed.) Conclusion
Hardwire It
Once staff are consistently rounding, use these tips to ensure that everyone is 100% compliant and rounding in a standardized way for continuous improvement:
• Validate behaviors through information learned from lea-
There is no question that hourly rounding improves patient care. You will see it for yourself. Your emergency department will enjoy more positive word of mouth as a result of hourly rounding. Moreover, you too will enjoy a new reality: one that is safer, quieter, and more efficient. I have had dozens of ED leaders tell me that they never thought they would get their staff to make hourly rounds.
January 2012
Yet, once staff saw the benefits, they got on board quickly and would never consider going back. Once a nurse goes into a patient’s treatment room during hourly rounds and finds a patient not breathing or climbing over a bed rail, he or she will be a believer for life. Hourly rounds keep patients safe. Once staff know a better way to provide patient care, their values dictate that they do it!
VOLUME 38 • ISSUE 1
der rounding on staff, patients, and discharge phone calls.
• Review rounding logs daily to ensure staff compliance with documentation.
• Review results that leaders have harvested at daily stand-up meetings or “huddles.”
• Report results monthly to staff, physicians, and senior leaders. Use the dashboard for hourly rounding in
WWW.JENONLINE.ORG
71
EVIDENCE-BASED PRACTICE/Baker
the emergency department at www.studergroup.com/ excellenceintheed. • Use individualized coaching during monthly one-onone sessions with employees as needed. • Reward and recognize without restraint!
3. Baker SJ. Post-visit phone calls save lives, improve clinical outcomes, and reduce readmissions. J Emerg Nurs. 2010;36(3):256-9. 4. Baker SJ. Key words: a prescriptive approach to reducing patient anxiety and improving safety. J Emerg Nurs. 2011;37(6):571-4. 5. Baker SJ. Hourly rounding with individualized patient care in the ED. In: Excellence in the Emergency Department: How to Get Results. Gulf Breeze, FL: Firestarter Publishing; 2009. p. 138.
REFERENCES 1. Pulse Report 2010 Emergency Department: Patient Perspectives on American Health Care. South Bend, IN: Press Ganey Associates; 2010:4. 2. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70.
72
JOURNAL OF EMERGENCY NURSING
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD [email protected]
VOLUME 38 • ISSUE 1
January 2012