Implementing and sustaining evidence-based practices in long-term care.

Improving fall prevention and skin integrity with purposeful rounding at St. Andrew’s Terrace

By: Leah Mackay, RPN, Resident Care Coordinator, Quality & Education; Brandi-May Kitchen, Quality Personal Support Worker; Shaila Aranha, RN, MScN, RNAO LTC Best Practice Coordinator, Waterloo Wellington Region.

St. Andrew’s Terrace, Cambridge

St. Andrew’s Terrace had a high number of falls and pressure injuries in 2017. The percentage of residents who fell in the last 30 days was 20.5 per cent and 5.1 per cent of residents had new or worsening pressure injuries (PI). The home was above the provincial benchmark for falls (16.4 per cent) and skin (2.7 per cent). Preventing falls and PI’s became the priorities in the home’s Quality Improvement Plan.

Leah Mackay, the Resident Care Coordinator for Quality and Education and Brandi Kitchen, the Quality Personal Support Worker (PSW) took the lead. They consulted Shaila Aranha and decided to implement the Registered Nurses’ Association of Ontario’s (RNAO) best practice guideline (BPG) on Preventing Falls and Reducing Injury from Falls, 4th edition (2017).

Leah and Brandi decided to work with other LTC homes in the regional Community of Practice (CoP) on falls prevention and management. The falls CoP learning sessions gave them a better understanding on how to reduce falls in their home. They did the RNAO Best Practice Champions e-learning series and joined the Champions Network.

Through funding from the LTC Best Practices Program, Leah attended the RNAO Nursing BPG Clinical Institute. She learned more about BPG implementation and how to sustain change.

With support from Shaila, in March 2018, the team reviewed their falls prevention program. Using a gap analysis, they identified their goals and developed an action plan. The team found that one intervention could address both their increased falls and skin breakdown. This was “purposeful rounds,” an approach in which staff checks residents every hour or two. In these rounds, staff asks about the “4P’s” - personal care needs, possessions, positioning and pain.

The team wrote an action plan with key tasks:
1. Develop a list of residents who were at high risk and could benefit from the rounds
2. Revise PSW assignments to enable them to conduct the rounds.
3. Educate all staff, residents and families on purposeful rounding.
4. Expand the rounds to include other team members across the home and family members.
5. Document the rounds with the Point of Care (POC) electronic documenting system and high risk binders
6. Evaluate purposeful rounds monthly

The purposeful rounds started across all four resident home areas in May 2018. Rounding was tried first, with residents were at high risk for falls and skin breakdown. Rounds were conducted every two hours on the odd hours of each shift.

The PSW’s assignment was changed. The old “3 + 1 PSW’s” plan split the work with three PSW’s assigned to residents on the floor and one PSW on baths only. The new assignment had the four PSW’s on the floor each assigned to eight residents. Both the residents and staff benefited from this approach. Residents were able to have the same PSW more often. PSW’s work assignments for resident care could be shared evenly. 

Monthly reviews of resident care plans for those screened as high risk for falls and skin breakdown took place. The intervention of purposeful rounds was added to the care plan. It became a routine practice for high-risk residents.

Ten high risk binders were placed across the home to improve communication - resident home areas, front office, volunteer’s office, life enrichment, kitchen, rehab room, and RN office. This helped everyone to become aware of the residents at high risk for falls and skin breakdown. It ensured use of the safety equipment for that specific resident.

The monthly review of the resident’s care plans, revision of PSW’s assignments for purposeful rounds, updating PSW documentation in POC, and having high risk binders with lists of current residents who had high-risk conditions were all effective strategies. Requiring all staff to have education was a key strategy. New staff received training during the monthly orientation day. 

Family members were engaged in this process. They received education of purposeful rounds and used the “4P’s” questions while visiting. Families shared the results of their rounds with staff members. They felt good about being part of rounding and liked knowing that their loved ones were safe and their needs were met.

The quality team leads gave kudos to recognize team members who did purposeful rounding completely and on time. The project did have a few challenges. Audits of some assignments showed that purposeful rounds were not done as expected. Nursing management helped to address this issue. They identified team members who had reoccurring incidents of incomplete rounding. Nursing managers gave coaching and feedback to these staff.

Purposeful rounding was a great success. It helped to provide a positive environment within the home. The falls and PI rates improved. The percentage of residents with new or worsening pressure injuries decreased to 4.3 per cent in 2018. With falls, the percentage of residents who fell in the last 30 days has steadily declined to 16.9 per cent. The home continues to monitor and refine its strategy.

- About St Andrew’s Terrace LTC Community
St. Andrew’s Terrace is a 128-bed long-term care home located in Cambridge, in the Waterloo Wellington region.

PDF: Improving fall prevention and skin integrity with purposeful rounding at St. Andrew’s Terrace