Apr 27, 2020, By: Kaitlan Laviolette
Take away messages:
- Utilization of best practice guidelines in long-term care can have significant impacts on resident safety and quality of life.
- The concept of purposeful hourly rounding for falls reduction in long-term care has excellent outcomes in terms of falls rates and reduces severity of injury post-fall.
- Implementation and uptake of quality improvement initiatives should be tailored to meet the learning needs of staff in long-term care.
Long-term care (LTC) can be a complex and challenging environment to work in. As the attending nurse practitioner for two homes—Grace Manor and Faith Manor, both part of Holland Christian Homes in Brampton, Ontario—I quickly came to the realization that LTC is a unique area of practice within the health care system. One of the first things I recognized was the need to provide primary care within the strict guidelines of the Long-Term Care Homes Act and its accompanying regulations.
Another realization was the challenges for staff and the organization as a whole in keeping up with changes in nursing best practice to provide excellent resident care. Without a formal educator role, nursing and PSW education often falls on the shoulders of the very busy directors of resident care, who must juggle staffing needs, policy writing, ministry requirements, filling beds, and managing resident concerns.
After noting these challenges, I soon came to the conclusion that they create the “perfect storm” with regard to high fall rates for our residents. With three to four staff members on a unit of 30 residents, it is impossible to have eyes on all residents at all times. Pair this with progressive cognitive decline, delirium, illness, or simply the fierce drive of a resident to maintain independence at all costs, and you may well end up with a resident on the floor.
Shortly after starting in LTC, I came to notice that a great number of falls were occurring at one home in particular. The second-floor unit of Faith Manor (FM2) is home to 60 residents. It is a secure unit with, mainly, a population of residents who suffer from cognitive impairment. In March 2018, there were a total of 39 falls in one month by 20 different residents. This translates to just over one fall per day.
The impact of one fall can be devastating on a senior: there is a possibility of death if they happen to hit their head and are on a blood thinner. There is also the risk of severe disability from a fracture, for example, to the hip, which can lead to increased pain, inability to walk, and as a result, poor quality of life. After our team assessed the number of falls and their impact on residents, improving resident safety became our main priority.
Spotlight on best practices
I decided to bring forth the idea of applying to become a Best Practice Spotlight Organization (BPSO) through a partnership with the Registered Nurses’ Association of Ontario (RNAO). In 2017, Holland Christian Homes’ Grace and Faith manors were accepted into the BPSO program, and we began our journey into best practice implementation.
Among the Best Practice Guidelines (BPG) we chose to implement in 2018 was Preventing Falls and Reducing Injury from Falls (4th ed.). One particular practice that we have implemented and believe should emerge as a promising practice in LTC is Recommendation 5.3: Implement rounding as a strategy to proactively meet the person’s needs and prevent falls.
With three to four staff members on a unit of 30 residents, it is impossible to have eyes on all residents at all times.
Although fall prevention and management are extremely complex, with many different individualized multifactorial approaches, we have found that a combination of these best practices and the completion of Purposeful Hourly Rounding has been the most effective strategy in LTC for falls reduction and minimization of injury.
Rounding and the 4Ps
The practice of Rounding is “the act of checking in on patients in person on a regular basis (e.g., hourly) to proactively meet their needs” (RNAO, 2017). It has been well established in the hospital sector; however, much less evidence exists to support its use in LTC. Although there are variations in Rounding resources available throughout the health care sector, one of the most widely utilized concepts is the 4Ps approach, which aims to address four specific key needs: Pain Control, Position, Placement (Possessions), and Personal Needs (Centre for Effective Practice, 2016). Our implementation of Purposeful Hourly Rounding included shared concepts from the 4Ps, adapted from the Alberta Health Services Comfort Rounds and The Perley and Rideau Veterans’ Health Centre Rounding Guide.
Our existing interdisciplinary falls team is led by the assistant director of resident care, Sellinor Ogwu, at Faith Manor. We implemented Purposeful Hourly Rounding mainly as a PSW-led initiative aimed at addressing the 4Ps with the use of a quick script with each hourly visit to the resident’s room or current location.
The entire project of Rounding alone took 7 months, between April 2018 to November 2018; falls BPG work started in January 2018, to ensure that a comprehensive falls program was in place to comply with best practices for identification of falls risk factors, interventions, and assessments.
Purposeful Hourly Rounding was implemented by our pre-existing falls team as part of our BPG implementation work. The team was composed of interdisciplinary members including myself, RNs, RPNs, PSWs, activation staff, an administrator, and a physiotherapist. Assistance was provided from our RNAO coach, Rebecca DeWitt (RN).
The initial challenge we faced during implementation was staff buy-in. Since Purposeful Hourly Rounding is PSW led, and as noted earlier, the staffing ratios were already very constrained, staff felt we were adding additional work to their already busy schedules.
Initial training consisted of face-to-face group learning with a presentation of the Comfort Care Rounding in Long-Term Care videos developed by The Perley and Rideau Veterans’ Health Centre and the Studer Group (2019). During this training, we also reviewed the documentation process for Purposeful Hourly Rounding and then gave the staff an opportunity to ask questions.
Following the training, implementation of Purposeful Hourly Rounding took place for all residents on FM2 starting on October 1, 2018.
Uptake, and “take 2”
Unfortunately, the uptake of Purposeful Rounding by staff did not go as we had hoped. During the measurement period (October 2018), staff completed Purposeful Hourly Rounding only 76% of the time.
We took the opportunity in November 2018 to re-educate our staff using a different approach. Didactic learning did not seem to be effective, so we tried the “See One, Do One, Teach One” approach based on the medical-surgical model. This proved to be highly effective.
… we have found that a combination of these best practices and the completion of Purposeful Hourly Rounding has been the most effective strategy in LTC for falls reduction and minimization of injury.
Each staff member was allotted 15 minutes for training, and we used an educational poster as a facilitation guide (Figure 1 [PDF, 214.4 KB]). During this time, the staff member would watch a demonstration of Purposeful Hourly Rounding by an instructor, initially with the use of a teaching mannequin (“see one”), and they would then demonstrate Purposeful Hourly Rounding to the instructor based on what they had just learned (“do one”). Lastly, they would become the instructor and teach their colleagues how to perform Purposeful Hourly Rounding (“teach one”).
This method of teaching included return demonstration, which was effective in providing real-time feedback or correction as required. It also allowed the opportunity for staff to practise the new skill as well as build peer-to-peer support.
Following the November education session, we saw a drastic improvement in our Purposeful Rounding completion rates, and most importantly, a reduction in the total number of falls and the number of residents falling. In November 2018, we had a total of 26 falls and a total of 9 residents who fell. One month later, in December, there was a reduction in total falls by 10 (38%) to a total of 16, and an improvement in the number of residents falling from 9 to 6 (33%).
Fast-forward to June 2019: we had a total of 7 falls (a 73% reduction from November) and a total of 6 residents falling. Month after month, we continued to see an improvement with our Purposeful Hourly Rounding completion rates from 76% to 99%. (For a detailed breakdown of our results, see Figure 2 [PDF, 158.9 KB], which shows pre- and post-implementation data.)
Another important improvement that was noted was a reduction in serious injuries sustained as the result of a fall (Figure 3 [PDF, 163 KB]). FM2 had a 10-month span with no fractures as the result of a fall. Injuries were limited to bruises and skin tears in those residents that did sustain an injury.
Although the experience of implementing Purposeful Hourly Rounding was initially challenging, the results were worth the effort. Since rolling out Purposeful Hourly Rounding on the second floor, we have now expanded Rounding to the first floor. The roll-out onto the first floor was a much smoother process, as we had now figured out the challenges and barriers after the initial implementation.
In fall 2019 we began slowly to roll out Purposeful Hourly Rounding to our sister home, Grace Manor, and by January 2020 we had fully implemented Purposeful Hourly Rounding throughout the entire facility. We are currently in the early stages of our data collection, but we have already started to see a reduction in our total number of falls.
As with any project, ongoing oversight with audits and continued training will be required to maintain this practice change. Moving forward, we have created an interdisciplinary training tool for every department in our organization to ensure that a culture of sustainability is maintained. We look forward to seeing our anticipated ongoing positive results in the future.
Acknowledgments: This work is part of the BPSO Designation, funded by the Ontario Ministry of Health and Long-Term Care.
Centre for Effective Practice. (2016). Falls prevention discussion guide.
Registered Nurses’ Association of Ontario. (2017). Preventing falls and reducing injury from falls (4th ed.).
Studer Group. (2019). Comfort care rounding in long-term care.
Kaitlan Laviolette, MN, NP-PHC Holland Christian Homes: Grace and Faith Manor LTC, is a primary care nurse practitioner currently working as an attending nurse practitioner in long-term care. She is passionate about working with the geriatric population and works hard to continue to improve nursing and resident care in the long-term care setting. She is an advocate for quality improvement and life-long learning to promote resident safety and improve quality of life. For more information, please contact: firstname.lastname@example.org.