Patient and nurse staffing characteristics associated with high sitter use costs

Building Clinical Leadership Competencies When Caring for Hospitalized Adults Experiencing Dementia

PURPOSE AND OBJECTIVES

Attempting to improve the experience of hospitalized adults with dementia and reduce patient attendant costs, we addressed hospital nursing staff confidence managing responsive behaviors through education, mentorship, and individualized patient care planning for adults with dementia.Responsive behaviors (such as pacing, calling out) is a term used to describe behaviors demonstrated by a person with dementia as a way of responding to something negative, frustrating, or confusing in their social and physical environment.

DESCRIPTION OF PROJECT

Under time restraints, we performed a rapid environmental scan and developed internal clinical resources and a learning strategy that informed a quality improvement initiative that focused on dementia care of hospitalized patients.

OUTCOME

Using quantitative and qualitative evaluation methods, the interventions increased confidence, competency, and leadership in clinical nursing leaders and improved person-centered care planning practices. The cost of patient attendant usage for this patient population decreased by 28% in 1 year.

CONCLUSION

This intervention, which was not a copyrighted program associated with administration costs, improved hospital-based dementia care and staff confidence in dementia care and reduced annual costs associated with patient attendant useage.

The use of constant observation with people with dementia in hospitals: a mixed-methods systematic review

OBJECTIVES

Constant observation is used in hospitals with people with dementia to manage their safety. However, opportunities for proactive care are not consistently recognised or utilised. A systematic review of constant observation was conducted to understand measures of effectiveness and facilitators for person-centred approaches.

METHOD

Electronic databases were searched between 2010 and 2022. Four reviewers completed screening, quality assessments and data extraction with 20% checked for consistency. Findings were presented through narrative synthesis (PROSPERO registration CRD42020221078).

FINDINGS

Twenty-four studies were included. Non-registered staff without specific training were the main providers of constant observation. Assessments and processes clarifying the level of observation encouraged reviews that linked initiation and discontinuation to a patient's changing needs. Examples of person-centred care, derived from studies of volunteers or staff employed to provide activities, demonstrated meaningful engagement could reassure a person and improve their mood. Proactive approaches that anticipated distress were thought to reduce behaviours that carried a risk of harm but supporting evidence was lacking.

CONCLUSION

Non-registered staff are limited by organisational efforts to reduce risk, leading to a focus on containment. Trained staff who are supported during constant observation can connect with patients, provide comfort and potentially reduce behaviours that carry a risk of harm.

The use of patient sitters at a Swiss hospital: A retrospective observational study

OBJECTIVE

Patient sitters are frequently used in acute care hospitals to provide one-to-one care for agitated or disorientated patients to assure the safety and well-being of patients. However, there is still a lack of evidence on the use of patient sitters, especially in Switzerland. Therefore, the aim of this study was to describe and explore the use of patient sitters in a Swiss acute care hospital.

METHODS

In this retrospective, observational study we included all inpatients who were hospitalized between January and December 2018 in a Swiss acute care hospital and required a paid or volunteer patient sitter. Descriptive statistics were used to describe the extent of patient sitter use, patient characteristics, and organizational factors. For the subgroup analysis between internal medicine and surgical patients Mann-Whitney U tests and chi-square tests were used.

RESULTS

Of the total of 27'855 included inpatients, 631 (2.3%) needed a patient sitter. Of these, 37.5% had a volunteer patient sitter. The median patient sitter duration per patient per stay was 18.0 hours (IQR = 8.4-41.0h). The median age was 78 years (IQR = 65.0-86.0); 76.2% of patients were over the age of 64. Delirium was diagnosed in 41% of patients, and 15% had dementia. Most of the patients showed signs of disorientation (87.3%), inappropriate behavior (84.6%), and risk of falling (86.6%). Patient sitter uses varied during the year and between surgical and internal medicine units.

CONCLUSIONS

These results add to the limited body of evidence concerning patient sitter use in hospitals, supporting previous findings related to patient sitter use for delirious or geriatric patients. New findings include the subgroup analysis of internal medicine and surgical patients, as well as analysis of patient sitter use distribution throughout the year. These findings may contribute to the development of guidelines and policies regarding patient sitter use.

The impact of COVID-19 on patient safety attendant use

ABSTRACT

Patient safety attendants (PSAs) provide constant direct observation to patients who have cognitive impairments or thoughts. Some estimates report that an acute care hospital in the United States may spend more than $1 million annually on PSAs, an expenditure often not reimbursed. With no national defined standards to regulate or monitor PSA use, this study sought to determine the impact of COVID-19 on a PSA reduction program in a large Midwestern healthcare system.

Implementation and Evaluation of an Acute Care Multicomponent Intervention for Dementia-Related Behavioral Expressions

Despite the high prevalence and negative outcomes associated with poorly managed dementia-related behavioral expressions (BE) during hospitalization, evidence-based interventions for BE management in acute care environments are lacking. To address this gap, we designed, implemented, and evaluated feasibility, utility, and exploratory nurse and patient outcomes associated with a low-cost, nurse-led multicomponent decision support intervention-the Personalized Approach and Targeted Interventions (PROACTIVE) Treatment Approach-which was implemented as a quality improvement program and evaluated with a historical matched comparison group. The intervention was feasibly implemented and improved nurse-sensitive outcomes (stress, confidence), practices (use of nonpharmacological approaches) for BE management, and perceived utility of intervention resources. Patients receiving the PROACTIVE Treatment Approach (N = 40) had higher rates of acetaminophen use, and shorter lengths of stay (N = 40). More rigorous evaluation is needed to better determine optimal implementation strategies and intervention impact. [Journal of Gerontological Nursing, 47(9), 21-30.].

The economic cost of delirium: A systematic review and quality assessment

INTRODUCTION

This review aims to systematically identify and appraise the methodological quality of claims on the cost of delirium; and discuss challenges and opportunities for improvements in the precision of the estimates.

METHODS

Searches of scientific papers and gray literature were performed up until June 2020. The Larg and Moss checklist was used to assess the methodological quality of the included studies.

RESULTS

After deduplication, the search identified 317 potentially relevant articles, of which 17 articles were eligible for inclusion. After adjusting for inflation and common currency, the cost of delirium ranged between $806 and $24,509 (in 2019 US$).

DISCUSSION

This review found significant variation among the cost estimates and methodological quality. There has been limited focus on dementia as a sequela of delirium in terms of economic implications, but recent evidence suggests cost implications of delirium may be 52% higher when dementia is considered.

A Multidisciplinary Consultation-Liaison Team Approach to Reduce Enhanced Observer Usage

BACKGROUND

There are few evidence-informed guidelines and findings to show that the use of sitters improves patient safety; overall, it is a costly intervention to address patients with disruptive behaviors.

OBJECTIVE

The purpose of this article is to demonstrate that the creation of a multidisciplinary consultation-liaison (C-L) team, integrated with a psychiatric C-L team, together can decrease sitter use and improve outcomes using nonpharmacologic interventions.

METHODS

This retrospective study describes the planning, implementation, and data collection using in creating an multidisciplinary C-L team to collaborate with the psychiatric C-L team and outcomes to support the approach. The multidisciplinary C-L team was composed of advanced practice registered nurses and creative art therapists. The teams worked closely with the medical units to develop and monitor criteria for sitter use. The key outcomes of the intervention improved patient safety and reduced overall cost.

RESULTS

In the first year of implementation of a multidisciplinary C-L approach, sitter use decreased by 72%. Nonpharmacologic interventions improved patient outcomes by providing education to medical staff that enhanced the assessment and implementation of enhanced observer use across all the medical units. Subsequent data also reflect a sustained reduction in cost over the next 2-year period, saving the institution nearly $70K a month.

CONCLUSION

An multidisciplinary C-L and psychiatric C-L team collaborated on the need for psychiatric medications, or nonpharmacologic interventions to address behaviors and decrease the need for an enhanced observer. The teams worked together to make policy revisions and algorithms and provide education, the result of which was significant financial savings and improved patient safety.

What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken.

AIMS

The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital.

METHODS

This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding.

FINDINGS

A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities.

DISCUSSION

The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study.

IMPLICATIONS FOR PRACTICE

Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

Innovations for integrated care: The Association of Medicine and Psychiatry recognizes new models

This editorial looks at the current state of the integration of medicine and psychiatry in clinical practice. We note selected recent triumphs and barriers to implementing integrated care, highlighting some gaps and priorities for future innovations. In contrast to the relatively more orderly culture of health services research, where some notable innovations in integrated care were funded, tested, and published, the health care marketplace can be a difficult place to identify and track the innovations that could shape health care reform. Recognizing the need to find, describe, and disseminate the most innovative models in integrated care, the Association of Medicine and Psychiatry (AMP) launched in 2016 the Innovative Models for Integrated Care Awards. Although many service innovations solve local problems, some can also act as models to be adopted in multiple settings. The projects that win AMP Innovative Models for Integrated Care Awards are selected for their innovativeness, their clinical importance, their generalizability, and their effectiveness. We briefly describe here the four models that earned these awards at the 2017 AMP Annual Meeting. They demonstrate innovations across a range of settings and populations: inpatient general hospital patients under constant observation in New York, severely mentally ill patients in a federally qualified health center in San Francisco, outpatients in a VA women's health center in Chicago, and HIV patients in an academic infectious disease clinic in Charleston, south Carolina. These model descriptions aim to encourage the implementation of innovative models that advance the integration of medicine and psychiatry.

Managing Eating Disorders on a General Pediatrics Unit: A Centralized Video Monitoring Pilot

Adolescents with severe eating disorders require hospitalization for medical stabilization. Supervision best practices for these patients are not established. This study sought to evaluate the cost and feasibility of centralized video monitoring (CVM) supervision on a general pediatric unit of an academic quaternary care center. This was a retrospective cohort study of nursing assistant (NA) versus CVM supervision for girls 12-18 years old admitted for medical stabilization of an eating disorder between September 2013 and March 2017. There were 37 consecutive admissions (NA = 23 and CVM = 14). NA median supervision cost was more expensive than CVM ($4,104/admission vs $1,166/admission, P < .001). Length of stay and days to weight gain were not statistically different. There were no occurances of family refusal of CVM, conversion from CVM to NA, technological failure, or unplanned discontinuation. Video monitoring was feasible and associated with lower supervision costs than one-to-one NA supervision. Larger samples in multiple centers are needed to confirm the safety, acceptability, and efficacy of CVM.

Constant Observation Practices for Hospitalized Persons With Dementia: A Survey Study

Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.

The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

A Multicomponent Model to Improve Hospital Care of Older Adults with Cognitive Impairment: A Propensity Score-Matched Analysis

OBJECTIVES

To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment.

DESIGN

One-year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units.

SETTING

Large tertiary medical center.

PARTICIPANTS

All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms.

INTERVENTION

Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care.

MEASUREMENTS

In-hospital mortality, length of stay, readmission, management of behavioral disturbances.

RESULTS

After propensity score matching, 476 of the 712 intervention visits were pair-matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in-hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30-day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p<0.01) or enhanced (22.1% vs 79.6%, p<0.01) observation, to be taking benzodiazepines (26.3% vs 38.0%, p<0.01), to be taking nothing by mouth (29.6% vs 40.8%, p=0.01), to be on bedrest (17.0% vs 25.8%, p=0.01), to be taking antipsychotics (41.2% vs 54.0%, p<0.01), or to have restraints (3.2% vs 6.9%, p=.01).

CONCLUSION

A multicomponent intervention of geographic cohorting, multidisciplinary approach, PES, and staff education may offer a new paradigm in the management of hospitalized older adults with cognitive impairment.

Management of delirium across an integrated health system

Facilitating throughput with systems thinking.

Interventions to improve working conditions of nursing staff in acute care hospitals: Scoping review

AIM

To conduct a scoping review to examine and map the interventions proposed for the improvement of the working conditions of nursing staff in acute care hospitals.

BACKGROUND

The Registered Nurse Forecasting (RN4CAST) project and other studies have determined the impact that the nursing staff has on the quality of care. The nursing staff's higher levels of burnout, job dissatisfaction and negative perception of the quality of care provided caused worse health outcomes.

METHODS

A scoping review was carried out. By searching in SCOPUS, PubMed, CINAHL, Cochrane, Dialnet and in the grey literature, 705 potentially relevant papers were identified. The final analysis included 21 papers and three grey documents.

RESULTS

The studies analysed proposed interventions at the macro-management, meso-management and micro-management levels, although the interventions at the macro- and meso-levels produce better staff outcomes.

CONCLUSIONS

The findings of this review can be applied to management at different levels: measures to improve the patient-nurse ratio at the macro-management level, the horizontal hierarchies at the meso-management level, the mind-body techniques at the micro-management level.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers and leaders should implement interventions at different organisational levels to improve the working conditions of the nursing staff and other health outcomes.

The Milieu Manager: A Nursing Staffing Strategy to Reduce Observer Use in the Acute Psychiatric Inpatient Setting

BACKGROUND

Rising acuity levels in inpatient settings have led to growing reliance on observers and increased the cost of care.

OBJECTIVES

Minimizing use of observers, maintaining quality and safety of care, and improving bed access, without increasing cost.

DESIGN

Nursing staff on two inpatient psychiatric units at an academic medical center pilot-tested the use of a "milieu manager" to address rising patient acuity and growing reliance on observers. Nursing cost, occupancy, discharge volume, unit closures, observer expense, and incremental nursing costs were tracked. Staff satisfaction and reported patient behavioral/safety events were assessed.

RESULTS

The pilot initiatives ran for 8 months. Unit/bed closures fell to zero on both units. Occupancy, patient days, and discharges increased. Incremental nursing cost was offset by reduction in observer expense and by revenue from increases in occupancy and patient days. Staff work satisfaction improved and measures of patient safety were unchanged.

CONCLUSIONS

The intervention was effective in reducing observation expense and improved occupancy and patient days while maintaining patient safety, representing a cost-effective and safe approach for management of acuity on inpatient psychiatric units.

Bearing Witness: The Lived Experience of Sitting With Patients

There is abundant literature focused on the practice of using hospital sitters as part of standard patient safety care. However, minimal attention has been paid to understanding the actual experiences of hospital workers as they sit with distressed and often agitated patients. With the overwhelming number of hospitalized patients who require sitters, attention must be paid to the healthcare workers' perspective. In this study a phenomenological approach was used to elicit the perceptions of these hospital sitters. Themes which emerged from the participant's lived experiences of sitting included: Accepting them, It's not about me, You're not alone, Taking it to heart, Lifts me up, and Supporting role, with an overarching focus of Bearing witness. Nursing implications for this study suggest that using advanced practice psychiatric nurses in med-surg settings may help to support the hiring and training of skilled sitters and lead to improved psychological nursing care. In addition, identifying health care workers who best "fit" the sitter profile may promote the role from one of safety surveillance to one of therapeutic engagement.

An urgent need to understand and address the safety and well-being of hospital "sitters"

BACKGROUND

Hospital sitters provide continuous observation of patients at risk of harming themselves or others. Little is known about sitters' occupational safety and well-being, including experiences with patient/visitor-perpetrated violence (type II).

METHODS

Data from surveys, focus groups, individual interviews at six U.S. hospitals were used to characterize the prevalence of and circumstance surrounding type II violence against sitters, as well as broader issues related to sitter use.

RESULTS

Sitter respondents had a high 12-month prevalence of physical assault, physical threat, and verbal abuse compared to other workers in the hospital setting. Sitters and other staff indicated the need for clarification of sitters' roles regarding patient care and sitter well-being (e.g., calling for assistance, taking lunch/restroom breaks), training of sitters in personal safety and de-escalation, methods to communicate patient/visitor behaviors, and unit-level support.

CONCLUSIONS

The burden of type II violence against hospital sitters is concerning. Policies surrounding sitters' roles and violence prevention training are urgently needed.

Improving patient safety by optimizing the use of nursing human resources

Background

Recent ecological studies have suggested that inadequate nurse staffing may contribute to the incidence of adverse events in acute care hospitals. However, longitudinal studies are needed to further examine these associations and to identify the staffing patterns that are of greatest risk. The aims of this study are to determine if (a) nurse staffing levels are associated with an increased risk of adverse events, (b) the risk of adverse events in relationship to nurse staffing levels is modified by the complexity of patient requirements, and (c) optimal nurse staffing levels can be established.

Methods/design

A dynamic cohort of all adult medical, surgical, and intensive care unit patients admitted between 2010 and 2015 to a Canadian academic health center will be followed during the inpatient and 7-day post-discharge period to assess the occurrence and frequency of adverse events in relationship to antecedent nurse staffing levels. Four potentially preventable adverse events will be measured: (a) hospital-acquired pneumonia, (b) ventilator-associated pneumonia, (c) venous thromboembolism, and (d) in-hospital fall. These events were selected for their high incidence, morbidity and mortality rates, and because they are hypothesized to be related to nurse staffing levels. Adverse events will be ascertained from electronic health record data using validated automated detection algorithms. Patient exposure to nurse staffing will be measured on every shift of the hospitalization using electronic payroll records. To examine the association between nurse staffing levels and the risk of adverse events, four Cox proportional hazards regression models will be used (one for each adverse event), while adjusting for patient characteristics and risk factors of adverse event occurrence. To determine if the association between nurse staffing levels and the occurrence of adverse events is modified by the complexity of patient requirements, interaction terms will be included in the regression models, and their significance assessed. To assess for the presence of optimal nurse staffing levels, flexible nonlinear spline functions will be fitted.

Discussion

This study will likely generate evidence-based information that will assist managers in making the most effective use of scarce nursing resources and in identifying staffing patterns that minimize the risk of adverse events.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0278-1) contains supplementary material, which is available to authorized users.

The role of sitters in delirium: an update

Purpose

The concept behind constant observation is not new. Whilst traditionally performed by nursing staff, it is now commonly performed by sitters. Details surrounding the usage, job description, training, clinical and cost effectiveness of sitters are not known; hence the reason for this review.

Methods

A literature search was performed in MEDLINE, Cochrane Database of Systematic Reviews, and PubMed from the years 1960 to October 2011. The definition for sitter used in the articles was accepted for this review.

Results

From this review, it is evident that sitters are being employed in a variety of settings. The question of which type of person would provide the most benefit in the sitter role is still not clear; whilst sitters have typically included family and volunteers, it may be trained volunteers who may offer the most cost-effective solution. The paucity of information available regarding the training and assessments of sitters and the lack of formal guidelines regulating sitters’ use results in a lack of information available regarding these sitters, and current available evidence is conflicting regarding the benefits in terms of cost and clinical outcome. The only strong evidence relating to clinical benefit comes from the use of fully-trained sitters as part of a multi-interventional program (i.e., HELP)

Conclusions

Current evidence supports a role for the sitter as part of the management of patients with delirium. The most cost-effective sitter role appears to be trained volunteers. Further research is needed to determine the specific type of training required for the sitter role. The creation of a national set of regulations or guidelines would provide safeguards in the industry to ensure safe and effective patient care.