Bitter Sitter

Tenzin Arya, Christina Bolster, Jen Cervantes, Tenzin Dadon, Mary Ho, Irena Lisek, Brooke McGrath, Dan McLean, Vicky Zerbato

Objectives • What is a patient sitter and why are they used?• Drawbacks regarding patient sitters • Statistics• What do White 7 nurses say?• Alternatives to patient sitters• Recommendations/implementation strategies

Patient Sitters

“Sitters are unlicensed assistive personnel

who provide constant observation of

high-risk patients and notify health care

providers when a patient condition

deteriorates” (Spiva et al, 2012, p. 341).

Patient Sitters

“…sitters are most often used for (a) patients with

behaviors that are potentially dangerous (e.g. agitated, wandering,

suicidal) or that may interfere with medical therapies (e.g. pulling out

lines or tubes) and (b) for patients at high risk of having a fall and fall

related injuries. Despite limited evidence about their effectiveness

for preventing falls and other adverse events” (Rochefort et al,

2011, p. 222).

Drawbacks

- Ability/Quality

- Evidence

- Cost

Ability/Quality

“Some hospitals in western societies use volunteers or

paid sitters (also called patient attendants or companions)

– who are not trained as nurses or certified nurse assistants to

stay with patients who are at high risk for falls as a fall

prevention strategy…Workers have argued

that, because the majority of the assistive personal

lack professional nurse education they cannot replace

nurses in preventing inpatient falls” (Tzeng, 2008, p. 177).

Evidence“Several researchers have demonstrated no improvement in fall rates

with sitter usage” (Spiva, 2012, p. 341).

“There is no research at this time to support the practice of using sitters

as being cost effective or preventing patient harm”

(Harding, 2010, p.330).

“The effectiveness of the use of sitters in preventing falls has been recognized

By hospital administrators, but whether they decrease in patient fall rates is

still uncertain (Tzeng, 2008, p. 177)

“The practice of one-on-one sitters is costly and is not evidence based,

and there are no data to show that it has significant effect on falls”

(Flaherty, 2011, p.295)

Cost“Using sitters was not cost effective for decreasing

patient falls becausethe gains did not off set the direct

expense related to the sitter program”

(Tzeng, 2008, p.177).

“Researchers report annual hospital spending in the

United States for sitter use at 1.3 million and costs are

not typically reimbursed by third party

payers” (Spiva, 2012, p.341).

Statistics• An estimated 99% of US hospitals use sitters

even though the costs have escalated over the

past decade.• Hospitals have reported an annual cost of

sitters

alone as high as 1.3 million dollars.• 56% psychiatric crisis and 44% fall risk• 55% ED and 45% in patient• Median length of sitter use: 55.5hrs

MGH Statistics

• Sitters took up 4.41 full time position/week

• Equivalent to $585/week ($13/hr)

• Increase in sitters = decrease in falls

(1.45 E7 & 1.3 W7)

• Lower sitter = higher restraint use

What does White 7 have to say about sitters?

“No specific protocol, we mostly rely on our clinical judgment.” - Mike Cabot

“Patient Observers are a waste of space!” - Anonymous

“Without looking at your statistics and research, my gut feeling is its cost ineffective”- Mike Cabot

“Yes, I’d be interested to see the open ward concept.”- Mike Cabot

“Let’s knock down some walls!” Delirium rooms sound like a good idea to improve pt. safety.”

–Harriet Green

What does White 7 have to say about sitters?

“I find the PCA sitters to be helpful and the Bulfinch sitters not as helpful. They call for unnecessary reasons frequently, and they cannot touch the

patients. What is the point of them?”- Beth Donnelly

“PCA sitters can do a lot more. They are safer for the patient. I guess the other sitters in a sense are helpful when watching patients who are at risk for falling, but [if they are falling] they can not do anything to help them.”

- Beth Donnelly

Alternatives

• Closer to nurses station

• Assigning high-risk patients to experienced nurses• 2:1 (Sitters)• Evaluation tools (Tzeng, 2008, p. 177)• Delirium room (Flaherty, 2011, p. 295)

• Implement training program/ higher requirements to be

eligible for observer jobs (Rochefort, 2011, p.229)• Music therapy (Vaajoki, 2011, p. )

Evaluation ToolsPatient Sitter Evaluation Tool

– Assess patient’s need for sitters with a goal to decrease sitters– Scores patient based on the following five risk factors:

Suicide precautions Danger to self Cannot follow safe instructions Interference with medical care Wanders

– Based on score, it indicates if a sitter is needed.

Patient Attendant Assessment Tool– Completed by patient's primary nurse

– Clinical assessment to ensure each sitter request has merit and cannot be

mitigated with different, non-personnel interventions. – Request must be submitted to nurse manager or nursing supervisor and

they ultimately decide if a patient sitter is indicated

Delirium room

• Used for patients that meet certain criteria to eliminate use

of pharmacological approaches, restraints and 1:1 sitters• 24 hour nursing care• Decrease negative outcomes of delirium• Cost of construction less than the annual cost of sitter

use

• TA-DA (tolerate anticipate don’t agitate)

BR RN

Delirium Room

Delirium Room

BR

RN

Music Therapy• Reduces respiratory rate

• Reduces heart rate

• Reduces blood pressure

• Stimulates a relaxation response

• Reduces overall pain

• Positive effect on patients experience while in the hospital

• Low risk intervention

• Music therapy may be used in combination with other

alternative

• Methods before the implementation of a sitter.

• Non-pharmacological

Requirements to be eligible for a sitter position

• More qualifications• Mandatory training programs• New job category • The need for sitters on the floor should not

interfere with the CNAs assigned to the floor

that day

Recommendations• Develop and implement a staff driven checklist of alternative• strategies (e.g. Music therapy a possibility)• Reevaluate the need for a sitter every 12 hours with the charge nurse • and/or nurse manager.• Sitter evaluation tool (completed at the end of each shift)• Use of in-house personnel with staff training (e.g. PCAs)• Staff Delirium training (T-A-DA - Tolerate, Anticipate, and Don’t

Agitate) • 2:1 patient/sitter ratio• Assign high risk patients to experienced nurses • Assign high risk patients to rooms that are located closer to the

nurses

station or in a room designated to high risk patients

Recommendations• Create a Delirium room

• Close to nurses station• Provide specific delirium room training that practice non-

pharmacological,

restraint free approaches• Goal of the room is T-A-DA – tolerate, anticipate and don’t agitate • A staff driven tool to evaluate/reevaluate a patients need to be

assigned

to a delirium room.• Develop a “Justification form” that requires the nurse to document

why there is a need for a sitter.• Music therapy (evidence based, non-pharmacological approach)

• Small radios in patient rooms with headphones where they can

choose their own music.

References Harding, A. (2010). Observation Assistants: Sitter Effectiveness and Industry Measures. Nursing Economic$, 28(5), 330-336. Spiva, L., Feiner, T., Jones, D., Hunter, D., Petefish, J., & Vanbrackle, L. (2012). An evaluation of a sitter reduction program intervention. Journal Of Nursing Care Quality, 27(4), 341-345. 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. Flaherty, J. H., & Little, M. O. (2011). Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium. Journal Of The American Geriatrics Society, S295-300. Rochefort, C. M., Ward, L., Ritchie, J. A., Girard, N., & Tamblyn, R. M. (2011). Registered Nurses' Job Demands in Relation to Sitter Use: Nested Case-Control Study. Nursing Research, 60(4), 221-230.

Vaajoki, A., Kankkunen, P., Pietilä, A., & Vehviläinen-Julkunen, K. (2011). Music as a nursing intervention: Effects of music listening on blood pressure, heart rate, and respiratory rate in abdominal surgery patients. Nursing & Health Sciences, 13(4), 412-418.