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A sitter-reduction program in an acute health care system.

KEEPING PATIENTS SAFE IS AN ominous responsibility for health care providers (Jaworowski et al., 2008; Worley, Kunkel, Gitlin, Menefee, & Conway, 2000) and failure to do so can find hospitals in legal battles (Worley et al., 2000). Legal settlements in the millions of dollars have been reported (Fiesta, 1991; Worley et al., 2000). Hospitals across the country are trying to provide safe and cost-effective health care with quality outcomes. Mission statements of health care organizations, including those that appear on the Internet, consistently include these goals. Nursing wants to be recognized for obtaining quality outcomes while protecting patients from harm (American Nurses Credentialing Center, 2011).

The term "sitters" has been defined as "a means to provide direct observation of patients for the purpose of providing a safer environment for the patient" (Harding, 2010, p. 330). The use of sitters or companions for continuous patient observation has been commonplace in acute care facilities (Salamon & Lennon, 2003). The main reasons cited for use of sitters include prevention of patient fails (Massachusetts Organization of Nurse Executives [MONE], 2009) and patient harm or self-mutilation (Badger, 1995; Lamdan, Ramchandani, & Schindler, 1996; Moore, Berman, Knight, & Devine, 1995; Salamon & Lennon, 2003; Santulli & Oxman, 1995). Patients with specific symptoms or conditions were also provided with sitters to help protect them from harming themselves or others. These include patients with hallucinations (Blumenfield, Milazzo, & Orlowski, 2000; Lamdan et al., 1996; Moore et al., 1995; Santulli & Oxman, 1995), agitation (Blumenfield et al., 2000; Jaworowski et al., 2008; Lamdan et al., 1996), psychosis (Goldberg, 1989), physical aggression (Badger, 1995; Lamdan et al., 1996; Moore et al., 1995; Santulli & Oxman, 1995), confusion, disorientation, or delirium (Badger, 1995; Jaworowski et al., 2008; Santulli & Oxman, 1996), and suicidal ideation (Blumenfield et al., 2000; Jaworowski et al., 2008; MONE, 2009; Salamon & Lennon, 2003; Santulli & Oxman, 1995; Worley et al., 2000). In addition, patients at risk of harming others (MONE, 2009; Worley et al., 2000); at risk for removal of lines, catheters, devices, or equipment (MONE, 2009); or those in restraints (Blumenfield et al., 2000) were provided a sitter. A patient might be assigned a sitter to mitigate the application of restraints (Lamdan et al., 1996; Salamon & Lennon, 2003).

Other reported indications for use of sitters include psychiatric or substance abuse sequela (Goldberg, 1989; Talley, Davis, Giocoechea, Brown, & Barber, 1990; Torkelson & Dobal, 1999; Worley et al., 2000), seizure disorders, use of mechanical ventilation, and eating disorders (Worley et al., 2000). As many as 480 sitters are used annually in hospitals (Blumenfield et al., 2000; Goldberg, 1987; Lamdan et al., 1996; O'Dowd, Freedman, Bernstein, Ricco, & McKegney, 1995).

Concerns Regarding Sitter Programs

Despite potential benefits of a sitter program related to patient safety, its use is of concern to hospital administrators and clinicians alike (Blumenfield et al., 2000). The primary concern associated with sitter programs is the associated significant cost (Blumenfield et al., 2000; MONE, 2009; Salamon & Lennon, 2003; Worley et al., 2000). Exact costs of sitter programs are not attainable as they are typically encompassed within personnel and overtime budgets (Blumenfield et al., 2000; Goldberg, 1989; Moore et al., 1995). Costs estimates of sitter programs range from $1,000 to $240,000 annually per hospital with an average of $51,800 (Blumenfield et al. 2000; Goldberg, 1987). In another study, the cost of a sitter program in three hospitals ranged from approximately $233,000 to $581,000 (Lamdan et al., 1996; Moore et al., 1995; O'Dowd et al., 1995). Others have reported estimated costs of their sitter program to be $565,370 (Worley et al., 2000).

Compounding the cost problem is the limited coverage by payers; a case-by-case analysis is typically employed (Torkelson & Dobal, 1999). In one report, when payers did not cover the cost of sitters, 59% of the time hospitals bared the expense; in 29% of the cases, hospitals and families shared the expense (Goldberg, 1987). Of further note, despite use of sitters to help prevent patient self-harm, this outcome has not been demonstrated in the literature (Jaworowski et al., 2008).

Alternatives to the Use of Sitters

Based on the expense associated with sitter programs, a number of alternatives to maintain patient safety have been suggested in the literature. These include use of personal alarms (Jaworowski et al., 2008; Salamon & Lennon, 2003; Santulli & Oxman, 1995; Torkelson & Dobal, 1999), diversional activities (Salamon & Lennon, 2003); placing patients in public places (e.g., the nurses' station) (Salamon & Lennon, 2003; Worley et al., 2000), family support (Goldberg, 1989; Jaworowski et al., 2008; Torkelson & Dobal, 1999; Salamon & Lennon, 2003; Worley et al., 2000), video monitoring (Jaworowski et al., 2008), implementation of relaxation techniques (Salamon & Lennon, 2003), toileting scheduling (Salamon & Lennon, 2003; Worley et al., 2000), treatment of pain (Salamon & Lennon, 2003), wrapping of intravenous lines (Salamon & Lennon, 2003), bed enclosure devices (Salamon & Lennon, 2003; Worley et al., 2000), seclusion (MONE, 2009; Salamon & Lennon, 2003), physical or chemical restraints (Fulop & Strain, 1986; MONE, 2009; Salamon & Lennon, 2003; Torkelson & Dobal, 1999), relocating the patient's room closer to the nurses' station (Salamon & Lennon, 2003), frequent observation (Heyman & Lombardo, 1995; Torkelson & Dobal, 1999), construction of "safe rooms" (Fiesta, 1991; Goldberg, 1989; Torkelson & Dobal, 1999), and use of volunteers (Jaworowski et al., 2008; Lamdan et al., 1996; Torkelson & Dobal, 1999). The decision of what strategies are indicated should be based on multidisciplinary collaboration and thorough knowledge of the patient, etiology of the patient's behavior, staffing, and unit design (Torkelson & Dobal, 1999).

Implementation of programs to minimize the use of sitters has resulted in significant cost savings for facilities. In one study, $340,000 annual savings was reported (MONE, 2009). It has been suggested costs can be reduced by informing nurses of the expenses associated with the use of sitters and keeping costs at the unit level (Lipkis-Orlando, Mian, Levy, & Lussier-Cushing, 1993; Worley et al., 2000).

Local Problem

In trying to address these national mandates for high value care in our organization, we reviewed interventions in the published literature that could be applied in our local setting to save money without negatively impacting patient safety. As we began to collect data to reduce pressure ulcers, restraint use, and falls, we looked at the interventions used to ensure optimal patient outcomes in these areas.

One intervention explored was "sitter" usage. In our facility, this was an opportunity for savings. We asked: "Did sitter usage add value to our outcomes?" The chief nursing officer charged nursing leadership to develop a program to reduce sitter usage without negatively impacting select quality indicators: falls, restraints, and pressures ulcers.

Intended Improvement

At the time we were planning to reduce sitter use, Emory Healthcare consisted of four hospitals, consisting of 57 inpatient units as well as multiple outpatient clinics. The four hospitals were Emory University Hospital (EUH), a 579-bed university teaching facility; Emory University Hospital Midtown, a 511-bed urban, tertiary care facility; Wesley Woods Geriatric Center (WWGC), which also handles long-term acute care patients; and the Emory University Orthopedic and Spine Hospital (EUOSH). EUH cares for oncology, transplant, pulmonary, inpatient psychiatry, clinical rehabilitation, and cardiothoracic patients. There are over 100 intensive care unit beds including surgical, medical, cardiovascular and coronary care, and neurology. The WWGC is divided into four units totaling approximately 100 beds: long-term acute care (LTAC), geriatric psychiatry, neuropsychiatry, and chronic and acute rehabilitation. Finally, EUOSH has approximately 100 beds devoted to the care of orthopedic and spinal surgery patients.

Methods

The study team was multidisciplinary in order to adequately address concerns and to get buy-in from the outset. Initially the team included staff nurses, physical therapists, sitters, nursing supervisors, risk management, and clinical nurse specialists. Later, internists, surgeons, psychiatrists, patient and family advisors, and members from the human resources department were added. All members were individually invited to participate by the specialty director of the Clinical Staffing Resources Center (CSRC).

Indications for the use of sitters in the facility were the same as those previously reported in the literature. The most frequently identified indications for sitter use in our facility were to monitor patients with confusion/altered mental status or who were at risk to fall and those with generalized weakness. On the hematology unit, patients who were thrombocytopenic and at risk to bleed were also provided with sitters. In some cases, sitters were requested by the nursing staff to "give the tired family members a break" or to mitigate call light use by patients who were afraid to be alone in a room.

During leadership rounding by the specialty director of CSRC where sitters were in place, it was learned patients and families were under the mistaken impression that if you wanted a sitter at our facility, one would be provided and paid for. At times, family members were found visiting with the patient an entire shift while a sitter was present. In one instance, on a 16-bed unit, there were four sitters provided, leaving one nurse tech to provide care for the entire unit of patients. Sitters were primarily hospital employees receiving overtime pay; agency employees filled the additional perceived needs.

Based on these findings, there was significant room for improvement in our processes for allocation of sitters. A goal was set to reduce sitter use by 50% across the health care system in 1 fiscal year without significant negative impact on quality. Consistent with recommendations by the Centers for Medicare & Medicaid Services (CMS, 2012) and the health care system's department of neurology, patients with suicide precautions, patients with implantable devices in the neurology unit, and any patient who was required to have 1:1 monitoring by any regulatory agency (e.g., CMS who requires 1:1 observation of patients in restraints or seclusion in the absence of video monitoring) were excluded.

Ethical Issues

Our primary concern with sitter reduction was patient safety. Safety huddles, which are 5-10 minute meetings among the nursing staff to identify patients with any safety risk (e.g., fresh postoperative patients), were expanded to include identification of patients at risk to fall. In that way, all staff could participate in monitoring patients in their assignment area. Further, intentional hourly rounding was simultaneously implemented to help improve quality metrics.

Setting

Environmental concerns were identified that could potentially increase the patient's risk of falls. The charge nurse or designee on each unit began making monthly rounds with a member of the environmental services department. Potential hazards were corrected. For example, towel racks, used by patients to help them lift up from the commode, were moved as the racks were not strong enough to support patients' weight. In addition, loose bathroom tiles were replaced, non-functioning lights were replaced, and all patient call lights are tested. Toilet extenders were placed strategically so that patients would not have to sit too low, thereby making it easier for them to rise from the commode.

Planning the Intervention

The team began by obtaining baseline data and answering preliminary questions. "Why do we use sitters, what was the cost, and were sitters the most efficient way to use staff?." An average 60 FTEs were used monthly for sitters with an associated annual cost of $1,728,000 in FY 2009; this included agency usage. These data were collected from electronic staffing software. This database includes rationale for each sitter assigned to a unit and the number of hours each sitter was assigned. The previous year's data were evaluated.

The study team was divided into three subgroups that worked on their assignments concomitantly. One subgroup evaluated possible alternative strategies and equipment available to help with sitter use reduction; another subgroup worked to develop communication to the staff and physicians; and one subgroup developed communication of this change for patients and families. This latter group invited patient family advisors to provide feedback on the initiative itself and the letters to patients and families that were drafted. Vendor fairs were coordinated and held for staff to learn about the alternatives to sitters. Approximately 10% of the 3,000 members of the nursing staff attended the fair and voted on which low bed they preferred. Some of alternative equipment that was evaluated included low beds with alarms, activity aprons, various non-skid socks, non-skid floor mats, bedside commode sensors, and chair alarms. Additional items evaluated included arm bands, chart stickers, and color-coded blankets to identify high-risk fall patients. The equipment selected for initial implementation were the low beds, chair alarms, activity aprons, arm bands, and non-skid socks based on tests of change that were initiated on select units with positive outcomes.

Simultaneous processes entailed eliminating unreasonable indicators for sitter use, benchmarking with Magnet[R]-designated hospitals to determine their strategies for keeping patients safe without sitters, and partnering with the information technology department to automate the sitter ordering process so usage and compliance with the new sitter guidelines could be tracked.

Sitter-Reduction Program Description

Once all of the subgroups' goals were attained, an effective "sitter stop" date was determined. Sitter alternative equipment was purchased and staff were educated on their indications for use and how to obtain them. Letters were sent to physicians, staff, patients, and families regarding the policy change surrounding sitter use. Communication was sent to the staff, physicians, patients, and families. All policies and related documents were revised to reflect the elimination of sitters. The specialty director of the CSRC attended several multidisciplinary meetings (e.g., chief quality officers, psychiatry consultants, nurse executive team, nursing leadership), and nursing unit practice councils to communicate this change. Despite initial skepticism by nursing staff, sitter use was eliminated (except for those predetermined cases) on the set date. The final implementation step involved a multidisciplinary process of changing the sitter request form from paper to an electronic version, which clearly delineated the criteria for sitter use. A goal to reduce sitter use by 50% in 1 fiscal year without significant negative impact on quality was set across the health care system.

Results

Over a 6-month period, sitter use dropped appreciably (see Figure 1). This reduction has been maintained to date. The change translates to an estimated savings of $1.2 million annually, with an agency savings of nearly $400,000 in 1 year (see Figure 2). The estimated cost savings includes monies spent on equipment as they are all patient charges.

At the time of the change, approximately 50 positions for nurse techs were posted on the job board across the health care system. In addition, there were approximately 40 sitters in need of a new position. Staff from the human resources department were invited to guide us in revising the sitter's job description to facilitate a transition from sitter to the nurse tech role. A number of the sitters were already certified nursing assistants. These new nurse techs transferred into vacant budgeted positions, meaning there was no unanticipated increase in payroll expense for the organization. (The sitter role was a non-budgeted position.) The role change to nurse tech translated into a small pay increase (approximately 2%-3%) for many of the sitters who now had increased job responsibilities. A few sitters opted to retire instead of assuming the nurse tech role.

Quality metrics are evaluated on an ongoing basis. To help mitigate any associated increase in falls or restraint use, volunteers were solicited to serve as falls champions on each unit. They meet monthly to evaluate specifics related to falls on their units and strategies to reduce fall rates. Patients at risk for falls are identified on the units at daily huddles allowing staff members to conduct more frequent rounding on patients who are at risk. The severity of injury rate from a fall decreased; the falls rate has not increased since the sitter-reduction program was implemented in April 2010 (see Figure 3). In fact, the current falls rate is the lowest it has been in the past 2 years. Restraint use continues to meet target metrics despite elimination of sitters (see Figure 4).

Throughout the change process, a number of barriers were identified that needed to be removed to ensure the attainment of desired outcomes. Some of the barriers encountered were related to creating a change in culture. Staff anticipated approval of a sitter for almost any reason. Despite discussions with staff, many remained reluctant to changing the sitter policy. Staff needed time to become comfortable using and trusting the alternative strategies, which included use of the new equipment. For example, despite attendance at vendor fairs, some nurses

would initially order a sitter despite the patient being placed in a low bed, which contained bed alarms. Staff from risk management were also reluctant to eliminate use of sitters for fear of being libel for injury for patients at risk for falls. However, the rate of serious injury related to falls is meeting target. One by one, the barriers of eliminating use of sitters are being eliminated. The next steps include continued monitoring and educating staff and system-wide implementation of intentional rounding to include scheduled toileting. At present, the intentional rounding process includes offering to assist patients to and from the bathroom. Scheduled toileting is currently being piloted on select units.

One of the lessons learned from this process was the importance of physician leadership buy-in from the outset. After being assured patients will be kept safe without the use of sitters, members of physician and nursing leadership partnered to craft the message to providers so they would more readily accept the elimination of sitters.

Conclusion

The goal of this program was to decrease the use of sitters without significant negative impact on patient falls and restraint use. Maintaining quality while being financial stewards is essential in today's health care climate (Salamon & Lennon, 2003). Sitter use was reduced by more than 50%. The quality metrics are monitored monthly.

The most difficult challenge associated with this practice change was shifting the mindset of the nursing staff. Ordering a sitter for any patient situation out of the ordinary was no longer an option. Staff were surprised to learn that presence of a sitter did not necessarily translate into a decrease in falls or other quality metrics. Rather, it was the intentional presence of the nursing staff that was pivotal to the successful reduction in sitter use.

REFERENCES

American Nurses Credentialing Center. (2011). Announcing the model for ANCC's Magnet Recognition Program[C]. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model.aspx

Badger, J. M. (1995). Reaching out to the suicidal patient. Nursing, 95, 24-32.

Blumenfield, M., Milazzo, J., & Orlowski, B. (2000). Constant observation in the general hospital. Psychosomatics, 41, 289-293.

Centers for Medicare & Medicaid Services (CMS). (2012). Regulations and guidance/transmittals. Retrieved from http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R37SOMA.pdf

Fiesta, J. (1991). Liability issues: Patients with psychiatric problems. Nursing Management, 22(9), 14, 17.

Fulop, G., & Strain, J. (1986). Psychiatric emergencies in the general hospital. General Hospital Psychiatry, 8(6), 425-431.

Goldberg, R.J. (1987). Use of constant observation with potentially suicidal patients in general hospitals. Hospital & Community Psychiatry, 38(3), 303-305.

Goldberg, R.J. (1989). The use of constant observation in general hospitals. International Journal of Psychiatry in Medicine, 19(2), 193-201.

Harding, A.D. (2010). Observation assistants: Sitter effectiveness and industry measures. Nursing EconomicS, 28(5), 330-336.

Heyman, E., & Lombardo, B. (1995). Managing costs: The confused, agitated, or suicidal patient. Nursing Economic$, 13(2), 107-118.

Jaworowski, S., Raveh, D., Lobel, E., Fuer, A., Gropp, C., & Mergui, J. (2008). Constant observation in the general hospital: A review. Israel Journal of Psychiatry and Related Sciences, 45(4), 278-284.

Lamban, RM., Ramchandani, D., & Schindler, B.A. (1996). Constant observation in a medical-surgical setting. The role of consultation-liaison psychiatry. Psychosomatic& 37(4), 368-373.

Lipkis-Orlando, R., Mian, P., Levy, G., & Lussier-Cushing (1993). Challenge for the 90s: A safe and cost-effective sitter program. MEDSURG Nursing, 2(6), 483-485.

Massachusetts Organization of Nurse Executives (MONE). (2009). Strategies to minimize the use of sitters. Retrieved from http://www.patientcarelink.org/uploadDocs/1/MONE_SitterSummaryFINAL.pdf

Moore, P., Berman, K., Knight, M., & Devine, J. (1995). Constant observation: Implications for nursing practice. Journal of Psychosocial Nursing, 33(3), 46-50.

O'Dowd, M.A., Freedman, J.B., Bernstein, G., Ricco, P., & McKegney, F.P. (1995). Reduction in use of constant observation in the general hospital and cost savings as a result of quality improvement monitoring. Psychosomatic& 36, 189-190.

Salamon, L., & Lennon, M. (2003). Decreasing companion usage without negatively affecting patient outcomes: A performance improvement project. MEDSURG Nursing, 12(4), 230-236.

Santulli, R., & Oxman, T. (1995). The bed enclosure device: An alternative to physical restraints for the agitated elderly. Psychosomatic& 36, 190-191.

Talley, S., Davis, D., Giocoechea, N., Brown, L., & Barber, L. (1990). Effect of psychiatric liaison nurse specialist consultation on the care of medical-surgical patients with sitters. Archives of Psychiatric Nursing, 4(2), 114-123.

Torkelson, D.J., & Dobal, M.T. (1999). Constant observation in medical-surgical settings: A multihospital study. Nursing EconomicS, 17(3), 149-155.

Worley, L.L.M., Kunkel, E.J.S., Gitlin, D.F., Menefee, L.A., & Conway, G. (2000). Constant observation practices in the general hospital setting. Psychosomatics, 41, 301-310.

ADDITIONAL READINGS

Boswell, D.J., Ramsey, J., Smith, M.A., & Wagers, B. (2001). The cost-effectiveness of a patient-sitter program in an acute care hospital: A test of the impact of sitters on the incidence of falls and patient satisfaction. Quality Management in Health Care, 10(1), 10-16.

Lawrence, P., Lindsay, C., Kirkpatrick C., Feign, H., Murdoch, H., & Martin, L. (1991). Caring for the suicidal patient. Nursing, 91(7), 60-63.

Executive Summary

> Maintaining quality while being financial stewards is essential in today's health care climate.

> One strategy considered effective for keeping patients safe is the use of sitters.

> However, research supporting the effectiveness of this intervention for reducing certain patient safety outcomes is limited.

> A sitter-reduction program in one hospital resulted in $1.2 million in annual savings without negatively impacting fall rates.

> The intentional presence of the nursing staff was pivotal to the successful reduction in sitter use.

ADAMS, MSN, RN, FNP, is Specialty Director, Clinical Staffing Resource Center, Emory University Hospital, Atlanta, GA.

ROBERTA KAPLOW, PhD, RN, AOCNS, CCNS, CCRN, is Clinical Nurse Specialist, Inpatient Oncology, Emory University Hospital, Atlanta, GA.


Figure 1.
Sitter Utilization Trends

Sitter Utilization - Agency and Hospital Staff

         Sep     Oct     Nov     Dec     Jan     Feb

FY09    72.4    49.3    65.8    66.5    59.7    54.2
FY10     51      64      53     48.6    36.2    27.6
FY11    15.8    19.8    18.8    18.6    20.1    13.3

         Mar     Apr     May     Jun     Jul     Aug

FY09    49.3    48.8    58.2     57      50      52
FY10    20.7    13.42   21.9     14      11     22.1
FY11    12.1    21.7    16.7    14.9    11.1

NOTE: Hospital staff denotes any staff assigned as a sitter
for the shift.

Figure 2
Cost Savings Associated with Sitter-Reduction Program

Agency Sitter Expenditure

FY09   $477,561.86
FY10   $91,991.27

Note: table made from bar graph.
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Author:Adams, Jewel; Kaplow, Roberta
Publication:Nursing Economics
Geographic Code:1USA
Date:Mar 1, 2013
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