EBP Analysis

A Call Light Responsiveness Program
Maya Shamailov, MSN, APRN, AG-CNS, PCCN; Suzanne Neal, BSN, RN, CMSRN;
James F. Bena, MS; Shannon L. Morrison, MS;
Nancy M. Albert, PhD, CCNS, CHFN, CCRN, FAAN
Background: Purposeful hourly rounding and information on whiteboards in patients’ rooms have been
known to reduce use of call lights.
Problem: Call light activation was higher than desired.
Methods: This continuous improvement initiative used retrospective data collection (pre-, early- and
maintenance postintervention) to assess call light responsiveness.
Intervention: A bundled purposeful hourly rounding approach was used.
Results: Call light frequency was higher in the early postintervention period than in the preintervention; how-
ever, there was no change in the frequency of call lights that extended beyond 5 minutes. In the maintenance
postintervention period, compared with the pre- and early postintervention periods, call lights per patient/unit
day and call lights extending beyond 5 minutes per patient/unit day decreased (all P < .001). Conclusions: Activation of a bundled purposeful hourly rounding approach was associated with a decrease in all call lights and call lights extending beyond 5 minutes per patient/unit day. Keywords: call lights, communication, hourly rounding, patient-centered care, whiteboards When hospitalized, a patient’s experience isa sum of their interactions with clinical nursing teams and medical outcome. In 2 sys- tematic reviews1 ,2 and a report of best practice,3 hourly rounding was a surrogate for nurse communication and nurse responsiveness. Pur- poseful hourly rounding by nursing personnel traditionally includes 4 Ps: pain, personal needs, positioning, and possesions.3 ,4 Many hospital units endorse hourly rounding as a best practice to reduce call light usage and increase quality of care.1 ,5 Author Affiliations: Office of Advanced Practice Nursing (Ms Shamailov), Bariatric and Metabolic Surgery Unit (Ms Neal), Quantitative Health Sciences (Mr Bena and Ms Morrison), and Office of Nursing Research and Innovation (Dr Albert), Cleveland Clinic, Cleveland, Ohio. We thank Jennifer E. King, BSN, RN, nurse manager, for her full support of this initiative during all phases of development and implementation, and Kevin Gazley, MBA, senior continuous improvement specialist, who guided the team through the change process. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Maya Shamailov, MSN, APRN, AG-CNS, PCCN, 2070 East 90th St, P32, Cleveland OH 44195 (shamaim@ccf.org). Accepted for publication: August 3, 2020 Published ahead of print: September 17, 2020 DOI: 10.1097/NCQ.0000000000000517 A call light system is the primary method of patient-nurse communication in a hospital set- ting, and is often used as a metric of nurse responsiveness.6 Reasons for calls included a need for assistance or medications, to initiate communication with the nurse, and to meet the needs of patients who have other requests.6 In a qualitative study on patients’ perceptions of using call lights, researchers believed that call lights were part of a system of care; in other words, call lights were not to be considered a de- vice; rather, call lights were a way to assure care connections.6 However, call lights can create un- necessary noise for clinicians and patients, that when mitigated could improve patient satisfac- tion with care. Further, when call lights are acti- vated, they create an audible signal that provides a cue to nursing personnel to take action. When nursing personnel respond to call light needs that could have been addressed in a systematic way during rounds, they create a disruption in the care needs and priorities of other patients and in the general workflow. Purposeful hourly rounding programs may use protocols; however, there is no one standard- ized best practice beyond programs that uses the 4 Ps,3,4 and in a systematic review program features and interventions had heterogeneity.1 Thus, there was not one best practice available to guide nursing personnel in action steps to reduce call light use. Within the Digestive Disease and Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. J Nurs Care Qual • Vol. 36, No. 3, pp. 257–261 • Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.jncqjournal.com 257 mailto:shamaim@ccf.org 258 A Call Light Responsiveness Program Journal of Nursing Care Quality Surgery Institute, the call light system was pre- viously set to maintain a blinking light until the system was deactivated in patient rooms. Nurs- ing practice stipulated that call lights were deac- tivated after patients’ needs were met. Prior to this intervention, factors associated with timely call light responsiveness were assessed. When summarizing patients’ rationale for call light ac- tivation, 80% of calls were related to needing items, toileting, pain management, and alarm- ing intravenous (IV) pumps. Institute leaders be- lieved that nonadherence to hourly rounding and inconsistent use of communication boards (whiteboards) were issues that affected call light responsiveness. The purpose of this continuous improvement initiative was to enhance nursing responsiveness to patients’ needs, as determined by call light activity, using a bundled intervention approach. The specific aims were to decrease the total number of calls and the number of calls that extend beyond 5 minutes. METHODS This continuous improvement initiative was con- ducted at a large, urban quaternary care med- ical center in the Midwest United States. The site was a bariatric medical-surgical unit that had 10 private rooms. The patient population was predominantly patients who were recover- ing from bariatric surgery; however, when other units within the Institute were full, overflow was accepted on this unit. The initiative outcomes in- volved retrospective data collection of call light activity during 3 periods: pre- (planning phase), early postperiod, and maintenance postinterven- tion period. Interventions Based on previously assessed patient needs and using an hourly purposeful rounding framework, interventions were developed beyond the 4 Ps. First, when rounding, nurses updated the pa- tient whiteboard that included names of care providers and the plan for the day. Second, a fifth “P,” for pump, was added to proactively assess IV pump, IV solution, and IV site status and take actions to prevent an alarm. Third, a designated break room was provided that allowed nurses to take a break and be considered off-unit. The des- ignated break room facilitated nursing personnel presence on the unit when not taking a formal break, thus enhancing unit presence and serving to increase responsiveness to call lights. In ad- dition, unit presence enhanced visibility of nurs- ing personnel to patients, and facilitated meeting patients’ needs preemptively. The final interven- tion component was the creation of a recogni- tion board that acknowledged nursing personnel teamwork. Nursing personnel, including leader- ship, could recognize colleagues for their efforts in hourly rounding and call light responsiveness. Gift cards were delivered to one distinguished team member each month during the interven- tion period, and they were recognized on the board (name and photograph). Data collection By day, the total of all call lights activated was re- trieved from the call light monitoring system re- port. The call light monitoring system report also provided the length of time the call light was acti- vated. Two coauthors manually counted all calls that exceeded 5 minutes in length. Data were en- tered into an Excel spreadsheet designed for this initiative by 2 of the coauthors. Data collection was completed over a 10-month period in 2018. The initiative preintervention data collection be- gan on January 15 and continued through April 16. The early postintervention period was initi- ated on April 17 and continued until July 16. The maintenance postintervention period initiated on July 17 and continued until November 16, 2018. Statistical analysis Categorical measures were described using fre- quencies and percentages, and the relationship between time and categorical variables was assessed using Pearson’s χ 2 tests. Normally dis- tributed continuous variables were described us- ing means and standard deviations, and the rela- tionship between time and normally distributed continuous variables was assessed using analysis of variance tests. Nonnormally distributed con- tinuous variables were described using medians and quartiles, and the relationship between time and normally distributed continuous variables was assessed using Kruskal-Wallis tests. Poisson regression was used to compare call light rates between periods. In these models, the number of days in the unit was used as an offset to allow calculation of the rate per unit day. Relative risks with 95% confidence intervals (CIs) are presented. Analyses were performed using SAS Software (version 9.4; Cary, North Carolina). Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. July–September 2021 • Volume 36 • Number 3 www.jncqjournal.com 259 RESULTS In total, 530 consecutive patients were as- sessed during the 3 assessment periods: 156 dur- ing the preintervention period, 145 during the early postintervention period, and 229 during the maintenance postintervention period. The pre- and early postintervention periods were 3 months in length, and the maintenance postinter- vention period was 4 months in length. Of pa- tients, mean (standard deviation) age was 49.5 (14.2) years, and 71.5% of patients were female. There were no differences in patient characteris- tics and surgical procedure themes based on time (see Supplemental Digital Content Table 1, avail- able at: http://links.lww.com/JNCQ/A766). The number of call lights during each period varied. Call light use increased in the early post- intervention period, compared with the preinter- vention period; preintervention, 6538 calls/156 patients (41.9 calls/patient and 11.51 calls/ unit day) and early postintervention, 7282 calls/145 patients (50.2 calls/patient and 12.53 calls/unit day); relative risk (95% CI) = 1.08 (1.05-1.12), P < .001 (Figure 1 and see Sup- plemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767). However, in the maintenance postintervention period, call lights were reduced by 13% and 20%, respec- tively, relative to the pre- and early postinter- vention periods, 9082 calls/229 patients (39.6 calls/patient and 10.07 calls/unit day) (Supple- mental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767, includes the relative risks). Overall, there was a decline in the volume of call lights that were activated and remained acti- vated for over 5 minutes before nursing person- nel responded. The number of calls/unit day that exceeded 5 minutes decreased dramatically dur- ing the maintenance postintervention assessment period compared with the early postintervention assessment period; relative risk reduction was 32% (95% CI, 0.60-0.76); P < .001. By the numbers, the changes during the 3 assess- ment periods were 3.7 calls/patient or 1.03 calls/unit day pre-, 4.0 calls/patient or 1.01 calls/unit day early post-, and 2.7 calls/patient or 0.69 calls/unit day in the maintenance postintervention period (Figure 2 and see Sup- plemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767). DISCUSSION In this continuous improvement initiative, the bundled 4-component intervention to reduce call light activation by patients was successful. The interventions reduced call lights/patient and call lights greater than 5 minutes/patient when the early postintervention periods were compared with the maintenance postintervention periods; however, there was an increase in call light activ- ity when pre- and early postintervention periods were compared. Since hospitalized patients had similar characteristics at all 3 assessment periods, patient factors were not likely to be the reason for our reductions in call light activity. Although we do not have a clear rationale for an increase in Figure 1. Number of call lights activated per patient/day during each assessment period. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. http://links.lww.com/JNCQ/A766 http://links.lww.com/JNCQ/A767 http://links.lww.com/JNCQ/A767 http://links.lww.com/JNCQ/A767 260 A Call Light Responsiveness Program Journal of Nursing Care Quality Figure 2. Number of calls/unit day that exceeded 5 minutes. call light activity early after initiative implemen- tation, we believe that adoption of the bundled intervention took time to diffuse into everyday practice. Few reports in the literature discussed the effect of hourly rounding on call light use. Using a quasiexperimental design, an hourly round- ing intervention decreased 6-month call light use among the experimental group, compared with a usual care group; however, in the 6 months following the end of the data collec- tion period, there were no longer differences between groups.5 In another study, call light responsiveness did not differ between pre- and postintervention groups that were assessed 3 months apart.3 In the final study, the author provided a table that reflected that call light use trended lower at 9 months after initiat- ing hourly rounding4; however, no inferential statistics were provided to substantiate findings. Our call light activity/patient was significantly reduced over time, especially from the 3-month early postintervention data collection period to 7 months after the bundled intervention was introduced. It may be that the combination of a whiteboard that facilitated plan of care communication between patients and nurses, purposeful hourly rounding that included the fifth P, use of a designated break area that en- sured nurse visibility and presence on the unit when not on a break, and a recognition program was superior to initiatives that only focused on 1 intervention, especially in relation to sustaining outcomes. Of the bundled intervention components, use of a patient whiteboard has been discussed in the health care literature. In 1 report, patients’ ability to remember their provider’s name and satisfaction with care improved when a vi- sual tool, specifically a whiteboard, was used.7 Whiteboards allow for transparency in commu- nication and individualization, both of which support patient-centered care8 and facilitate agreement of goals of care between providers (nurse caregiver, attending physician, nurse prac- titioner, or fellow).9 Whiteboard communication improved teamwork and supported interpro- fessional communication,8 possibly because messages were updated and displayed in loca- tions that fostered reading. The full potential and efficacy of whiteboards as a means of enhancing responsiveness has not been examined.8 Further, no literature was available that assessed the association between use of whiteboard messages and call light activation. Whiteboard use may be enhanced when there are established unit-based guidelines and best practices for content and for review and updates. Limitations There were some limitations to this continuous improvement initiative. Data were assessed on 1 specialty unit of single center in a Midwest hospital, and involved a small number of care- givers. The population was younger than global medical-surgical patients treated in many adult hospitals. It is possible that the younger patient population may have had less (or more) needs Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. July–September 2021 • Volume 36 • Number 3 www.jncqjournal.com 261 requiring call light responses. The bundled inter- vention may be more difficult to sustain than an intervention with 1 component. Sites with a cul- ture of responsiveness that differs from ours and those without diffusion plans, quality improve- ment leader monitoring, or evaluation of out- comes may have a difficult time with systematic uptake and utilization of the interventions. CONCLUSIONS Total number of call lights and call lights with response time that extended beyond 5 minutes were reduced after introducing a bundled ap- proach that included 3 interventions: purposeful hourly rounding using 5 Ps and whiteboard com- munication, designation of an employee break room, and a unit-based employee recognition program. It is unknown which components of the intervention were most powerful, or if the combination of all components prompted im- provements in call light outcomes. REFERENCES 1. Mitchell MD, Lavenberg JG, Trotta R, Umscheid CA. Hourly rounding to improve nursing responsiveness: a systematic re- view. J Nurs Adm. 2014;44(9):462-472. doi:10.1097/NNA. 0000000000000101 2. Sims S, Leamy M, Davies N, et al. Realist synthesis of in- tentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why. BMJ Qual Saf. 2018;27(9):743-757. doi:10.1136/bmjqs- 2017-006757 3. Daniels JF. Purposeful and timely nursing rounds: a best prac- tice implementation project. JBI Database System Rev Imple- ment Rep. 2016;14(1):248-267. doi:10.11124/jbisrir-2016- 2537 4. Brosey LA, March KS. Effectiveness of structured hourly nursing rounding on patient satisfaction and clinical out- comes. J Nurs Care Qual. 2015;30:153-159. doi:10.1097/ NCQ0000000000000086 5. Krepper R, Vallejo B, Smith C, et al. Evaluation of a standard- ized hourly rounding process (SHaRP). J Healthc Qual. 2014; 36(2):62-69. doi:10.1111/j.1945-1474.2012.00222.x 6. Montie M, Shuman C, Galinato J, Patak L, Anderson CA, Titler MG. Conduits to care: call lights and patients’ percep- tions of communication. J Multidisc Healthc. 2017;10:359- 366. doi:10.2147/JMDH.S144152 7. Pimentel VM, Sun M, Bernstein PS, Ferzli M, Kim M, Goffman D. Whiteboard use in labor and delivery: a tool to improve patient knowledge of the name of the delivery provider and satisfaction with care. Matern Child Health J. 2018;22(4):565-570. doi:10.1007/s10995-017-2425-6 8. Cholli P, Meyer EC, David M, et al. Family perspectives on whiteboard use and recommendations for improved practices. Hosp Pediatr. 2016;6(7):426-430. doi:10.1542/hpeds.2015- 0182 9. Justice LB, Cooper DS, Henderson C, et al. Improv- ing communication during cardiac ICU multidisciplinary rounds through visual display of patient daily goals. Pedi- atr Crit Care Med. 2016;17(7):677-683. doi:10.1097/PCC. 0000000000000790 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Student Name: EBP Journal Article in APA format: Is this an Evidence Based Article? Name of Journal and Year article was written? Yes/No Name of Journal Year: .2 points State the problem What was the goal of the project in the article? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal? Problem: Goal: State how this article correlates with your group problem and goal. .2 points Strengths (Internal) What’s was good about your article? Why was this project successful? List attributes of the article, i.e. support from administration, councils, colleagues, institutions. Did this implementation take place on a unit or area like yours? .4 points Weakness (Internal)- issues Example: lack of education, lack of staffing, staff readiness, lack of support; size, managerial style. .4 points Opportunities (External) Example: Lack of supplies, educationalneeds, stakeholders, baseline (your baseline data), what needs to be improved? .4 points Threats - (External) Staff buy in, support, limitations and barriers, supply cost, cost of implementation, time, money, realistic? .4 points Total Points = 2 points

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