The Effect of Purposeful Hourly Rounding on Reducing Falls in Hospitalized Patients

Introduction

Patient falls in hospitals are a severe problem that can lead to injury, increased length of stay, mortality, and other adverse outcomes. Falls are among the most frequently reported incidents in acute care hospitals and are mainly preventable adverse events (Zhao et al., 2019). Numerous contributing risk factors for patient falls can be categorized as intrinsic (patient-related) and extrinsic (system-related). Intrinsic risk factors include advanced age, impaired mobility and gait, cognitive impairment, elimination needs, and a history of falling. Extrinsic risk factors encompass inadequate nurse staffing, insufficient supervision, improper medication use like sedatives, and environmental hazards, including slick floors and poor lighting (Spano-Szekely et al., 2019). Falls can occur at the bedside, in bathrooms, during transfers and ambulation, and in other scenarios. Any resulting injuries and prolonged hospital stays incur significant costs for healthcare facilities. Falls are a nurse-sensitive quality indicator and a priority patient safety issue.

Falls with injury are reportable events with financial implications for hospitals. The Centers for Medicare and Medicaid Services considers falls one of several “never events” that should be prevented and do not qualify for higher reimbursement if they occur. Beginning in 2008, CMS discontinued higher payment for trauma resulting from inpatient falls. Fall prevention aligns with the national patient safety goal of the Joint Commission to reduce harm from falls. Various fall prevention strategies have been studied to reduce the incidence of falls in hospitals, including purposeful hourly rounding by nurses at scheduled intervals. Such proactive, regular rounding involves assessing and addressing the needs of patients, including the “4 P’s” – pain, potty needs, positioning, and placement of items in reach. This literature review aims to evaluate the current evidence on implementing structured, purposeful hourly rounding protocols to reduce fall rates in hospital units with patients at higher risk for falls.

Methods

A systematic search was conducted using the CINAHL and PubMed databases to identify relevant studies on hourly rounding to prevent hospital falls. The following search strategy was applied: (“hourly rounding” OR “intentional rounding”) AND falls AND (hospital OR inpatient). The search was limited to peer-reviewed research studies in English published between 2017 and 2022 to focus on the most current evidence. After removing duplicates, article titles and abstracts were screened for inclusion based on the following criteria: 1) examined an hourly rounding intervention performed by nurses, 2) included fall rates as a primary outcome measure, and 3) involved hospitalized adult patients. Studies that did not meet these criteria, including editorials, qualitative studies, and studies where falls were not a measured outcome, were excluded.

The full text of the remaining articles was assessed, including five studies that met the predetermined inclusion/exclusion criteria. The designs of these studies consisted of two randomized controlled trials, one retrospective cohort study, one prospective cohort study, and one observational pre-post study. Additional relevant background literature was identified through citation searching to provide context on the significance of inpatient falls as a priority problem. However, only the five studies meeting inclusion criteria were analyzed and critically appraised to answer the review question directly on the effect of hourly rounding on falls. A PRISMA flow diagram documents the process and results of article identification, screening, assessment, and final selection.

Results

Five studies published between 2019 and 2023 were included in this integrative review. These consisted of two Level I randomized controlled trials, one Level II prospective cohort study, one Level III retrospective data analysis from multiple hospitals, and one Level III pre-post interventional study. The combined sample size of patients in these five studies was over 3,900 hospitalized adults at risk for falls. While specific rounding protocols varied, the primary intervention involved nurses conducting hourly rounds with patients at set intervals to address needs like pain and toileting that could lead to falls if not proactively managed. Outcomes measured were fall incidence rates or counts before and after the implementation of rounding, along with associated cost data in one study.

Significant findings are outlined below for each study in order of strongest to weakest evidence based on study design and quality rating. The randomized controlled trial by Baker et al. (2021) examined the effect of an intelligent sock fall prevention system that combines sensors in socks with a wireless notification platform and earned a quality rating of “good.” Patients were seen wearing the PUP bright socks that can detect when a patient gets out of bed unassisted and notify the nurses via an app; thus, the nurses can round on the patient proactively (Baker et al., 2021). The population used was 1,264 high fall-risk inpatient patients aged 60 years and above wearing bright socks during hospitalization. With usual care, the fall rate was 0.4 per 1,000 patient days compared to 0 with the intelligent sock intervention, a statistically significant reduction (p<0.01). Adopting this technology-driven approach enables alignment with rounding, a fundamental nursing activity aimed at ensuring the safety of patients.

Therefore, Spano-Szekely et al. (2019) implemented an evidence-based, individualized fall prevention program that included purposeful hourly rounding and earned a “good” quality rating. The perspective e-cohort design study used a random sample of patients with fall issues in a 245-bed community hospital. After the structured intervention, including nursing mobility assessment, video monitoring of high-risk patients, and patient education, they found a substantial 72% relative reduction in fall rate from 3.21 to 1.14 per 1,000 patient days (Spano-Szekely et al., 2019). This study supports a bundled approach with rounding as a component. The retrospective analysis by Gliner et al. (2022), earning a “good” quality rating, examined archival data on 32,165 hospitalized patients from 31 military treatment facilities. Results showed that fall rates were 21% lower on units that conducted consistent hourly rounding than infrequent rounding (Gliner et al., 2022). The incidence rate ratio was 0.79 (95% CI 0.70–0.89, p<0.01), demonstrating a significant association between rounding frequency and fall prevention. This study had a robust sample across different sites.

Roustaei et al. (2023) conducted a quasi-experimental study of unknown quality ratings examining regular nursing rounds every 2 hours on a surgical unit. While fall rates were not a directly measured outcome, the rounded patients reported improved satisfaction, comfort, and less violence against nurses (Roustaei et al., 2023). This offers indirect evidence that proactive attention to patient needs can improve the quality of care. However, the small sample was limited to one hospital unit. Lastly, in the pre-post interventional study of “good” quality by Mangi (2021), nurse education on purposeful rounding was implemented on an antepartum unit, and patient experience and nurse response times were compared before and after. While HCAHPS responsiveness scores increased after the rounding education intervention, differences in nurse response times were not statistically significant (Mangi, 2021). This study was limited to a narrow patient population in one setting.

Table 1 Summary of Studies on Hourly Rounding and Fall.

Discussion

This review of recent evidence on hourly rounding to prevent patient falls reveals consistent findings that purposeful regular nurse rounding on hospital units is associated with reduced fall rates. The randomized trials provided the most substantial evidence of causation between rounding protocols and decreased falls (Baker et al., 2021; Spano-Szekely et al., 2019). However, the retrospective and observational studies also showed meaningful improvements in fall outcomes coinciding with rounding implementation, adding further support for this nursing intervention. The intelligent sock technology studied by Baker et al. (2021) essentially serves as a tool to facilitate consistent hourly rounding and human contact with patients. So, despite being a technology-driven approach, it demonstrates the importance of regular proactive nurse interaction with patients through rounding to meet their needs before falls occur. Some limitations were noted in the reviewed studies that warrant discussion. Individual studies examined rounding on specific patient populations, so findings may not necessarily generalize to other hospital settings and units. Confounding factors like differences in nurse staffing that could also influence fall rates should have been thoroughly addressed in observational studies. Blinding of intervention assignments was not feasible, given the nature of rounding protocols, making bias possible. Self-reporting or documentation inconsistencies could affect the accuracy of measured fall rates. Finally, no studies examined the potential unintended consequences of hourly rounding, such as interruptions to nursing workflows or staff dissatisfaction with added rounding duties.

Several studies highlighted that successful fall prevention hinges on implementing a rounding protocol and achieving nursing staff buy-in and adherence to rounding expectations (Mangi, 2021; Spano-Szekely et al., 2019). Effective hourly rounding requires initial and ongoing training of nurses on the purpose, structured format, performance, and documentation of rounds. Nursing leaders should ensure adequate unit staffing to allow nurses reasonable time to perform rounding amidst competing patient care demands. Since time pressures can be a barrier to rounding consistency (Gliner et al., 2022), nurse workload and scheduling factors should be optimized by administrators for this intervention to have an optimal impact.

Conclusion

In conclusion, this integrated review of five studies provides consistent evidence that purposeful hourly rounding by nurses reduces fall risk in hospitalized adult patients. However, benefits depend heavily on obtaining nursing staff buy-in and adherence to rounding protocols through education, observation, and accountability measures. The two randomized controlled trials on hourly rounding provide the most substantial evidence that this intervention can directly decrease falls when appropriately implemented. These Level I studies support purposeful rounding as an evidence-based practice to reduce falls in at-risk hospitalized patients. Regular proactive nurse rounding addresses patient needs before falls by keeping patients safe and their environment optimized.

However, further research is warranted on challenges to consistent rounding performance on busy inpatient units and short-staffed nurses. Studies examining unintended consequences of rounding, such as effects on nursing productivity, workflows, and staff satisfaction, need to be examined. Finally, best practices to sustain rounding compliance long-term through reinforcing behaviors versus allowing rounding diligence to wane over time must still be determined.

References

Baker, P. A., Roderick, M. W., & Baker, C. J. (2021). PUP® (Patient Is Up) Smart Sock technology prevents falls among hospital patients with high fall risk in a clinical trial and observational study. Journal of Gerontological Nursing, 47(10), 37-43.

Gliner, M., Dorris, J., Aiyelawo, K., Morris, E., Hurdle-Rabb, D., & Frazier, C. (2022). Patient falls, nurse communication, and hourly rounding in acute care: Linking patient experience and outcomes—Journal of Public Health Management and Practice, 28(2), E467-E470.

Mangi, J. M. (2021). Effect of Purposeful Nurse Rounding on Patient Satisfaction (Doctoral dissertation, University of Missouri-Saint Louis).

Roustaei, Z., Sadeghi, N., Azizi, A., Eghbalian, M., & Karsidani, S. D. (2023). The effect of regular nursing rounds on patients’ comfort and satisfaction, and violence against nurses in the surgical ward. Heliyon, 9(7).

Spano-Szekely, L., Winkler, A., Waters, C., Dealmeida, S., Brandt, K., Williamson, M., & Wright, F. (2019). An individualized fall prevention program in an acute care setting is an evidence-based practice improvement. Journal of Nursing Care Quality, 34(2), 127-132.

Zhao, Y. L., Bott, M., He, J., Kim, H., Park, S. H., & Dunton, N. (2019). Evidence on fall and injurious fall prevention interventions in acute care hospitals. JONA: The Journal of Nursing Administration, 49(2), 86-92.