This past year, the CUSP Team of B5, led by CUSP Champion Olivia Casaletto, RN, initiated a remarkably successful project that had an incredibly positive impact on the patients and nursing staff of B5, thanks to all the hard work of the B5 Nursing Team.

To understand the magnitude of the success, we must touch on the background of this project. In 2023, B5 had a total of 41 patient falls for the year. By July of 2024, there were already 40 falls for the year, with a rate of 5.7 falls per month. This led to an investigation into how to address this growing safety concern. It was identified in baseline data that 48% of falls occurred between 0300 and 1100 on Monday through Friday. There was also an average of 50.35 call lights that rang during that same time period. It was also identified that some of the reasons B5 could have an increased fall rate were due to patient needs not being met, an inconsistent use of fall prevention supplies, and a lack of employee education on fall prevention.

Our goals with this project implementation were to decrease the number of falls between 0300 and 1100 by 50% and decrease call light use by 25% between 0300 and 1100. The main strategy of the project was to implement purposeful Enhanced Safety Rounding (ESR) between 0300 and 1100, rounding on the 45-minute mark of every hour starting at 0245 until 1045. In these rounds, both the RN and the NA were to round together and assess the 4 P’s of patient needs: Pain, Personal Needs, Positioning, and Personal Items. After completing the rounding, the staff would then sign off on a sheet that was in each of the rooms to state that the rounding for that hour was completed. In addition to the ESR, staff members also received education on fall prevention, post-fall care and documentation, and the ESR process. Unit leadership also worked with Supply Chain to ensure an adequate stock of fall prevention supplies so staff would have the proper tools in place to help ensure patient safety.

Since the project’s roll out, B5 had both a 72% decrease in falls and a 34% decrease in call light usage in the time frame assessed. Both outcomes have exceeded the project goals set. This is a direct reflection of the entire nursing team stepping up and embracing the project as a team and always attempting to execute the ESR to the best of their abilities, even on the busiest of shifts, to ensure the promotion of patient safety. This project has by far had a significantly positive impact on patients, not only reflected in the data but also in patient feedback. Patients and families have shared positive comments regarding how well they feel looked after. They shared that they often felt like they were having their needs addressed before they were sometimes even aware of the need themselves, and felt reassured in knowing someone would always be coming back to check on them. One of the comments from a patient to a member of the leadership team was “With your staff, I have never felt alone or forgotten”.

While this nurse-driven project was initially rolled out to improve patient safety, we have also seen benefits for our Nurses and Nurse Assistants alike. All staff have benefited from the decrease in call light usage, as well as developed a newfound sense of teamwork and team building between the two roles on the unit. It promoted coordination of care and an increase in communication between nurses and nursing assistants in order to best meet the needs of all patients. While this rounding was only completed between 0300 and 1100, both shifts implemented their enhanced teamwork across their entire shift every day, not just during the time of the safety rounding.