Creative Nursing, Volume 19, Issue 3, 2013

PATIENT SAFETY
Hourly Rounding for Falls Prevention:
A Change Initiative
Daryl Dyck, RN, MN (CNS)
Tracy Thiele, RPN, BScPN, MN
Rodney Kebicz, RN, MN (CNS)
Michelle Klassen, RN
Carly Erenberg, BMR-PT

Fall-related injuries are a particular concern within the elderly population, and trends
toward an aging demographic will keep this issue at the forefront in health care. We are
challenged to develop creative strategies to significantly reduce harm and fall rates among
the elderly. This article describes the process of establishing an hourly rounding initiative
in a health care facility. Hourly rounding is supported by the literature as an effective
strategy for falls prevention and patient safety. When the initiative was not successfully
adopted initially, the implementation process was critically examined and an innovative
sustainability plan was developed to ensure that the change would be embedded in the
organizations culture. Through this opportunity, nurses and allied health members from
all levels were able to collaborate on strategies for this patient safety initiative.

n health care, change is inevitable. Whether it is a modification in practice policy

or a change in our patients health, change encompasses various aspects of the
health care profession. Nurses today need to collaborate creatively with an interprofessional team to effect change to ensure best practice.
Falls and fall-related injuries are of particular concern within the elderly population, and it is challenging to develop creative programs and strategies that significantly reduce rates of these events. Deer Lodge Centre (DLC), a 431-bed long-term,
chronic care, and geriatric rehabilitation facility in Winnipeg, Canada, began instituting a falls prevention program in 2007. By 2012, this multifaceted program consisted
of several components including routine screening of all new patients for fall risk
factors; adoption of a standardized assessment tool to be completed within 48 hours
of admission; establishment of clinical practice guidelines; distribution of falls and
fall-prevention equipment algorithms; and the provision of mandatory falls education for nurses and health care aids. This program resulted in a downward trend in
the overall fall rate for 5 consecutive years. In spite of this positive trend, it was felt
that there was an opportunity to further reduce fall and injury rates.

STATEMENT OF PROBLEM
Fall reduction programs require multiple components and a multidisciplinary
approach to be able to succeed (Becker & Rapp, 2010; Szczerbinska, Zak, &
2013 Springer Publishing Company
http://dx.doi.org/10.1891/1078-4535.19.3.153

Daryl Dyck, RN, MN,

(CNS), is a Clinical
Nurse Specialist at
Deer Lodge Centre in
Winnipeg, Manitoba,
Canada.

Tracy Thiele, RPN,

BScPN, MN, is the
Manager of Nursing
Initiatives at the Winnipeg Regional Health
Authority in Winnipeg,
Manitoba, Canada.
153

Rodney Kebicz, RN,

MN, (CNS), is a Clinical Nurse Specialist at
Deer Lodge Centre in
Winnipeg, Manitoba,
Canada.

Michelle Klassen, RN,

is a Unit Manager in
Long-term Care at
Deer Lodge Centre in
Winnipeg, Manitoba,
Canada.

Carly Erenberg, BMRPT, is a Physiotherapist at Deer Lodge

Centre in Winnipeg,
Manitoba, Canada.

iomkiewicz, 2010). Hourly rounding has been identified as an effective falls

Z
reduction strategy in acute care settings (Meade, Bursell, & Ketelsen, 2006; Meade,
Kennedy, & Kaplan, 2010; Woodard 2009); however, there is a paucity of literature
discussing this intervention in long-term care settings. In 2010, DLC attempted to
establish an hourly rounding program but was unable to either fully integrate or
sustain the program. A second attempt to introduce hourly rounding reexamined the
intervention and implementation process to develop a creative sustainability plan to
ensure that the change would become embedded in the organizational culture.

ESTABLISHING THE CHANGE INITIATIVE

The hourly rounding program was originally trialed on a single nursing unit at
DLC in 2010. During this time, two members of the projects nurse working team
attended leadership training sessions through the Dorothy Wylie Nursing/Health
Leaders Institute in Toronto, Canada. This institute brings together interprofessional health care leaders from across Canada with the purpose of building leadership skills that can assist in bringing about successful change initiatives. The
Institutes leadership principles helped to clarify the process for initiating and
establishing our hourly rounding project. The institute emphasized the importance of team building, empowering the team to make change happen, nurturing
vision, engaging the stakeholders, and managing the project as a team.
At that time, DLCs definition of hourly rounding referred to periodic and frequent patient checks as a means of assessing and addressing fall risk behaviors
related to toileting, comfort, and positioning needs. An hourly rounding logo was
designed to be placed at the bedside (see Figure 1).
A tracking sheet was developed and was used for all patients who were considered at high risk for falls, whether falling or not. These high-risk patients were
identified through the use of our validated Falls Risk Assessment Tool, which is
still in use.
Establishing a shared vision and achieving full adherence to the protocol
were the main challenges in our first attempt, and although we gathered a team
of influential nursing members, we neglected to include interprofessional stakeholders. Compounding the sustainability challenges, we were not able to realize
consistently improved outcomes (i.e., decreased falls) for the trial unit as promised;
therefore, the decision was made not to go center-wide. In 2011, the challenge of

Figure 1. Deer Lodge Centre Hourly Rounding Logo.

154

Dyck et al.

Rodney Kebicz, RN,

MN, (CNS), is a Clinical Nurse Specialist at
Deer Lodge Centre in
Winnipeg, Manitoba,
Canada.

Michelle Klassen, RN,

is a Unit Manager in
Long-term Care at
Deer Lodge Centre in
Winnipeg, Manitoba,
Canada.

Carly Erenberg, BMRPT, is a Physiotherapist at Deer Lodge

Centre in Winnipeg,
Manitoba, Canada.

iomkiewicz, 2010). Hourly rounding has been identified as an effective falls

Z
reduction strategy in acute care settings (Meade, Bursell, & Ketelsen, 2006; Meade,
Kennedy, & Kaplan, 2010; Woodard 2009); however, there is a paucity of literature
discussing this intervention in long-term care settings. In 2010, DLC attempted to
establish an hourly rounding program but was unable to either fully integrate or
sustain the program. A second attempt to introduce hourly rounding reexamined the
intervention and implementation process to develop a creative sustainability plan to
ensure that the change would become embedded in the organizational culture.

ESTABLISHING THE CHANGE INITIATIVE

The hourly rounding program was originally trialed on a single nursing unit at
DLC in 2010. During this time, two members of the projects nurse working team
attended leadership training sessions through the Dorothy Wylie Nursing/Health
Leaders Institute in Toronto, Canada. This institute brings together interprofessional health care leaders from across Canada with the purpose of building leadership skills that can assist in bringing about successful change initiatives. The
Institutes leadership principles helped to clarify the process for initiating and
establishing our hourly rounding project. The institute emphasized the importance of team building, empowering the team to make change happen, nurturing
vision, engaging the stakeholders, and managing the project as a team.
At that time, DLCs definition of hourly rounding referred to periodic and frequent patient checks as a means of assessing and addressing fall risk behaviors
related to toileting, comfort, and positioning needs. An hourly rounding logo was
designed to be placed at the bedside (see Figure 1).
A tracking sheet was developed and was used for all patients who were considered at high risk for falls, whether falling or not. These high-risk patients were
identified through the use of our validated Falls Risk Assessment Tool, which is
still in use.
Establishing a shared vision and achieving full adherence to the protocol
were the main challenges in our first attempt, and although we gathered a team
of influential nursing members, we neglected to include interprofessional stakeholders. Compounding the sustainability challenges, we were not able to realize
consistently improved outcomes (i.e., decreased falls) for the trial unit as promised;
therefore, the decision was made not to go center-wide. In 2011, the challenge of

Figure 1. Deer Lodge Centre Hourly Rounding Logo.

154

Dyck et al.

establishing this new program was brought to another forum (DLCs Clinical Education Committee) to discuss how we might try again.
Seeking expertise in falls prevention, we joined the Registered Nurses Association of Ontarios Falls Facilitated Learning Series (FFLS) program. At our site, an
interprofessional team consisting of an occupational therapist, a physiotherapist,
unit managers, clinical nurse specialists, and a data specialist was established to
reexamine our hourly rounding process. Our new team saw the value of running a
second trial on two different nursing units whose managers were members of the
team. A second trial would allow us to identify changes or processes that needed
to be considered. Participating in the FFLS provided our group with feedback,
valuable insight, and support in addressing our implementation challenges.
We realized that we needed to promote the idea that hourly rounding was more
than just a quick check to make sure the patient is breathing and has not fallen.
Through education, stakeholder involvement, and early adopters modeling the
way, hourly rounding was promoted as a proactive falls prevention strategy with
the goal of decreasing falls and, more importantly, as a means of promoting patient
safety, health, and comfort. Part of the difficulty in our first trial was convincing
staff to share the vision that hourly rounding would create a win-win situation for
them (e.g., Fewer falls equals less work) and most importantly for their patients.
Sustainability of the initial hourly rounding pilot relied on convincing the staff
that the initiative would consistently produce positive results; when the results
were not consistent, maintaining excitement for the new intervention was difficult.
A crucial aspect that was underused during our first attempt was the opportunity
to share, celebrate, and showcase the hard work and achievements related to the
project. The sharing of success stories through a variety of avenuespersonally
between managers and staff during shift report and staff meetings, with the plan
of ongoing quarterly fall rate statistic reviewswas encouraged.
Another challenge was determining who was responsible for performing the
hourly rounding. The initial trial designated specific hours throughout the day,
evening, and night shifts for which either the health care aide or nurse would be
responsible. This highly structured format was not sustainable; therefore, in the
new version, staffs on each unit were made responsible for designing their own
schedules, allowing for flexibility and adjustments to respond to what might be
happening on the unit. This fostered ongoing, collaborative conversations between
team members involved with each patients care.
The tools we had initially developed were reexamined and revised. The hourly
rounding guide targeted the areas of comfort, positioning, and toileting (Meade
etal., 2006; Meade et al., 2010; Woodard, 2009). Included in the revised guide were
examples of the types of observations that should be made when entering the
room and examples of questions that could be asked to address potential needs.
The guide also reminded staff to reassure the patient that staff would be back
in an hour to check on them. As Florence Nightingale stated, Apprehension,
uncertainty, waiting, expectation, fear of surprise, do a patient more harm than
any exertion . . . always tell a patient and tell him beforehand when you are going
out and when you will be back (Dover Publications, 1969, p. 38).
Our tracking form that was to be completed after each round, noting whether
an intervention of toileting, positioning, or comforting had taken place, was revised to make it easier to complete. In the second trial, we encouraged staff input
into the design of the tracking form and clarified that rounding did not have to
take place exactly on the hour, but could be done simultaneously with other tasks.

Hourly Rounding for Falls Prevention

Through
education,
stakeholder
involvement, and
early adopters
modeling the
way, hourly
rounding was
promoted as a
falls prevention
strategy with
the goal of
decreasing
falls and, more
importantly,
as a means of
promoting patient
safety, health,
and comfort.

155

A crucial
aspect that was
under-utilized
during our first
implementation
attempt was
the opportunity
to share,
celebrate, and
showcase the

Thisflexible approach was designed to promote more consistent documentation,

thus allowing for ongoing evaluation.
Our previously designed falls logo (see Figure 1) that highlighted the three
aspects of hourly rounding was retained. Initially, the logo was placed in a less
visible area in the patients room because of concerns for privacy and confidentiality. In our second trial, the logos were placed outside the patients rooms,
providing quick identification of those patients who were on the hourly rounding program. The hourly rounding intervention was added to our Falls Protocol
Algorithm poster (see Figure 2), which was distributed to each unit.

DEER LODGE CENTRE: FALLS PROTOCOL ALGORITHM

hard work and

Patient / Resident admitted to DLC (Rehab / Chronic Care / PCH / Day Hospital)

achievements

Initiate Routine Practice for Falls Prevention

related to the

project.

F amily to provide fall history

A ssessment of needs and abilities
L ook at environment / hazards
L ying / standing BP
S how surroundings and orientate

i t i on i n g
Pos

rti

ng

i le

tt i n

C o mf o

12

To

Initiate Hourly Rounding on admission for 72 hours

Falls Risk Assessment Tool (FRAT) is administered

(On admission)

High Risk
(Note as Focus problem)

Provide High Risk Decal

Low / Medium Risk

If resident falls after admission 

High Risk
(Re-do FRAT)

Consult:
Physician prior & new medical problems, medications, orthostatic hypotension
Physiotherapy mobility / gait aids / transfers
Occupational Therapy equipment / wheelchair
Pharmacy medication review
Nutrition services nutrition / hydration
Consider:
Falls Equipment (refer to Falls Equipment Selection Algorithm Form # CL0262-W)

Refer to Falls Assessment and Management Regional Clinical Practice Guidelines.

Interventions / Care Plan should address Risk Factors identified on FRAT Tool
Reassess need for Hourly Rounding after 72 hours

Review Interventions / Care Plan regularly: after a fall; at Post Admission Conference;
at Inter-Disciplinary Quarterly Team meetings.
(Hint optional: Regardless of fall risk, re-doing the FRAT prn or quarterly may be helpful)

Figure 2. Falls Protocol Algorithm.

156

Dyck et al.

Hourly rounding was also discussed at team meetings, and a survey requesting feedback on the program was solicited from staff members of the two new
trial units. Involving frontline staff at the developmental stage had been important in our first trial and was essential in our new approach. The interprofessional
working group also chose to recognize the hard work of staff in the development
and trial process by providing small snacks and cards of thanksvital factors in
the success of the program.
Having sufficient resources is part of the solution to issues of sustaining
change. We had the full support of senior management for this effort. The centers
data analysis department also provided invaluable support. For example, the inclusion of data on key metrics such as falls per unit per 1,000 patient bed days,
monthly rates, and falls on admission benefited the working group and provided
an opportunity to share with staff the progress of their efforts. Falls data also assisted our working team in identifying a target population for the intervention.
In our first attempt, we identified all patients who were at high risk for falls as
the patients who would benefit from hourly rounding, but this proved to be too
unwieldy. There were just too many patients to be rounding on properly every
hour. In our second approach, we initially looked at a subpopulation that was at
highest risk for falls and who had fallen at least once in the past month, thinking
this would be a more manageable and important group to monitor. However, statistics from one of our trial units indicated that one-third of their new admissions
had a fall within their first week of hospitalization. Therefore, we decided that
each individual arriving at our facility, regardless of risk, would receive hourly
rounding during the first 72 hours, after which reassessment would determine
whether hourly rounding would continue. In addition, any patient deemed by
the health care team to benefit from hourly rounding would also be assigned this
intervention.
Finally, to introduce the program to the whole center, a professionally produced 6-minute video, Hourly Rounding: A Falls Prevention Strategy, was rolled
out during a lunch time spectacularcomplete with red carpet and popcorn
(thevideo is available for viewing through the DLC Web page at http://www
.deerlodge.mb.ca/edFallsPrevention.html). The involvement of staff actors engaged the staff watching the clip and generated a lot of energy and excitement.
Scenes portrayed in the video included examples of appropriate and inappropriate rounding and a cameo by Florence Nightingale discussing the virtues of
rounding. Units were provided with an accompanying folder containing a copy
of the video, logos, and examples of good rounding. Viewing the video and signing the education attendance record consumed approximately 10 minutes; staff
emphatically concurred that this was a reasonable time frame to easily accommodate into their work day.

In the second
trial, we clarified
that rounding did
not have to take
place exactly
on the hour, but
could be done
simultaneously
with other tasks.

EVALUATION
A staff survey was distributed and results were used as a learning tool for the
hourly rounding working group. The survey addressed items such as whether
staff felt the hourly rounding process prevented falls. One-to-one progress checks
during the trial assessed staff perceptions of the effectiveness of hourly rounding. The interprofessional working group members participated in these progress
checks as a collaborative approach to program evaluation. Progress checks also

Hourly Rounding for Falls Prevention

157

An encouraging
finding was
that staff had
begun initiating
the program for

monitored completion rates of the hourly rounding tracking forms. An encouraging finding was that staff had begun initiating the program for patients whom they
thought would benefit from rounding without having been instructed to do so
a sign that the program was finding its way into the organizational culture. This
was a valuable indicator of staff engagement and awareness of the hourly rounding initiative as an effective harm reduction tool.

patients whom
they thought
would benefit
from rounding
without having
been instructed
to do so a sign
that the program
was finding its
way into the
organizational
culture.

CONCLUSIONS
Hourly rounding is not a new concept, but the creativity that was employed in
reimplementing it at DLC made it a highly anticipated intervention. The overarching innovative strategy was the way in which our working group revisited
and addressed the various aspects of our previously failed attempt at establishing hourly rounding by using new approaches to develop a sustainable program.
Wedetermined that the key factors in developing a sustainable program included
allowing sufficient preparation time,
soliciting assistance from experienced organizations,
fostering interprofessional collaboration,
adopting a creative approach to implementation, and
engaging staff throughout the process.
An early result from one of our trial units has shown a reduction in fall rates.
Ultimately, the sustainability question will be answered over time.

REFERENCES
Becker, C., & Rapp, K. (2010). Fall prevention in nursing homes. Clinics in Geriatric Medicine,
26(4), 693704.
Dover Publications. (1969). Notes on nursingWhat it is and what it is not by Florence
Nightingale. New York, NY: Author.
Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds on patients
call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 5870.
Meade, C. M., Kennedy, J., & Kaplan, J. (2010). The effects of emergency department staff
rounding on patient safety and satisfaction. The Journal of Emergency Medicine, 38(5),
666674.
Szczerbinska, K., Zak, M., & Ziomkiewicz, A. (2010). Role of method of implementing
multi-factorial falls prevention in nursing homes for elderly personsThe EUNESE
project. Aging Clinical & Experimental Research, 22(3), 261269.
Woodard, J. L. (2009). Effects of rounding on patient satisfaction and patient safety on a
medical-surgical unit. Clinical Nurse Specialist, 23(4), 200206.

Correspondence regarding this article should be directed to Daryl Dyck, RN, MN, (CNS), at ddyck2@
deerlodge.mb.ca

158

Dyck et al.