Reference: Tzeng, H., Yin, C., & Grunawalt, J. (2008). Effective assessment of use of sitters by nurses in inpatient care settings. Journal of Advanced Nursing, 64(2), 176-183. doi:10.1111/j.1365-2648.2008.04779.x
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Purpose: To report on the evaluation of the impact of adopting the Patient Attendant Assessment Tool (PAAT) on nurses’ requests for sitters, use of restraints, and falls and fall injury rates.
\n| \n Study Design \n | \n\n Inclusion/ \nExclusion Criteria \n | \n\n Sample size/ Characteristics \n | \n\n Time Frame \n | \n\n Intervention/ Treatment \n | \n\n Measurement/ \nData Collection Methods \n | \n\n Statistics \n | \n
| \n Retrospective \nDescriptive \nCorrelation \n | \n\n In early August 2005, the study hospital started to partner with a human resource agency to fill the need for sitters \n\n Average hourly billing rate for a sitter is $13Æ91 per hour. \n\n | \n\n The frequency of each risk factor and the average score per month were abstracted from the completed PAATs. A total of 417 completed PAATs from unit 1 and 545 from unit 2 were analysed. \nBoth units had 32 bedsand a similar skill mix and staffing pattern (i.e. each unit has its own nurse manager and clinical nurse specialist). \n | \n\n August 2005 to February 2007 \n | \n\n Patient Attendant Assessment Tool (PAAT) \nInstructions for use of tool, and a list of suggested alternatives to the use of sitters (e.g. moving pt. near the staff station and providing frequent toileting). The tool includes five risk factors and a designated score for each risk. The total score was calculated by clinical nurses; a patient with a score of four or candidate for a sitter. \n | \n\n Data from three sources: \n
\n Primary outcome variables studied were (1) use of sitters; (2) number of restraints ordered and (3) total number of falls and number of falls resulting in injury per 1000 patient days. \n | \n\n SPSS \nDescriptive, independent t-tests, Pearson and Spearman correlation analyses were used (alpha value was set at \n0Æ05). Descriptive analyses (mean and standard deviations) were performed on all the study variables separately for each study unit on the data collected before and after piloting of PAAT. The independent t-tests were used to compare differences between these two study units on all study variables, using all available data points. \n | \n
| \n Results \n | \n\n Conclusions \n | \n\n Gender \n | \n||||
| \n There were 19 data points (months) for both study units. Using all available data points, independent t-tests between these two units showed that unit 1 (mean = 6Æ49) had more RN hours per patient day compared with unit 2 (mean = 6Æ02) (t = 2Æ78, P = 0Æ01). Based on the findings of the independent t-tests, there was no significant differences. \nFor unit 1, correlation analyses showed that, if the number of requests for sitters per month was higher, the total number of restraints would be lower (Pearson r = _0Æ57, P = 0Æ01). Where RN hours (Pearson r = _0Æ55, P = 0Æ02) and total nursing HPPD (Pearson r = _0Æ62, P = 0Æ01) were higher, total fall rate was lower. However, where RN hours (Spearman r = 0Æ48, P = 0Æ04) and total nursing HPPD (Spearman r = 0Æ47, P = 0Æ04) were higher, the rate of injuries from falls was higher. \nFor unit 2, where the number of sitter requests was higher, the total fall rate was higher (Pearson r = 0Æ49, P = 0Æ04). \nhe PAAT helped improve the fill/request rates for sitters. The use of soft limb holders decreased after adoption of this tool. The results also showed that if the number of sitter requests was higher, the total number of restraints would be lowerbut the total fall rate would be higher. \n | \n\n Our findings were not conclusive in terms of whether better fill/request rates for sitters would lead to fewer restraints being ordered. Moreover, a better fill/request rate did not result in a lower number of total falls and injuries from falls per 1000 patient days. Use a tool similar to PAAT. \n\n | \n\n N/A \n\n \n | \n||||
| \n Setting \n | \n||||||
| \n Two acute adult medical units of a Michigan hospitals. \n\n \n | \n
Reference: Rochefort, C. M., Ward, L., Ritchie, J. A., Girard, N., & Tamblyn, R. M. (2012). Patient and nurse staffing characteristics associated with high sitter use costs. Journal of Advanced Nursing, 68(8), 1758-1767. doi:10.1111/j.1365-2648.2011.05864.x
\nPurpose: To study of the relationships between patient health conditions, nurse staffing characteristics and high sitter use costs.
\n| \n Study Design \n | \n\n Inclusion/ \nExclusion Criteria \n | \n\n Sample size/ Characteristics \n | \n\n Time Frame \n | \n\n Intervent \n | \n\n Measurement/ \nData Collection Methods \n | \n\n Statistics \n | \n
| \n Descriptive \nCorrelation \n | \n\n Medical-Surgical patients receiving a sitter \n | \n\n cohort = 43,212 medical/surgical patients. \nAll 1151 patients who received a sitter were selected \nSitters are paid unlicensed assistive healthcare providers. \n\n They are contracted through external private agencies. \n | \n\n Admit \n2007 -2008 \n | \n\n Use of sitters \n | \n\n Four clinical and administrative databases: \nlinked by unit, patient and hospital admission date. \n
To determine the extent to which 2 conditions (Disruptive/dangerous behaviors, and falls) are associated with high sitter use costs, we used validated coding rules to create a dichotomous variable indicating the presence of one or more discharge diagnostic codes suggestive of gait and mobility impairments (Wilchesky et al. 2004). \nDuring the period of the study, the contracted hourly sitter wages, in Canadian dollars, was $15Æ50/hour. \nTo estimate the relationships between patient health conditions, nurse staffing characteristics and high sitter use costs, we created a dichotomous variable to categorize sitter use costs between high (‡$1000) and low (<$1000). This is equivalent to comparing the upper two quintiles and the bottom three quintiles of the overall sitter costs distribution. \n\n | \n\n descriptive statistics to summarize patient health conditions and nurse staffing characteristics for patients with high and low sitter use costs. \nMultivariate logistic regression enabled us to estimate the relationships of patient health conditions, nurse staffing characteristics and high sitter use costs. The outcome variable was sitter use costs, dichotomized as high (upper two quintiles) vs. low (bottom three quintiles). This model included 4 groups of explanatory variables that were entered simultaneously: (a) patient physical and mental health conditions, (b) patient demographic characteristics and comorbidities, (c) nurse staffing characteristics and (d) nursing unit characteristics. The unit of analysis was the patient hospitalization. \nRegression coefficients estimated using Generalized Estimating Equation (GEE) framework, a first order autoregressive correlation structure, as repeated hospitaladmissions for a given patient are time ordered. \n\n 95% CI \nSAS 9.2 \n\n \n | \n
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| \n Results \n | \n\n Conclusions \n | \n\n Gender \n | \n
| \n There were 1151 patients who contributed 1179 hospitalizations in the analyses (28 patients had two hospitalizations). The median sitter use cost, in Canadian dollars, was $772Æ35 \n
High risk of fall or fall-related injuries (gait and mobility impairments): \n
| \n\n The presence of dementia, delirium and other cognitive impairments and, of schizophrenia and other psychoses were each associated with an increased likelihood of high sitter use costs; falls were not associated. \n• Lower levels of worked hours per patient per day by RN and patient care assistants were each associated with an increased likelihood of high sitter use costs. \n• Higher Registered Nurses years of collective experience was associated with an increased likelihood of high sitter use costs. \nImplications for practice and/or policy: \n• Studies of interventions aimed at increasing staff knowledge and skills in caring for patients with comorbid psycho-geriatric conditions are required, and the impact of these interventions on sitter use costs should be assessed. \n• Additional studies are required to understand the mechanisms by which higher Registered Nurses years of collective experience are associated with higher sitter use costs better. \n• Further research on the impact of various nurse staffing and sitter use policies on the costs of using sitters is warranted. \nRNs are directly involved in the decisions to order and discontinue sitter use. No formal policy is available to guide these decisions. \n\n | \n\n Low Sitter Cost \nMale 457 (68%) Female 215 (32%) \n\n High Sitter Cost \nMale 330 (65.1%) Female 177 (34.9%) \n\n | \n
| \n Setting \n | \n||
| \n Academic health center, Montreal (Canada) \n | \n
Reference: Harding, A. D. (2010). Observation assistants: Sitter effectiveness and industry measures. Nursing Economic$, 28(5), 330-336.
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Purpose: To determine impact of sitters on falls etc.
\n| \n Study Design \n | \n\n Incl \nCri-teria \n | \n\n Sample size/ Charact \n | \n\n Time Frame \n | \n\n Intervention/ Treatment \n | \n\n Data Collection Methods \n | \n\n Statistics \n | \n
| \n \n Process improve-ment \n\n \n | \n\n N/A \n | \n\n The efforts of process improve- ment for sitter usage in a free- standing, 140-bedacute care hospital receiving 54,000 ER visits annually, in suburban Massachusetts \n | \n\n January 2009 \n | \n\n
| \n\n Observa-tion Assistant – Sitter Request Form \n\n | \n\n Descrip-tive \n | \n
| \n Results \n | \n\n Conclusion \n | \n\n Gender \n | \n||||
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| \n\n The sitter utilization case was unable to provide correlation of sitter use to decreased fall rates, There was no relationship between ED or inpatient volume and actual sitter use \n | \n\n N/A \n\n \n | \n||||
| \n Setting \n | \n||||||
| \n Good Samaritan Medical \nCenter, Brockton, MA. \n\n | \n
Reference: Adams, J., & Kaplow, R. (2013). A sitter-reduction program in an acute health care system. Nursing Economic$, 31(2), 83-89.
\nPurpose: To provide alternatives to sitters.
\n| \n Study Design \n | \n\n Inclusion/ \nExclusion Criteria \n | \n\n Sample \n | \n\n Time Frame \n | \n\n Intervention/ Treatment \n | \n\n Measurement/ \nData Collection Methods \n | \n\n Statistics \n | \n
| \n QI \n | \n\n The most frequentlyidentified indications for sitter use in our facility were to monitor patients with confusion/altered mental status or who were at riskto fall and those with generalized weakness. \n\n Sitters were primarily hospital employees receiving overtime pay; agency employees filled the additional perceivedneeds. \nBased on these findings, there consistent with recommendations by CMS (CMS, 2012) and the health care system's department of neurology, patients with suicide precautions, patients with mplantable devices in the neuro unit, and any pt who was required to have 1:1 monitoring by any regulatory agency (e.g., CMS who requires 1:1 observation of pts in restraints or seclusion in the absence of video monitoring) were excluded. \n | \n\n Emory \nFacilities \n | \n\n 6 mo \n | \n\n 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). \n\n Safety huddles, which are 5-10 minute meetings among the nursing staff to identify pts with any safety risk (e.g., fresh postoperative patients), were expanded to include ID of pts at risk to fall. In that way, all staff could participate in monitoring pts in their assigned area. Further, intentional hourly rounding was simultan implemented to help improve quality metrics. \n\n The charge nurse or désignée on each unit began making monthly rounds with a member of the environmental services dept. \n\n Potential hazards were corrected (i.e., towel racks, used by pt to help them lift up from commode, were moved as racks were not strong enough to support pts. weight; loose bathroom tiles and non-functioning lights were replaced; all pt call \nlights tested; toilet extenders were placed strategically so that pts would not have to sit too low, thereby making it easier for them to rise from the commode. \n\n Sitter altern equipt purchased and staff were educated on their indications for use and \nhow to obtain them. Letters sent to physicians, staff, pts, 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 \nthe elimin of sitters. The specialty director of the CSRC attended several multidisciplinary meetings (e.g., chief quality officers, \npsychiatry 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. \nSitter request form changed from paper to electronic version, which clearly delineated the criteria for sitter use. \n | \n\n 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. \n\n The team began by obtaining baseline data and answering prelim questions. \"Why do we use sitters, what was the cost, and were sitters the most efficient way to use staff?\" An average 60 ETEs were used monthly for sitters with an assoc annual cost of $1,728,000 in EY 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 # hrs each sitter was assigned. \nThe previous year's data were evaluated. \nStudy team was divided into 3 subgroups that worked on their assignments concomitantly. \n
Vendor fairs held for staff to learn about the alternat to sitters. Approx 10% of the \n3,000 members of nsg staff attended the fair and voted on which low bed they preferred. Some of alternative equipment \nthat was evaluated included low beds with alarms, activity aprons, various non-skid socks, non-skid fioor mats, bedside commode sensors, and chair alarms. Additional items evaluated included arm bands, chart stickers, and colorcoded blankets to identify highrisk \nfall 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. \nSought to eliminating unreasonable indicators for sitter use, benchmarking with Magnet®-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 \n | \n\n Cost $ \nFall rates \n(1,000 Pt Days) \n% restraint use \nBarriers \n\n | \n
| \n Results \n | \n\n Conclusions \n | \n\n Gender \n | \n||||
| \n Issues with Sitters - Review of Lit \n
tech to provide care for the entire unit of patients \n\n Emory Program \n
\n | \n\n Alternatives: \n
informing nurses of the expenses associated with the use of sitters and keeping costs at the unit level (Worley et al., 2000). \n
\n Need to surmount barriers and change culture: \nStaff reluctant to change 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. \n\n | \n\n Sitters defined “A means to provide direct observation of pts for the purpose of providing a safer environ for the patient” (Harding, 2010, p. 330). \n | \n||||
| \n Setting \n | \n||||||
| \n Emory \nHealthcare consisted of four hospitals, \nconsisting of 57 inpatient \nunits as well as multiple outpatient \nclinics. \n | \n