Background and Rationale
According to the Centers for Disease Control and Prevention (2012), falls in individuals can result in significant trauma and increased mortality rates. They report that approximately one-third of adults aged 65 and older experience falls annually. In long-term care facilities, there is a high incidence of falls, with an average of 1.5 falls per nursing home bed each year (Vu, Weintraub, & Rubenstein, 2004). To address this issue, guidelines were published in 2001 by the American Geriatric Society, British Geriatric Society, and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention (Shimada et al., 2009). These guidelines stressed the importance of staff education programs, gait training, proper use of assistive devices, and medication review and modification. However, Shimada et al. (2009) observed that these interventions are more effective for independently mobile and cognitively intact long-term care residents than those with limited mobility or cognitive impairment.
According to certain research studies, implementing scheduled patient rounding, which includes activities such as checking rooms every hour, assisting with toileting, eliminating obstacles in resident’s rooms, and providing diversion activities for those prone to wandering, can potentially reduce the occurrence of falls in long-term care communities (Shimada et al., 2009).
Some facilities still use bed alarms instead of scheduled rounding for fall prevention programs (Hubbartt, Davis, & Kautz, 2011). This type of alarm is activated when a patient at risk of falling tries to get out of bed without using the call light, and the alarm can be heard throughout the unit. Can bed alarms effectively replace frequent scheduled rounding in preventing falls? PICO Question
The literature review focuses on the population residing in long-term care facilities, specifically individuals who require additional assistance with their daily activities. The demographic of these residents has shifted towards those with greater disability and cognitive impairment, as more individuals now have access to home care options. Consequently, these individuals are at a higher risk of experiencing falls (Spector, Fleishman, Pezzin & Spillman, 2001).
The identified intervention is called scheduled patient rounding. This involves a provider checking on the patient at least once every hour to enhance supervision of residents. During scheduled patient rounding, the provider may ensure safety, help with toileting, and provide diversion activities for those who tend to wander.
The use of bed alarms is the central element of the comparison intervention. This involves activating a sound from the bed alarm if a patient tries to leave without help. Consequently, staff members are alerted and can provide assistance, minimizing the need for scheduled rounding.
The CDC (2012) states that the outcome of reducing fall rates can help prevent various forms of moderate to severe trauma, including head injuries, hip fractures, and skin breakdown caused by falls.
Thus, the inquiry is whether implementing a patient rounding program or utilizing bed alarms leads to a greater reduction in the annual fall rate among residents in long-term care facilities?
A literature review was conducted to investigate the impact of hourly rounding and bed alarms on fall rates in long-term care facility residents. The search was performed using three online databases: CINAHL, PubMed, and The Cochrane Library. Initially, a search in the CINAHL database using the keyword “bed alarm” (limited to English language) resulted in 14 articles, with three being relevant. However, combining the keywords “bed alarm” and “hourly rounding” did not yield any results. On the other hand, searching for “hourly rounding” and “fall” generated one useful article. In PubMed, a search for “bed alarm” and “falls” produced 11 articles, with one being applicable to the study. Adding the keywords “hourly rounding” and “falls” led to six articles. One duplicate article from previous studies was excluded while two were valuable for this study.
Moreover, when searching The Cochrane Library using MeSH heading “accidental falls,” a total of 7694 articles were returned. To narrow down the search, MeSH headings bed alarm and hourly rounding were included resulting in six articles; one of which was relevant for this study. Additionally, by examining the reference section of an identified article and searching its title on the Cochrane database another article that addressed the clinical question was found.
In summary, a total of nine articles are pertinent to this literature review.
Although nine articles were identified as relevant to the current study, not all of them examined the relationship between bed alarms and hourly rounding. The majority of the existing evidence focused on either the impact of bed alarms on fall risk and rate or the effects of hourly rounding on fall risk and rate. Some of the evidence discussed multiple interventions for fall prevention, making it difficult to determine whether bed alarms or hourly rounding specifically led to a statistically significant outcome.
Of the nine articles found, there was a wide variation in study design and level of evidence. One systematic review was identified, but it was not relevant to the specific clinical question and therefore excluded. No meta-analysis studies were discovered. The highest level of evidence available for this literature review was a randomized controlled trial. Out of the nine articles, only two were suitable randomized controlled trials. There were also two quasi-experimental studies and three pilot studies. Additionally, one article utilized a case-controlled study design and another employed a descriptive and repeated measures design.
During the synthesis of the evidence, the difficulty arose in locating studies that specifically focused on residents of long-term care facilities. Many studies were conducted in an acute care setting, which may have included a wider age range in its population. Even though one unit was classified as a geriatric unit, it was still categorized as acute care. Nonetheless, the compiler of this literature review believed that these studies still addressed the clinical question at hand. While residents in a long-term care facility may have a higher prevalence of dementia and Alzheimer’s disease diagnoses, a medical-surgical unit would encompass patients with psychiatric disorders, drug/alcohol withdrawal, and confusion/delirium. Both long-term care facilities and acute care settings have residents or patients who are considered at risk of falling.
Two studies have been questioned regarding the appropriateness of the population they studied. In one study conducted by Tideiksaar, Feiner, and Maby (1993), no statistical difference was found in fall rates between the control and experimental groups after implementing bed alarms as part of a fall prevention protocol. It is worth noting that fall data was not collected prior to the study and both groups had low fall rates. Similarly, another study by Lowe and Hodgson (2012) reported zero falls during a two-week period when hourly rounding was introduced. However, the fall data showed that there had already been no falls on this unit for two months before the study commenced. This raises questions about whether these units were suitable choices for the studies, and if other units with a greater need for intervention should have been selected instead.
The efficacy of bed alarms and scheduled hourly rounding systems in reducing fall rates remains inconclusive based on conducted studies. Some studies focused on the PICO question and discovered that bed alarms did not decrease fall rates. Notably, three studies supported this finding. Shorr et al. (2012) conducted a large-scale study involving 27,672 patients in an acute care setting, which revealed that increased usage of bed alarms did not have a statistically significant impact on falls, fall-related injuries, or restraint usage when compared to a control group. Another smaller case-controlled study by Tideiksaar, Feiner, and Maby (1993) also confirmed that increased usage of bed alarms did not result in a statistically significant reduction in fall rates. Additionally, Hubbartt, Davis, and Kautz (2011) conducted a pilot study concluding that implementing bed alarms as an intervention in an acute care setting did not lead to a decrease in fall rates.
According to a study conducted by Capan and Lynch (2007), the implementation of a personalized seven-step fall prevention program, occasionally including bed alarms, resulted in a decrease in the facility’s fall rate below its benchmark rate. The facility aimed to reduce the fall rate from 0.45 falls per 100 patient-days to 0.35 falls per 100 patient-days. After using the multidisciplinary program for 100 days, the fall rate decreased to 0.32 falls per 100 patient-days. Although it is unclear if this decrease was statistically significant, it surpassed the desired outcome established by the facility.
The success of this program should not be solely attributed to bed alarms but rather to an individualized multidisciplinary approach to preventing falls. There is no evidence indicating that incorporating only bed alarms as a fall prevention intervention leads to lower fall rates.
Despite insufficient evidence to support the use of bed alarms, studies have shown that implementing an hourly rounding schedule effectively prevents falls.
Meade, Burselff, and Ketelsen (2006) conducted a study using a quasi-experimental nonequivalent groups design to evaluate the effectiveness of an hourly and every two hour nurse rounding protocol in reducing falls. The results showed a statistically significant decrease in the fall rate with the hourly rounding protocol. Similarly, Tucker, Bieber, Attlesey-Pries, Olson, and Dierkhising (2012) evaluated a structured hourly rounding program on two orthopedic units and observed a significant decrease in falls after implementing the program. Another study by Olrich, Kalman, and Nigolian (2012) also utilized a quasi-experimental design and found a 23% decrease in the fall rate after introducing an hourly rounding program. Although not included in these three studies, Lowe and Hodgson (2012) also examined the effects of hourly rounding and found no falls during its implementation. However, it is important to note that this unit did not experience any falls prior to the implementation of hourly rounding as well.
Nonetheless, a study conducted by Krepper et al. (2012) discovered that implementing an hourly rounding protocol did not result in a decrease in the fall rate. The study aimed to examine the impact of hourly rounding on various factors such as fall rates, patient satisfaction scores, call light usage, readmission rates, and nurse’s steps per shift. Despite not observing a statistical decrease in fall rates, the study did find that hourly rounding led to a reduction in the number of steps taken by nurses as well as patient call light usage.
Based on the United States Preventative Services Task Force (USPSTF) evidence grading schema, I would classify the evidence for this review as category B and of fair quality. The evidence is sufficient to determine the health outcome of this intervention, although it would have been beneficial to include larger studies or systematic reviews in the literature review. Consequently, based on the fair evidence findings and absence of harm to patients, it is recommended to implement hourly rounding for eligible patients. I selected the USPSTF evidence grading schema because its grading categories are clearly defined through an algorithm. A summary of the article review is provided in the appendix. Practice Recommendations
After reviewing the given information, I conclude that further research is necessary. The studies conducted have been limited in scope, making it challenging to establish a universal recommendation. Recommendation #1
Based on research findings, it is suggested that incorporating an hourly rounding protocol can be beneficial to a fall prevention program. Out of the studies conducted, only one did not observe a decrease in fall rates with hourly rounding, whereas three studies reported a reduction in fall rates. Additionally, while one study indicated that a multidisciplinary individualized approach to fall prevention was effective and involved the use of bed alarms, three studies found no evidence of bed alarms reducing fall rates. It is worth noting that bed alarms were selectively employed on confused or impulsive patients within the multidisciplinary approach.
The hourly rounding protocol should involve both registered nurses and nursing assistants working together as a team. They can be assigned specific hours to round on certain patients, such as having the registered nurse round on patients during even hours and the nursing assistant round on patients during odd hours. Recommendation #2
My second recommendation is to use bed alarms sparingly in fall prevention programs and not automatically put a bed alarm on every patient who is at risk of falling. This includes patients who are confused and impulsive. It should be up to the registered nurse caring for the patient to make this decision. The long-term care facility or hospital unit could have a questionnaire or flow sheet that registered nurses can use as a reference tool to determine if a particular patient would benefit from a bed alarm. For instance, if a patient is confused but not impulsive and unable to move, there would be no need for a bed alarm. This alarm would likely only go off when the patient is being turned by nurses or nursing assistants, resulting in false alarms that could lead to alarm exhaustion and slower response times from nurses.
Strength of Recommendation
The “Strength of Recommendation Taxonomy” (SORT) (Ebell et al., 2004) was used to determine the strength of recommendation. Both recommendations were classified as “B,” which means they are based on inconsistent or limited-quality patient-oriented experience (Ebell et al., 2004). To achieve an “A” strength, two randomized controlled trials supporting the recommendation should be included in the literature. There were no systematic reviews or meta-analyses consistently supporting the recommendation. However, it did not receive a “C” grade, representing an opinion-based recommendation, because it has some evidence-based practice support (Ebell et al., 2004).
To implement these recommendations, a significant amount of time and adherence would be required. The first step would involve obtaining approval from management of the facility. It would be appropriate to approach management by explaining the issue of falls and presenting the findings from the literature review. Additionally, highlighting the financial cost associated with falls would further emphasize the importance of an effective fall prevention protocol. According to the Centers for Disease Control and Prevention (2012), the average cost of a fall in individuals over 72 years old is $19,440.
If these recommendations are approved, a new fall prevention protocol would be introduced to the staff gradually. Nurses and nursing assistants would receive education on how to implement this protocol, either through online training or in-class instruction. It may also be helpful to introduce a flow sheet that guides staff in determining whether a patient or resident requires a bed alarm. Once the staff is adequately educated, the implementation of the program can commence. To ease the transition, it might be beneficial to start with just a few rooms on the unit, allowing registered nurses and nursing assistants to become accustomed to the new protocol. This gradual approach would facilitate better incorporation of the program and increase adherence to rounding procedures. Regular auditing may be necessary to ensure that everyone fulfills their responsibilities, as an ineffective hourly rounding program would result in diminished effectiveness overall.It is suitable to gradually introduce the program to the rest of the unit once adherence has been demonstrated through auditing. Additionally, the new plan should incorporate a follow-up audit and gather staff opinions on the program. If there has been a reduction in fall rates since the program started, it is important to share this success with the staff.
In conclusion, further research is needed to determine whether hourly rounding or bed alarms are more effective in reducing fall rates. This literature review supports the recommendation of implementing a fall prevention program that includes hourly rounding and appropriate use of bed alarms. Long-term care facility residents would benefit from this protocol, as it is supported by existing evidence that suggests it can decrease fall rates and improve the longevity of elderly individuals.
References
Capan, K., & Lynch, B. (2007). Reports from the field: patient safety. a hospital fall assessment and intervention project. Journal of Clinical Outcomes Management: JCOM, 14(3), 155-160. Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention.(2012). Falls among older adults: an overview. Retrieved from website: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Ebell, M., Siwek, J., Woolf, S., Susman, J., Ewigman, B., Bowman, M., & Weiss, B. (2004). Strength of recommendation taxonomy: a patient-centered approach to grading evidence in the medical literature. Journal of the American Academy of Family Physicians, Retrieved from http://www.aafp.org/afp/2004/0201/p548.html Hubbartt, B., Davis, S., & Kautz, D. (2011). Nurses’ experiences with bed exit alarms may lead to ambivalence about their effectiveness. Rehabilitation Nursing, 36(5), 196-199. Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., Xing, Y., & Myers, K. (2012). Evaluation of a standardized hourly rounding process (sharp). Journal for Healthcare Quality, 00(0), 1-7. Lowe, L., & Hodson, G. (2012). Hourly rounding in a high dependency unit. Nursing Standard, 27(8), 35-41. Meade, C., Bursell, A., & Ketelsen, L. (2006). Effects of nursing rounds on patients’ call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70. Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: a replication study.The following sources discuss the impact of enhanced supervision on fall rates in residential aged care, the effects of an intervention to increase bed alarm use in preventing falls in hospitalized patients, the characteristics of long-term care users, the efficacy of a bed alarm system in an acute-care setting, outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units, and the preventability of falls in nursing homes. These sources provide valuable insights on fall prevention strategies and their effectiveness in different healthcare settings.
Author (Year)
Title
Journal
Purpose/Problem/Objective
Study Design and Level of Evidence
Sample (Setting)
Data Collection/Methods
Measurement/Data Analysis
Results/Findings
Implications
Strengths/Limitations
Shorr, R., Chandler, M., Mion, L., Waters, T., Minzhao, L., Daniels, M., Kessler, L. & Miller, S. (2012)
Impact of an intervention aimed at promoting the utilization of bed alarms as a preventive measure against falls in hospitalized individuals.
Annals of Internal Medicine
1. This study aims to assess if there is a correlation between the increased usage of bed alarms and a reduction in falls as well as a decrease in the need for restraints. It is a pair-matched, cluster randomized controlled trial that took place in a 16 unit hospital, involving a total of 27,672 patients from various general medical, surgical, and specialty units.
The nursing units were numbered 1-16 and paired randomly with a neighboring number. One unit in each pair served as the control group, while the other unit served as the intervention group. The assignment of nursing units to either the control or intervention group was done randomly. Data was collected over a span of six months.
Control: Maintain the current fall prevention program by using bed alarms for patients at high risk of falling.
Intervention: Implementation of alarms in bed, chairs, and toilets in each patient room for fall prevention. The distribution of falls was analyzed utilizing a Wilcoxon test.
The study utilized a negative binomial regression model to examine the contrast among various groups.
Rates were altered according to covariates including staffing, demographic, and psychotropic drug administration variables. The rate of falls, injuries from falls, or the use of restraints did not display a statistically significant change when compared to the control group despite the increase in bed alarm usage.
It is possible that hospitals may be using bed alarms excessively or inappropriately as a method to prevent falls, which has clinical implications. The study has several strengths: it is a randomized controlled trial (RCT), has a large sample size, and the data collection accounted for relevant covariates and adjusted rates accordingly.
Limitations:
1. The study was conducted at a single site.
2. The study was not blinded.
APPENDIX 1
Author (Year) – Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S. & Xing, Y. (2012)
Title – Title
Journal – Journal
Purpose/Problem/Objective – Purpose/Problem/Objective
Study Design/Level of Evidence – Study Design/Level of Evidence
Sample (Setting) – Sample (Setting)
Data Collection/Methods – Data Collection/Methods
Measurement/Data Analysis – Measurement/Data Analysis
Results/Findings – Results/Findings
Implications – Implications
Strengths/Limitations – Strengths/Limitations
Assessment of SHaRP, a standardized hourly rounding process.
Journal for Healthcare Quality
Research to determine if implementing an hourly rounding protocol will lead to enhanced patient satisfaction, quality, safety, and efficiency scores in two 32 bed cardiovascular surgery units.
The units were almost identical in terms of census, number of admissions/discharges/transfers, hours in patient day, and staff turnover.
Data was collected over a six month period.
Control group: There was no implementation of an hourly rounding protocol.
Intervention group: Implementation of the hourly rounding protocol.
Comparing call light use between both groups using independent sample t-tests.
Methods utilizing survey regression were employed in order to examine the perception of nurses regarding their available time.
Chi-square tests were used to measure patient satisfaction in the two groups.
Wilcoxon two-sample non-parametric tests were utilized to assess the crude rates of falls and readmissions for both groups.
The intervention group demonstrated a noteworthy decrease in call light usage and the number of steps taken per nurse during a day shift.
There were no significant statistical differences in patient falls, 30-day readmission rates, and patient satisfaction scores.
The clinical significance of this study is that it found that hourly rounding can lead to a reduction in call lights and the number of steps taken by nurses per shift. The study has several strengths: it is a randomized controlled trial (RCT), it lasted for 6 months (compared to previous studies that typically only last 4 weeks), it is an inexpensive intervention, and the intervention and control units had similar characteristics as mentioned in the sample section.
Weaknesses:
1. The study only randomly sampled 2-3 shifts per week due to differences in staffing between day/night.
2. The study was conducted only at one hospital on sister units.
Author (Year)
Title
Journal
Purpose/Problem/Objective
Study Design/Level of Evidence
Sample
(Setting)
Data Collection/Methods
Measurement/Data Analysis
Results/Findings
Implications
Strengths/Limitations
Capan, K. & Lynch, B. (2007).
Reports from the field: patient safety. A project focusing on hospital fall assessment and intervention.
Journal of clinical outcomes management: JCOM
A pilot study was conducted on a medical/neurology unit in a hospital setting to describe a specific fall protocol that was developed and to assess the effects of its implementation on fall rates among patients. This particular floor had a high incidence of falls and it was determined that a new fall prevention tool/protocol was necessary. The fall rate was measured over 100 patient-days while the multi-disciplinary fall prevention protocol was in place.
This protocol assessed fall risks in individuals by seven risk factors and then implemented patient-specific interventions. The interventions consisted of a wrist band, door magnet, fall prevention guide, hip protectors, assessment of orthostatic hypotension, a low bed, bed alarms, toileting assistance, and medication reviews.
The research group established benchmark goals for changes in the fall rate, aiming for a fall rate of 0.35 per 100 patient-days.
They measured both the fall rate and the severity of falls. They categorized falls into three groups: no injury, minor injury, and severe injury.
In this particular pilot study, the fall prevention protocol was found to have reduced fall rates from 0.45 to 0.32, exceeding their target outcome.
Implications: More studies may arise to examine the individualization of fall prevention protocols, given that this provides a reason for future studies to develop. Strengths:
1. Inexpensive interventions.
2. Sets a clear outcome.
Limitations:
1. This study is a pilot, therefore it does not provide the highest level of evidence as it only includes one hospital and one unit.
2. The statistical significance of the change in fall rate was not analyzed.
Author (Year)
Title
Journal
Purpose/Problem/Objective
Study Design/Level of Evidence
Sample (Setting)
Data Collection/Methods
Measurement/Data Analysis
Results/Findings
Implications
Strengths/Limitations
Meade, C., Burselff, A., & Ketelsen, L. (2006).
The impact of nursing rounds on patients’ utilization of call lights, level of satisfaction, and safety.
The American Journal of Nursing’s objective is to analyze the motivations behind call light usage and the impact of one-hour and two-hour nursing rounds on call light activity, patient satisfaction, and patient safety. The research adopts a quasi-experimental nonequivalent groups design.
Data was collected for six weeks from a total of 14 hospitals, which consisted of 27 medical, surgical, or medical/surgical units.
Each unit implemented either an hourly rounding system or a two-hour rounding system.
Data was collected by analyzing three factors: the number of call lights, patient satisfaction surveys, and fall rates.
Control group: Units that have not implemented hourly rounding or 2-hour rounding.
The experimental group received either hourly rounding or q2h rounding. Binomial testing was conducted to compare the experimental group to the control group and determine if there were any significant differences.
STATS software was used to perform statistical computations using the procedure for computing the difference between two independent means.
Paired t-tests were utilized to analyze the difference in the number of falls. The findings indicated a significant decrease in the number of call lights when employing hourly rounding as well as 2-hour rounding.
There was a notable rise in patient satisfaction scores when hourly rounding was implemented.
There was a significant decrease in the rate of falls with hourly rounding.
Implication for integrating an hourly rounding initiative on hospital units. Advantages:
1. Control and experimental groups have been matched according to similar characteristics and census.
2. Statistically significant outcomes that could have practical implications.
Limitations:
1. We had to exclude 8 hospitals (19 units) from the study because they did not comply.
2. We did not gather satisfaction scores from nurses/CNAs.
Author (Year)
Title
Journal
Purpose/Problem/Objective
Study Design/Level of Evidence
Sample (Setting)
Data Collection/Methods
Measurement/Data Analysis
Results/Findings
Implications
Strengths/Limitations
Tideiksaar, R., Feiner, C., & Maby, J. (1993).
Falls prevention in an acute-care setting: Evaluating the effectiveness of a bed alarm system
The purpose of this study, conducted in The Mount Sinai Journal of Medicine, was to evaluate the effectiveness of a bed alarm system in reducing falls in a geriatric hospital unit. The study consisted of 70 patients, including 60 women and 10 men, with ages ranging between 67 and 97 years old. These patients were selected from a 16-bed acute care geriatric unit and were assigned randomly to different groups.
Control group: No bed alarms
Experimental group utilized bed alarms.
Each group received the same amount of nursing attention.
Collected data included information on the number of alarm activations and the reasons for activation, true activations, diagnoses, medications taken, as well as the use of restraints and siderails. Statistical significance of the number of falls before and after the bed alarm intervention was determined using Fisher’s exact test.
Additional data was collected to ascertain the underlying causes for certain findings. However, there was no statistical significance observed in the number of falls following the implementation of bed alarm intervention.
They discovered that patients often attempted to get out of bed without assistance because they needed to use the toilet. As a result, implementing timed toileting could potentially reduce the risk of falls. One of the strengths of this study is that it was a randomized controlled trial.
2. The target population for fall risk.
Limitations:
1. Small unit
2. Study from 1993
3. No data on what fall rate was like before study. Both experiment and control had low fall rates—did this unit always have low fall rates? Should the study have been done elsewhere?
The author (Year), Title, Journal, Purpose/Problem/Objective, Study Design/Level of Evidence, Sample, (Setting), Data Collection/Methods, Measurement/Data Analysis, Results/Findings, Implications, Strengths/Limitations. Olrich, T., Kalman, M., & Nigolian, C. (2012).
A replication study on the topic of hourly rounding.
Medsurg Nursing
To determine the efficacy of implementing an hourly rounding program in reducing patient fall rates, call light usage, and improving patient satisfaction scores, a quasi-experimental study was conducted. The study included two medical-surgical units of similar size and fall rates. Data including the number of falls, call light usage, and patient satisfaction levels were collected over a period of 6 months.
Control group: no hourly rounding
Experimental group: hourly rounding
Nurse managers and Clinical Nurse Specialists (CNS’s) regularly checked on Registered Nurses (RN’s) to ensure they were conducting hourly rounding. Measures of central tendency and variability were computed for the three variables.
The fall rate after the hourly rounding intervention was compared to the pre-intervention data using both chi-square tests and rank sum tests. Although the fall rate decreased by 23%, this decrease was not found to be statistically significant. However, it was still considered clinically meaningful.
