The use of continuous video monitoring (CVM) is evolving into a standard of care within the inpatient setting. It is increasingly accepted as an effective intervention to decrease falls and enhance environmental safety in inpatient settings.1 As video monitoring becomes more prevalent, concurrently the need for exploration related to sustainability of video monitoring programs increases. Acceptance and utilization rates of technology can be directly related to overall program success. Recent published research shows acceptance of video monitoring in the inpatient setting.2 In one study, a positive correlation was found with perceived ease of use and perceived usefulness of CVM.3 As this technology becomes a standard of care, expansion readiness of CVM programs to meet organizational needs should be identified and clearly defined. The purpose of this article is to identify data metrics to inform expansion of CVM programs when determining readiness for growth.
At a large academic Magnet-designated medical center in the Pacific Northwest in the US, nursing leadership identified that the need for sitters was rising and there was a lack of alternative resources. CVM was a solution and thus was implemented in the fall 2018. Three years postimplementation, CVM has been successfully ingrained into the culture of safety through staff engagement, standard work, patient/family engagement, data tracking management, and versatility of utilization.4 Much of the initial implementation work focused around program development and ensuring the technology was a trusted resource for at-risk patient populations. Although trust is not easily obtained, frontline staff has adopted the technology as an important part of environmental safety management.
General CVM program overview
Our CVM program4 was initiated with the intent to improve our culture of safety through added video monitoring resources that would allow our support staff such as certified nursing assistants (CNAs) to be available in staffing and not primarily fulfilling sitter needs. The CVM station is staffed by video monitoring technicians (VMTs). VMTs hired have at least 1-year health care experience and are provided training in behavioral health monitoring. One VMT can monitor up to 12 patients at once using a variety of interventions such as 2-way communication to a secure centralized station, 360° display with pan/tilt/zoom, night vision via automatic infrared illuminator, and emergent STAT alarm functionality. For patients with language barriers, the system offers 16 prerecorded prompts in a variety of languages. VMTs can intervene directly with the patient or call the nursing staff to intervene in person. Communication and coordination between team members are essential to provide a safe environment to patients who require video monitoring.
Nurses ensure they give a proper report to VMTs at the change of every shift to identify risks and interventions to mitigate adverse events. Clear and consistent communication is needed throughout the patients stay to ensure effective and safe monitoring interventions as the patient progresses. In addition, VMTs document via a CVM flow sheet in our electronic health record indicating overall patient behaviors and associated interventions. This information is embedded into a Cognitive Behavioral Profile that gives a snapshot of all behavioral type interventions over the course of the patient's inpatient stay.
Initial positive outcomes
Many organizations, including our own, have benefitted from video monitoring technology in relation to prevention of adverse events.5 Inpatient settings seem to be particularly capitalizing on utilization of CVM and benefitting from a reduction in adverse events.1 At our facility, we recorded an average of 5593 adverse events prevented per 1000 patient-days in the past year alone, as reported by the VMT. Adverse events that are prevented include falls, elopements, and abusive behaviors and devices are maintained, among others.
When the VMT sounds the STAT alarm due to concerning patient behaviors, nursing staff averages an 11-second response time to the patient bedside. This is 6 seconds below the accumulative comparison average of systems that use the video monitoring technology provided by Avasure. This emphasizes nursing staff buy-in and trust in the VMT's monitoring capabilities within our culture of safety. Buy-in has also been achieved through versatility of use throughout the COVID-19 pandemic. One study suggests that CVM had a positive impact in the height of the pandemic as it allowed for continuous observation of patients who were exhibiting at-risk behavior yet kept the nurses protected from unnecessary and prolonged exposure.6 We found this to be true of CVM and often use the technology in rooms of patients with COVID-19 to limit nursing exposure, preserve personal protective equipment, and enhance communication with the patient. After 2 years of utilization, we found that the technology promotes staff engagement and influences utilization of the technology beyond that of traditional sitters.
Readiness for program growth
Weighing the balance of program cost and associated program expansion needs can be difficult, particularly in cost-containment environments. The postpandemic world poses many challenges financially and has changed the way patients interface with health care.7 For example, patients are avoiding nondiscretionary care, meaning they are evading interfacing with the health care system in the midst of the pandemic.8 This reduction in patient volume in some settings, in conjunction with increased costs of supplies and supply chain issues, has created financial restraints that most organizations are balancing daily. Thus, making a case of CVM program expansion can be difficult as the up-front cost of technology is substantial.
It was clear, however, that our organization's supply of cameras could not meet the demand. We had a growing video monitoring wait-list and continued growth of sitter usage in our facility. In addition, with current staffing shortages, urgency to get our CNA staff back out on the unit, and using cameras in every sitter room that met CVM inclusion criteria was a priority. Despite budget challenges and financial constraints, with the right metrics, organizations can clearly show video monitoring benefits outweigh that of the associated costs and that return on investment can be easily obtained through sitter reduction, prevention of adverse events, and staff satisfaction.
High-level evidence such as systematic reviews are being published related to CVM. These reviews indicate that video monitoring not only is effective against adverse events9 but also show with moderate certainty that CVM reduces sitter use and does not adversely impact the number of adverse events in organizations.10 This evidence informs organizations of the worth of video monitoring, but individual organizations need to show that initial program implementation is ready for expansion if camera supply does not meet demand. Research is limited to high-level certainty regarding implementation success, for example, utilization of advanced practice nurses to promote interdisciplinary collaboration and the development of successful policy and procedure.11 However, details on how to sustain and/or expand a program do not exist in the current literature. The next section of this article explains the metrics we used to show the value of CVM in our organization, which allowed for expansion of our program with additional purchase of cameras and expansion of our VMT labor pool.
Data metrics to inform expansion
Rising and sustained utilization rates
One suggestive metric that indicates readiness for expansion of video monitoring programs is climbing and/or high stabilized utilization rates. Our initial goal for CVM utilization was more than 50% of the cameras in use at all times. Within the first year of CVM use, utilization of remained greater than 80% consistently for all devices including our 10 mobile units and 3 stationary ceiling mounts located in our medicine unit and pediatric emergency department. This is a total of 13 cameras in use 80% of the time. The stationary ceiling mounts are increasingly difficult to keep in use due to patient placement issues. Nursing units need to have the right patient in the right bed at the right time to use a ceiling camera. With capacity constraints, achieving this can be a barrier to ceiling mount utilization.
One article discusses this dilemma by explaining that when cameras are stationary, placing patients into those rooms who meet inclusion criteria was a barrier.12 This was mitigated by obtaining more mobile devices versus stationary cameras to achieve additional flexibility.12 Mobile devices provide additional flexibility, and our organization's 10 mobile units are in use 90% to 95% of the time. With this high utilization rate, and an average length of stay of 64 hours per patient, there is little camera availability despite increased demand from the nursing staff. This leaves only the highest-risk patients on camera, with less room for utilization of CVM for primary fall prevention and overall environmental safety management for less at-risk patients.
With a large organization of 576 inpatient rooms, taking into consideration the ratio of available cameras to beds, we were clearly falling short of meeting sitter needs. Yet, we were achieving a cost savings through the replacement of up to 13 sitters every shift. In 2018, we were able to stabilize the upward trend and decrease overall sitter usage in adult acute care by a small margin (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/JNCQ/A927). Equating this decrease in overall sitter usage with the implementation of CVM, we can show a cost savings of 2 million a year. This equates to $200 000 cost savings per camera per year. This does not include savings on prevention of adverse events such as falls, elopements, line pulls, etc. Determining savings on adverse events can be increasingly difficult because the VMT's perception of an event saved cannot be easily quantified into actual events. However, the savings on sitter replacement alone provides enough savings for ample return on investment.
Increase sitter needs
Over time, our organization has seen an increase in demand related to patients who require constant observation in all settings. Regardless of stabilization in acute care sitter use postimplementation of CVM in 2018, this upward trend has been evident since closure of our psychiatric care unit (1 Northwest) in 2017, which resulted in 142% increase in sitter use in all care areas (see Supplemental Digital Content, Figure 2, available at: https://links.lww.com/JNCQ/A928). This combined need has resulted in a record number of sitter hour needs extending into 2021. The continued upward trajectory is related to increased behavioral health population growth, particularly in the adult and pediatric settings. This is not unique to our organization: it is a national trend for inpatient pediatrics and adults. In pediatrics, the prevalence of behavioral health admissions has been increasing over time, yet the length of stay has been shortened.13 This results in higher acuity needs and thus more intense monitoring, such as sitter use. The same can be shown in adults in whom roughly half of patients on hospital medicine services have active psychiatric comorbidity according to a recent study.14 Beyond behavioral health population increases, general fall prevention efforts in large hospitals is also a video monitoring focus as it is estimated that falls in acute care settings range from 1.3 to 8.9 per 1000 patient-days.10
Not all organizations are alike, thus identifying specific sitter needs is important when assessing replacement of sitters for cameras. Collected data via daily sitter audits show that sitters are instituted for a variety of needs, some of which exclude patients from CVM utilization (eg, high-risk suicide). The impetus for sitter use in our organization in pediatrics, based on 478 audits, includes eating disorders (24.8%), specifically meals plus 30 minutes (15.86%) suicide risk (34.64%); restraints (3.55%); holds in place (7.87%); and elopement (13.20%). Sitter use for adults (n = 576 audits) incudes fall prevention (29.45%), elopement (20.86%), safety of lines/tubes (26.71%), suicide (4.69%), substance withdrawal (4.06%), and seizures (1.33%). When CVM cannot be implemented because of exclusion criteria, sitter usage is still a necessity. Alternatively, when CVM can be used in replacement of a sitter, wait-lists create a barrier and are yet another indicator that program expansion is imminent.
Video monitoring wait-list growth
A wait-list is defined and created by the assurance that all sitters in the system have been trialed on camera and/or excluded because of inclusion criteria constraints. Patients who meet inclusion criteria for CVM, yet there are no available cameras, remain on the CVM wait-list and are prioritized if a sitter is currently present with the patient. This list is managed by the VMTs in collaboration with charge nurses and nursing leadership. It is sent out daily by email to create transparency in the process and ensure each sitter is accounted for in the organization. This provides nursing leadership a chance to follow up with charge nurses and clinical nursing staff if there is a discrepancy in the process and/or a safety need that is not being escalated.
Two years postimplementation, it was obvious that our CVM wait-list continued to grow and remained a constant reminder that expansion was needed to meet inpatient demand. To predict needed camera increases, we tracked our wait-list over several months. The data showed that consistently sitters were present at these rates (n = 243 wait-list entries): 0 to 4 sitters (16%), 8+ sitters (28%), and 5 to 8 sitters (55%). The wait-list data showed 2 to 3 patients waiting for available cameras 33% of the time, 3+ patients waiting 33% of the time, and 33% of the time there was no wait-list. Trends identified were that units that used CVM early before sitters and/or for safety needs had more time on the wait-list. For example, our neuro/stroke unit often uses CVM for fall prevention, and patients remain on the wait-list without the use of a sitter and thus are not prioritized to receive a camera. This creates safety issues as patients with stroke are often more at risk for inpatient falls due to loss of functionality post stroke.15
There is also an associated cost with consistent wait-list increases. Since implementation of tracking our wait-list, we had 164 instances of patients on the wait-list who had a sitter but were unable to fulfill the CVM request due to inability to triage patients off camera. This equaled $44 000 expense to the organization from missed opportunities related to CVM capacity in just a 4-month period of time. By averaging this loss over a year, there is a risk of losing $134 000 annually due to limited availability of cameras. This variance alone is nearly enough to purchase additional cameras based on our initial program expense in 2018.4 Thus, the tracking of CVM wait-list growth can show missed opportunities that provide clear metrics for expansion of CVM programs.
Frontline staff perception
According to a recent study, understanding staff satisfaction is essential to the acceptance of CVM technologies.3 Thus, frequent and intentional check-ins with staff about their overarching needs and/or readiness of program growth is essential. Our initial CVM Satisfaction survey was done 2 years post–go-live. This survey implemented in 2020 (n = 181 nurse respondents) showed that 86% of staff agreed that CVM freed up more ancillary staff for patient needs and 76% reported that it makes sitter break coverage easier. In addition, 67% reported that CVM helps prevent adverse events and 71% reported that VMTs are attentive and keep patients safe. Finally, 78% reported confidence in communication efforts with VMTs and comfort in their ability to be communicated with if there is an overall safety concern. This survey showed that nursing staff were accepting of the technology and most felt it was part of our culture of safety in the organization.
As we continued to prepare for program growth, it was important to survey staff on readiness for expansion in 2021. This particular survey (n = 49 nurse responses) is ongoing with focused attention on investment in the program and perceptions of the need for additional cameras in the organization. Staff included in the survey comprised charge nurses, clinical nurses, and nursing assistants. It showed that 96% were satisfied or neutral with CVM capabilities related to patient safety, 94% were satisfied or neutral with the decision of the organization to invest in CVM, and 96% believed investing in additional cameras was operationally necessary. Some of the qualitative responses included “worthwhile investment,” “we need more as we get wait-listed a lot and need them when we are understaffed,” “cameras are very helpful and we are often waiting for one to become available,” “save lines and falls,” “there is always a wait-list,” and “they're a great resource for a variety of specific situations.” These subjective responses show a perceived need among a variety of nursing staff related to CVM expansion.
Readiness for growth is evident through both objective and subjective data within our organization. A variety of metrics including high stabilization of CVM utilization rates, sitter use demands, wait-list growth, and national/local increases in behavioral health care needs show meaningful metrics that will be used for CVM expansion in our organization. One of our most powerful metrics, however, is the subjective data related to staff perception of expansion needs. Research shows that increasing nurse engagement is positively related to staff involvement in organizational decision-making and that leaders should identify strategies to encourage this collaboration.16 Thus, ensuring that we act on the need for expansion from a staff nurse perspective is an imperative aspect of multilevel empowerment in our Magnet organization.
Our program was successful in writing an expansion initiative using these metrics, and we plan to add an additional 13 cameras to our fleet. In addition, our partner community hospital decided to leverage an opportunity to expand our CVM program into their facility. Thus, we will be adding on a total of 23 additional cameras as part of the program expansion and creating a hub and spoke model with our community partners.
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