Nurse Rounding in the Digital World Glynda Summers Executive Director Nursing & Midwifery, Cairns & Hinterland Hospital & Health Service Christie Moon Kirsty Allwright

Technology • Cairns Hospital has deployed a digital platform to provide point of access to patient information called the Interactive Patient Station (IPS)

• The IPS is a Cybernet 22” medical grade monitor mounted on an articulating arm with medical grade washable keyboard • Staff will use this terminal to access electronic medical records, medical imaging, pathology results, internet and other clinical systems. • It seemed timely to use this portal to instigate the Nurse Rounding initiative

Technology Cybernet 22” Medical Grade Monitor and Keyboard mounted on an articulating arm

Cairns Interactive Patient Station

THE NURSE ROUNDING PROJECT

• • • •

Gr 7 Nurse as project officer Project Plan Nurse Rounding Steering Committee Regular meetings with Cairns Hospital Nursing leadership group to update

Implementation • Nurse Rounding steering committee used a 5 stage approach for implementation • Planning phase • Diagnostic phase • Education • Implementation phase and • Sustainability phase

Implementation Plan

Implementation Strategies

• Risk register • •

•

• • • • •

All risks identified on the Risk Register have mitigation strategies Staff are encouraged to express risks/issues which are then added to the risk register so that any issues are resolved or have workarounds prior to going live A lot of time has been spent discussing these risks with other hospitals around Australia to gain an insight on how they manage their issues/risks and feedback is fed back to staff to assure them of the process

Staff training on the rounding process New procedure developed In-services to raise awareness Steering committee to help reinforce the change Pre- implementation data to measure effectiveness of the Nurse Rounding procedure

Staff Questionnaire Research to evaluate best practice procedures – nursing survey Poor

Satisfactory

Good

Very Good

Rarely

Some of the time

Most of the time

All of the time

Never

Some of the time

Most of the time

All of the time

Overall job satisfaction? I feel positive about my job and work life? On the ward that you work on is there a structured rounding process that is routinely performed? You perform the following tasks when rounding: o

Asses the patient for pain?

o

Ensure the patient’s environment is safe and they have their belongings including call bell in reach?

o

Ask the patient if they require assistance with toileting?

o

Offer assistance to reposition if they are unable to do it themselves?

You routinely tell the patient when they can expect you to return to your bedside? On an average day, my workload is manageable? I have sufficient time to provide the direct care that my patient needs? This work area runs smoothly? If I received care by this nursing team, I would be happy with the standard of care provided? Patient safety behaviours are modelled by senior staff in the work area? Comments:

Nurse Rounding Rounding is defined as a ‘systematic, proactive, nurse-driven, evidence based intervention that anticipates and addresses the needs of hospitalised patients’ (Halm, M. 2009)

Halm, M. ‘Hourly Rounds: What Does the Evidence Indicate?’ American Journal of Critical Care, 2009, V8, No.6

Background • Rounding has been common practice since the Nightingale era. However, over the years, these basic processes have been largely lost. • Patient’s value the nurse-patient relationship and the time spent with nurses • Aside from improving the patient experience, the expectation is to see a marked improvement in the following indicators: oReduction in falls oReduction in hospital acquired pressure injuries oReduction in call bell usage oPatient and staff satisfaction

Pressure Injuries Reported at Cairns Hospital per 1000 Accrued Patient Days

14

Dec 14

Actua l

Prior year

Jun 15

State wide average

Falls Reported at Cairns Hospital Per 1000 Accrued Patient Days

Dec 14

Jul 14

Actua l

Prior year

Jun15

State wide average

The Rounding Process • Nurse Rounding allows staff to ask relevant questions at the bedside and log this directly into the IPS • The questions are evidence based and are designed to improve nurse sensitive indicators such as hospital acquired pressure injuries and falls. • Once the round has been completed, staff set the expectation that they will be back in an hour and confirm whether there is anything else the patient requires before leaving the room • Research suggests patients become less anxious about having their needs met as they learn to trust the process, hence reducing call buzzers.

The PEEP principle CHHHS nurse rounding steering committee decided to use the acronym PEEP in their Nurse Rounding procedure. Pain: Have you assessed your patient for pain? Elimination: Does your patient need to go to the bathroom and would or need assistance? Environment: Assess the patient is safe in their surroundings with no potential hazards and has everything they need within reach (ie. water, call bell etc) Positioning: Have you attended to pressure area care or repositioning?

Clinical Applications

Nurse Rounding on the Oneview IPS terminal

Leader Rounding • A dashboard is also displayed for staff to see ‘at a glance’ whether patients have been rounded to allow prompt response times • Timely reporting can be generated by Managers at any stage • The Dashboard can be used by team leaders to ensure everyone is participating in Nurse rounding or ‘at a glance’ if a nurse requires assistance with their workload

Leader Rounding Dashboard

Nurse Rounding Summary

What staff say…. • “A great formalised plan to ensure the basic needs of the patient are met in a timely manner” • “Most nurses already attend patient rounding in their own form one way or another, however this will help nurses with their time management and provide consistency throughout the hospital in meeting the patients needs.” • “The combination of technology and nursing allows nurses to efficiently deliver effective nursing care that involved the patient in their care during their admission”

Outcomes and Lessons Learned • Some staff resistance is inevitable as it involves a big change in the way they currently carry out their nursing practice. It involves re-training their time management skills and enforcing team nursing • Staff responded well to evidence based research as to reasons why they should be doing Nurse Rounding • Digital log ensures that staff follow the procedure correctly as they can only round on one patient at a time and they have to physically go into the patients room and log the questions to complete their round. This also ensures nurses are spending more time at the patients bedside, rather than completing documentation at nursing stations.

• Pre- implementation data showed good levels of staff job satisfaction at CHHHS. • CHHHS average response time to a call bell is remarkably good at three minutes. • Pre-implementation data showed CHHHS is above the state average for Nursing sensitive indicators in pressure injuries • Pre-implementation data showed CHHHS is below the state average for Nursing sensitive indicators in falls • With these results CHHHS will be able to use this benchmark to develop their own report to share and monitor the effectiveness of Nurse Rounding

Conclusion • The ability to deliver this strategy on a digital platform at the point of care takes nursing practice to a whole new level • An innovative clinical initiative which allows nurses to provide basic nursing care proactively rather than reactively • Added advantage of improving key nurse sensitive indicators