Final Results Summary: Emergency Department Rounding Study

It is important to note that physicians were not actively involved in the rounding experiment; however, the significant findings indicate the behaviors staff performed influenced the physicians’ behavior.

INTRODUCTION, OBJECTIVES AND DESIGN

BACKGROUND
This study was designed to determine the most effective type of rounding in Emergency Departments and expand our array of rounding tools and interventions that were initially documented in the Hourly Rounding Study (AJN, September 2006). There is no published, empirical evidence on the effects of rounding in the Emergency Department.  Consequently, as Emergency Departments continue to be in a state of crisis, this research is important, because of the need for nursing staffs to understand ‘patient best practices’ in the ED, both in the treatment and waiting/triage areas. Additionally, as the ED accounts for an average of 51% of hospital admissions nationally (AHA, 2006), hospitals would be well served to introduce interventions that increase overall ED patient satisfaction and exhibit best practices. 

STUDY OBJECTIVES

• Determine the ‘best practice’ strategies for rounding, relative to time intervals (30 minute, hourly or hourly with IPC-Individualized Patient Care) and employee practices in patient treatment and reception areas in EDs as determined by specific numeric measures and patient satisfaction ratings;
• Determine if implementing IPC (Individualized Patient Care) within a hourly rounding format enhances satisfaction beyond the levels induced simply from hourly rounding
• Determine if consistent rounding reduces patients Left Without Being Seen, patients Leaving Against Medical Advice and patient falls.
• Determine if rounding reduces patient call lights and the number of family members/patients coming to the nurse’s desk to inquire about care.
• Understand if staff and physicians perceive a difference from practicing the behaviors.

RESEARCH TREATMENTS
Three different rounding treatments were used for the study.  Julie Kennedy taped a training video to ‘show’ staff how to do the rounding.  Each hospital received multiple copies.   They were:

Treatment One: Hourly Rounding in Treatment and Waiting Areas

• Rounding was done on patients in the treatment areas every hour and in the triage/waiting areas on patients/family members every hour.  Rounding logs were used for documentation.

Treatment Two: Hourly Rounding In Treatment and Waiting Areas WITH IPC

• Patients were asked their expectations (i.e., IPC process) upon being admitted to the treatment room by the admitting nurse. Rounding was done on patients in the treatment areas every hour and in the triage/waiting areas on patients/family members every hour and documented on logs. (Note: As you see here, the difference is the introduction of IPC).

Treatment Three: 30 Minute Rounding in Treatment and Waiting Areas

• Rounding was done on patients in the treatment areas every 30 minutes and in the triage/waiting areas on patients/family members every 30 minutes.  Rounding logs were used for documentation.

ROUNDING PROTOCOL
The behaviors addressed during the rounding included PPD in the treatment area (P=ask about pain;  P-address the plan of care;   D-tell patients about waiting times and tests/processes needing to be done).  In the reception area rounding, staff addressed PD only.

RESULTS FROM THE NUMERIC MEASURES

As seen in the tables below, the rounding interactions significantly reduced the numbers of patients who Left Without Being Seen, patients leaving Against Medical Advice and patient falls.  Collectively, the 28 hospitals realized large reductions in only a month’s time.  Rounding also significantly reduced the number of patient call lights

** The majority of ED indicated they have minimal to no falls in a year’s time.

Note:  Five hospitals indicated they could not guarantee the reliability of their counts on a 24-hour basis because they did not have 24-hour coverage at the desk.  These results represent 23 hospitals.

RESULTS BY TYPE OF ROUNDING

The type of rounding was randomly-assigned to each ED except for the 30-minute rounding.  Any ED having 150 minutes or less in turnaround time from registration to discharge was assigned the 30-minute rounding, so we could ensure the staff would have a minimum of 4 rounding interactions with a patient.  The initial sample was:

• 11 doing 30-minute rounding
• 12 doing One-Hour Rounding
•  9 doing One-Hour Rounding with IPC

With the four hospital eliminations, the final sample was: 10 doing 30-minute;  9 doing One-Hour, and 9 doing One-Hour with IPC.  It is interesting to note the only category not having any hospital eliminated was One-Hour Rounding with IPC.

The results were separated by rounding group and analyzed.  The findings indicate that one-hour rounding with IPC was the most effective for the measures we are currently able to analyze.

PATIENT SATISFACTION FINDINGS
The patient satisfaction data was provided by each hospital’s vendor.  The questions were chosen by the principal investigator and reflect the behaviors that were performed during the rounding experience.  The breakdown of vendors used by these hospitals was:

• Press Ganey          46% (n=13)
• NRC                     18% (n= 5)
• Field Research      14% (n=  4)
• PRC                     11% (n=  3)
• Avatar                     4% (n= 1)
• Gallup                     4% (n= 1)
• In-house                  4% (n= 1)      (i.e., hospital does survey itself)

Not all of these vendors use the same measurement scale for the answers nor ask questions in the same format; however, the ‘conceptual nature’ of the various questions measured the same construct.  Therefore, they were able to be used.  It was necessary, however, to separate the 5-point and 4-point scaled questions, because they cannot be equalized. NOTE: separations were not done for the three different rounding treatments because it was impossible to combine 5 and 4-point scales.  Also, three hospitals from the same system could not supply patient satisfaction data, because they transitioned from one vendor to another during the study period.  Therefore the sample for this analysis totals 25 hospitals.

5-POINT SCALED QUESTIONS;   n=20 hospitals   71% of the total sample

4-POINT SCALED QUESTIONS;   n=5 hospitals   29% of the total sample

STAFF AND PHYSICIAN PERCEPTIONS

All members of the ED staff (RNs, Techs, Physicians and Physician Extenders (NP, PA) were asked to fill out a very brief questionnaire prior to the rounding and after the rounding.  The questionnaire asked them to self-rate how well they performed certain behaviors with patients and several questions about their emergency department specifically.
EMERGENCY DEPARTMENT STAFF SELF-RATINGS BEFORE AND AFTER THE ROUNDING EXPERIMENT

SUMMARY:    Six of the 12 behavioral questions had significant changes from the pre-rounding to post-rounding periods.

The findings indicate the staff perceived significant changes in their behavior with patients regarding: communicating with and updating them about their plan of care (.004) and giving patients an estimate of their waiting time (.001); better introducing themselves to patients (.01); communicating delays (.01); telling patients when they would be back (.03); remembering to ask patients if they have questions (.01).
EMERGENCY DEPARTMENT PHYSICIAN AND PHYSICIAN EXTENDER (PA, NP) SELF-RATINGS BEFORE AND AFTER THE ROUNDING EXPERIMENT

SUMMARY:    Two of the nine behavioral questions had significant changes from the pre-rounding to post-rounding periods.

The findings indicate physicians and physician extenders (i.e., NP and PA) perceived significant increases in their communicating with and updating patients about their care (.04) and asking patients about their pain and pain management (.01).

The other changes in questions were not significant.  It is important to note that physicians were not actively involved in the rounding experiment; however, the significant findings indicate the behaviors staff performed influenced the physicians’ behavior.

APPENDIX

Acknowledgements
We gratefully acknowledge the following hospitals, their Emergency Departments, physicians, managers and staff for participating in this study:

1. Altoona Regional Medical Center
2. Baylor Medical Center at Garland
3. Baylor Plano Specialty Hospital
4. Baylor Regional Medical Center at Grapevine
5. Central Carolina Hospital
6. Children’s Healthcare of Atlanta- Egleston Campus
7. Children’s Healthcare of Atlanta-Scottish Rite Campus
8. CMC University Hospital
9. Delray Medical Center
10. Emory Crawford Long Hospital
11. F.F. Thompson Hospital
12. Genesis Medical Center-Illini Campus
13. Hackensack University Medical Center
14. High Point Regional Health System
15. INOVA Fairfax Hospital –Pediatric ED 
16. Joe DiMaggio Children’s Hospital
17. Marshall Medical Center
18. Medical Center of Plano
19. Mercy General Hospital
20. Peninsula Medical Center
21. Piedmont Medical Center
22. Saint Anne Mercy Hospital
23. Sherman Hospital
24. South Fulton Medical Center
25. St. Joseph’s Hospital
26. Swedish Medical Center-Issaquah
27. Valley Hospital and Health System Adult ED
28. Valley Hospital and Health System Pediatric ED

NUMERIC MEASURES AND MEASUREMENT TACTICS