ASSIGNMENT: PREVENTING PATIENT FALLS

ASSIGNMENT: PREVENTING PATIENT FALLS

ASSIGNMENT: PREVENTING PATIENT FALLS

PREVENTING PATIENT FALLS is a challenge for all health care organizations. Patient falls in the adult population carry a heavy financial burden and a significant cost in human suffering. Falls in the acute care setting cause additional morbidities, are associated with psychosocial trauma, and increase mortality risk for older adults (Tideiksaar 2010). In the hospital setting, 9%- 15% of falls result in injury (Tideiksaar 2010). According to the Centers for Disease Control and Prevention (CDC, 2013), the financial cost of a fall with injury in an older adult is estimated at $17,500. In response to these risks, nurses often turn to 1:1 patient companions as an intervention to prevent falls (Rochefort, Ward, Ritchie, Girard, & Tamblyn, 2012). Because of the expense of 1:1 patient companions, remote video monitoring has become an attractive option to reduce falls as it allows one telesitter to observe and verbally redirect multiple patients from a remote location.

The specific aim of this study was to evaluate the effectiveness of remote video monitoring with a dedicated telesitter in order to reduce falls, as well as to reduce patient companion usage in the inpatient adult population.

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Literature Review Patient companions are a costly fall-prevention intervention with equivocal results. Many organizations have implemented strategies to decrease patient compaNion usage without any significant change in fall rates (Adams & Kaplow, 2013; Laws & Crawford, 2013; Salamon & Lennon, 2003; Spiva et al., 2012). Harding (2010) reflected on the use of physical sitters to decrease falls. They were unable to provide correlation of sitter use to decreased fall rates, elopement, or assault behaviors. Harding (2010) summarized there was currently no research to sug-

EXECUTIVE SUMMARY With increasing acuity and simultaneous pressures for optimal productivity, reducing unnecessary patient compan- ions has been a focus for many health care organizations. At the same time, nursing lead- ers are seeking to accelerate improvement in patient safety, specifically the prevention of falls. This study suggests the use of remote video monitoring is a safe tool for fall prevention. While there was a decrease in 1:1 sitter usage, there was no corollary increase in falls. In fact, falls decreased 35%. Not only was video monitoring a safe intervention, it was more effective than patient compan- ions alone in decreasing falls by expanding the number of patients who are directly observed 24/7.

Lisbeth Votruba Bridget Graham Jeana Wisinski

Ayesha Syed

Video Monitoring to Reduce Falls And Patient Companion Costs

For Adult Inpatients

BRIDGET GRAHAM, MSN, RN-BC, CNL, is Clinical Nurse Leader, Senior Adult Unit, Mercy Health Saint Mary’s, Grand Rapids, MI.

JEANA WISINSKI, BSN, RN, is Clinical Nurse, Intensive Care Unit; Rapid Response Team Nurse; and Falls Committee Member, Mercy Health Saint Mary’s, Grand Rapids, MI.

AYESHA SYED, BSN, RN-BC, is Clinical Nurse, Senior Adult Unit, and Falls Committee Member, Mercy Health Saint Mary’s, Grand Rapids, MI.

LISBETH VOTRUBA, MSN, RN, was a Clinical Nurse Specialist and Magnet® Program Director, Mercy Health Saint Mary’s, Grand Rapids, MI, at the time this article was written. She is currently Vice President of Quality Control and Innovation, AvaSure, LLC, Belmont, MI.

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gest the use of constant observa- tion reduces the risk of patient harm related to risk for falling or other harm.

Although there has been little peer-reviewed research on the effectiveness of video monitoring for patient safety, several organiza- tions have published or presented quality improvement data on the success of remote video monitor- ing in their institutions for reduc- ing falls and patient companion costs. A video surveillance system that successfully reduced falls was featured in a practice brief pub- lished by the Advisory Board (2009). Another hospital featured video monitoring to decrease sit- ters as one of its top 10 most cre- ative nursing ideas for the year in its annual report for nursing (University of Utah Health Care 2012). Briggs and Steele (2007) concluded video monitoring would not only improve out- comes, but would also save money directly, lower legal costs, and improve patient satisfaction. The authors found that during their trial of video monitoring at night- time hours, not a single patient on video monitoring experienced a fall. Due to this success, they expanded the program to 24 hours a day and experienced one fall during the first year of video mon- itoring. One New Orleans hospital turned to video monitoring to relieve a staffing crisis in the wake of Hurricane Katrina (Goodlett, Robinson, Carson, & Landry, 2009). Researchers found the use of video monitoring could be an acceptable alternative to 1:1 patient companions in reducing falls in hospitalized patients. The cost analysis also supported the utilization of video monitoring, showing it allowed the facility to reduce its sitter cost from $960/day for four patients to $240/day for four patients.

Methods Study design. The intervention phase of this prospective, descriptive study took place over

a 9-month period. During the intervention phase, a dedicated tele- sitter was added to the central monitoring unit (CMU) 24/7 to observe up to 12 patients at high risk for falls in three adult inpatient units as an alternative to using a patient companion. The telesitter workstation was located in the CMU, at a workstation adjacent to the hospital’s two current cardiac monitor technicians (CMTs).

During previous construction projects, 92 non-recording cam- eras were mounted in the ceilings of all inpatient rooms of three inpatient units (AvaSure®, LLC, Belmont, MI). To protect patient privacy, the video cameras were non-recording. In addition to the cameras, infrared lighting was installed for better night vision, as well as speakers and microphones to allow for two-way communica- tions between the patient and tele- sitter. The number of patients actively monitored was limited to 12. This allowed the telesitter to focus on a limited number of patients and to visualize them eas- ily on the three viewing screens, which were each split into four quadrants.

Protocols. Protocols were cre- ated for the telesitter to utilize when determining how to react to potential patient falls and other safety concerns. The telesitter was responsible for responding to patients attempting to stand or get out of bed by verbally redirecting them via the microphone. If this was unsuccessful, the telesitter would contact the primary nurse via the personal communication device. A second responder, often a patient care assistant (PCA), was identified at the beginning of each shift for the telesitter to contact if the primary nurse did not respond immediately. When a patient was in imminent danger of falling, the telesitter remained in constant verbal contact with the patient while directing one or both of the adjacent CMTs to contact the patient’s nurse and/or PCA.

When admitting a patient to video monitoring, the primary nurse communicated to the tele- sitter the reason the patient need- ed monitoring, including fall risk, safety of medical equipment, elope ment risk, and potential for seizure. This communication also included why the patient was at risk for falls: mobility problems, strength or balance deficits, cogni- tive impairment, problems with elimination, and/or a history of falls. For patients with communi- cation difficulties, severe confusion, or delirium, the nurses could request the telesitter not commu- nicate via microphone with the patient, but to directly contact the nurse first.

Training. An 8-hour training day was provided for the telesit- ters that included the three domains of adult learning: cogni- tive, affective, and psychomotor (Bastable & Doody, 2008). These individuals were educated on the importance of fall prevention, which was emphasized through pa tient examples. They also learn – ed adherence to the study proto- col, including documentation. Lastly, they learned the necessary psychomotor skills by role-play- ing, including hands-on use of the technology. Training was provid- ed to charge nurses during month- ly charge nurse meetings and clin- ical nurses during monthly staff meetings.

Setting. This research study took place in a 350-bed urban, not- for-profit, Magnet®-designated hos – pital. The intervention took place in three inpatient, adult units including a critical care/interme- diate unit, a neuroscience unit, and a senior adult unit. Approval was obtained from the institution- al review board to conduct the research with a waiver of consent. Consent for video monitoring was included in the organization’s gen- eral consent for treatment.

Selection criteria. All adult patients admitted to one of the three study units during the inter- vention stage were eligible to be selected for video monitoring with

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the exception of those meeting exclusion criteria. Patients with behavioral restraints and those at risk for harm to self or others were excluded from the study.

Selection criteria were created by a small workgroup consisting of two staff nurses, a clinical nurse specialist and a clinical nurse leader. The group reviewed litera- ture on the identification of fall risk and created algorithms that were individualized to each unit’s unique patient population. This tool assisted the charge nurses in identifying the patients most at risk for falls. Although the Morse Fall Scale is utilized in this insti- tution, it was too sensitive to nar- row down to the 12 patients most at risk for a fall. Fall history was considered a strong risk factor (Oliver, Daly, Martin, & McMurdo, 2004). Other variables that impact patients’ judgment and impulsivi- ty were also considered; confusion is identified by a positive Con fusion Assessment Method (Katzman, Brown, Fuld, Schechter, & Schimmel, 1983), and culprit drugs were identified by the Beers criteria (Beers, 1997). As alcohol with- drawal can be a significant cause for impulsivity and confusion, the Clinical Institute Withdrawal As – sessment (CIWA) score (Hingson & Howland 1987; Puz & Stokes, 2005) was used as well.

Sample. During the 9 months of the intervention period, there were 5,041 discharges from the study units. A total of 828 unique adult patients were monitored dur- ing 992 video monitoring episodes. A portion of the 828 patients had more than one episode of monitor- ing. This would occur as nurses were attempting to wean patients off 1:1 patient companions or were utilizing family to help monitor patients for safety. This left 4,213 adult inpatients who did not meet criteria and were not monitored on video.

Data collection. Baseline data were collected in the 9 months prior to the intervention phase of this study on the three study

units. The baseline data included falls per discharge and the number of 1:1 patient companion hours per month. A fall was defined as an unplanned descent to the floor with or without injury. During the 9 months of the intervention phase while video monitoring was in progress, data on falls per dis- charge and 1:1 patient companion hours continued to be collected. In addition, the telesitters kept paper logs recording the patients monitored, admission date, time to video monitoring, discharge date, and reason(s) the patient was monitored. They also logged their interventions, which included verbal redirections via micro- phone to the patients and calls to care providers on their personal communication devices regarding patients’ behavior.

Data analysis. Most data were analyzed using simple descriptive statistics, except the change in falls was also analyzed with paired t- test using a 95% confidence inter- val.

Results The number of falls decreased

significantly from 85 to 53 (p< 0.0001, 95% CI) comparing 9 months of baseline data to 9 months of intervention data on the three units. Table 1 demonstrates the overall decrease of patient falls including all adult inpatients on the three study units; those who were video monitored and those who were not. This represented a 35% decrease in falls. Of the 828 patients selected for video moni- toring, 13 (1.6%) experienced a fall. During the same time period

there were 40 falls (1.7%) among the 4,213 adult patients admitted who were not selected for video monitoring. Patient companion hours decreased 10% from an average of 1,930 hours per month to an average of 1,735 hours per month during the study period.

The average length of time for each video monitoring event was 2.5 days. The length of time on video ranged as high as 28 days.

Telesitters redirected patients via the microphone 5,413 times (an average of 10 times per shift) during the study. They made 5,880 calls to caregivers (an aver- age of 11 per shift) during the same time period.

Findings. The most compell – ing outcome was the 35% reduc- tion in falls when comparing the baseline data from the 9 months prior to the intervention to the 9- month intervention phase where video monitoring was used. However, a comparison of the fall rate of the selected patients to the non-selected patients during the intervention phase is also interest- ing. During the intervention phase, 16% (828) of the patients were selected by charge nurses for video monitoring. Although they were identified as higher risk for falls, the fall rate among patients selected for video monitoring (1.6%) was actually slightly lower than the fall rate (1.7%) of 84% of the remaining patients. This sug- gests video monitoring is a safe alternative to patient companions and does not increase the fall risk for patients.

The capital cost of this project was included in the construction

Table 1. Falls per Patient Discharge for All Three Study Units

(Baseline compared to intervention time period; p<0.0001, 95% CI)

9 Months Baseline 9 Months Intervention Falls 85 53 Total patient discharges 5,109 5,041 Falls per patient discharge 1.7% 1.1%

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budgets of the three units. These equipment costs were incurred years before the full-time equiva- lents (FTEs) were allocated to ded- icated telesitting, so it is difficult to analyze the return on invest- ment for the original equipment purchase. However, analysis of the ongoing staffing costs was done. Decreasing the fall rate by 35% would lead to an annualized avoidance of 37 falls per year at this organization. Based on a fall with injury estimate of 9%-15% (Tideiksaar, 2010), there would be three to five falls with injuries avoided. Using the CDC’s (2013) estimate of $17,500 per fall, implementing video monitoring will avoid between $52,000 and $87,500 in fall costs each year. If the modest reduction in patient companions persists, it will lead to a decrease of $25,200 in sitter costs each year. Combining the fall cost avoidance and sitter-reduc- tion savings would be $77,200 to $112,700 each year. This comes close to offsetting the 24/7 telesit- ter staffing cost of approximately $120,000. Because of the improve- ment in patient safety, this differ- ence was acceptable to the pro- ductivity team at this organiza- tion, which chose to continue funding the telesitter FTEs after completion of the study. ASSIGNMENT: PREVENTING PATIENT FALLS

Discussion With increasing acuity and

simultaneous pressures for opti- mal productivity, reducing unnec- essary patient companions has been a focus for many health care organizations. At the same time, nursing leaders are seeking to accelerate improvement in patient safety, specifically falls preven- tion. This study suggests the use of remote video monitoring is a safe tool for fall prevention. While there was a decrease in 1:1 sitter usage, there was no corollary increase in falls. In fact, falls de – creased 35%.

During the first 2 months of the intervention phase of the study, there was a learning curve

where several potentially avoid- able falls occurred on camera. There were sometimes inaccurate assumptions between the nurse and the telesitter regarding when the nurse should be notified or what the patient could be permit- ted to do independently. Three months into the study, retraining was done both with nurses on the study units and telesitters to increase the communication bet – ween the RN and the telesitter regarding individualized expecta- tions for patients. At the same time, there was additional training and monitoring to increase the fre- quency by which telesitters were redirecting patients via the micro- phone. Retraining was successful. In the initial 3 months of the study, eight falls were observed on camera. After retraining was pro- vided, seven falls were observed over a 6-month timeframe.

Three of the falls on video- monitored patients occurred with toileting activities. For high-risk falls patients, the organization’s expectation was these patients will not be left unattended in the bathroom or on the commode. Telesitters were empowered to notify the charge nurse whenever they observed a fall-risk patient unattended in the bathroom or on the commode. This was consid- ered an unexpected benefit of the program.

Nurses found other uses for video monitoring besides fall pre- vention. When all 12 monitors were not needed for fall preven- tion, they were also used to pre- vent elopement, protect patients from interfering with their med- ical devices, and to monitor seizure activity. Protecting vulner- able adults with conditions such as dementia, substance abuse withdrawal, or brain injuries from leaving the facility, or eloping, has often produced anxiety in nurses. A patient with dementia and dependent on oxygen therapy may frequently remove a nasal cannula or oxygen mask. In such a situa- tion, video monitoring was used

to redirect the patient and contact the nurse if necessary. Because one of the study units was a neu- roscience unit, there were also patients newly diagnosed with a seizure disorder, and telesitters were asked to notify the nurse if they observed seizure-like activi- ty. This was separate from the hos- pital’s epilepsy monitoring unit where patients with diagnosed seizure disorders are monitored with electroencephalogram and a separate video system that had recording capability.

This study took place over an 18-month period including both the baseline data collection and intervention stages. During this time, nurse leaders continued to implement strategies to prevent falls beyond video monitoring. For example, one of the study units changed its staffing grid to add an additional patient care assistant during the busiest times of the day during the intervention phase of the study. The increase in staffing may also have decreased the fall rate as well.

It is a major challenge for hos- pital leaders to implement effec- tive strategies to avoid such unpredictable occurrences as the elopement of a vulnerable patient or a severe injury from a fall, while maintaining good financial stewardship. The aim of this study was to determine if video technol- ogy is a safe and effective tool to decrease falls while also decreas- ing patient companion costs. It was demonstrated that not only is video monitoring a safe interven- tion, it is more effective than patient companions alone in decreasing falls by expanding the number of patients who are direct- ly observed 24/7.

Implications Predicting which patient is

most likely to fall continues to be a complex challenge for nurses. Despite the efforts to create criteria for identifying patients most at risk for falls, 40 patients not selected for video monitoring fell during the

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study period. The criteria used were history of a previous fall and scores that would indicate im – paired judgment such as CIWA, Beers criteria, and the Orientation- Memory-Concentration Test. An area for further study is accurate criteria for selecting the most appropriate patients for video monitoring. Implications for fur- ther study could also include investigating the most appropriate length of shift for a telesitter and the most effective telesitter-to- patient ratio.

Thirteen patients fell while on video. Further investigation is war- ranted on whether a smaller telesit- ter-to-patient ratio would allow telesitters to be more attentive or if a telesitter-triggered alarm mecha- nism would decrease the number of falls on camera (at the time of the study, the manufacturer of the sys- tem had not yet incorporated an alarm feature). Con versely, given 40 patients fell without video observation, it would be useful to study whether increasing the tele- sitter-to-patient ratio would de – crease the total number of falls by allowing more patients access to the telesitter intervention.

As this is a new way to deliver care, there is a learning curve and a trust curve for both nurses and tele- sitters caring for video-monitored patients. Staff selection and train- ing for this new role as well as using consistent staff is crucial for success. $

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ASSIGNMENT: PREVENTING PATIENT FALLS

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