BY IMPLEMENTING a clinical assessment bundle (CAB) stratifying delirium, dementia, and fall risk levels, nurses have been able to make sound clinical judgments to initiate or discontinue one-to-one sitters. Internal benchmarking shows a reduction in sitter hours, costs, and falls in 2015 compared with 2014. This article describes implementation of a CAB to stratify safety risk behavior levels by applying the clinical assessments for delirium, dementia, and fall risk. It provides nurses with clinical assessment criteria to use as a basis for their clinical judgment and helps them practice at the top of their license to appropriately initiate or discontinue a one-to-one sitter.1
Falls and fall prevention in hospitals are nurse-sensitive indicators of quality.2 To ensure the safety and well-being of patients with delirium and associated agitation, confusion, impulsivity, disorientation, and aggression, hospitals routinely use sitters for constant one-to-one observation. Sitters have become the mainstay and standard practice across healthcare for the management of patients with delirium and associated safety risk behaviors.3-7 The supporting evidence about the clinical benefits of constant one-to-one observation and improved clinical outcomes is limited.8 Fall data suggest the use of sitters may be associated with a higher percentage of assisted falls because members of the staff are already present and capable of assisting the patient to the floor, lowering fall injury rates.8,9
In the acute care setting, one-to-one sitter usage is driven primarily by nurses' requests to support a safe environment.3,10,11 A review of the literature uncovered little research that used consistent criteria for sitter deployment with a standardized patient risk level stratification guide to support decisions to initiate or discontinue sitters.
Literature suggests that implementing operational or equipment changes to monitor patients with hyperactive delirium behaviors can reduce sitter usage and care costs and improve patient safety for patients with delirium. This includes cohorting patients and altering unlicensed assistive personnel (UAP) assignments into smaller groups of four patients or fewer. Some organizations have instituted monitoring units that use mobile or stationary constant video monitoring. Various hospitals agreed that sitter staffing expenses were consistently high and continuing to escalate.10,12-16
The intent of this evidence-based project was to translate a CAB of best practices for prevention and treatment of delirium into an innovative safety risk stop-light stratification tool designed for our nurses to use when making clinical judgments to appropriately initiate or discontinue one-to-one sitters. As the level of behavioral safety risk increases based on the clinical assessments, the intensity of the nurse-led interventions increases up to and including the decision to utilize one-to-one sitters.
Internal sitter benchmarks were calculated from the 2014 sitter data by our physician epidemiologist-strategist, a Lean Six Sigma black belt. (See Understanding Lean Six Sigma.) We'd spent approximately $2.8 million of unbudgeted, nonreimbursable salaries to provide an average of 568 sitters per month, yet in the quality data reported for all adult inpatient units, fall rates hadn't declined. Although alternate nurse-led interventions were available to staff to manage delirium safety-risk behaviors, cultural and customary first-line practice expectations were to seek provider orders to initiate one-to-one sitters. Although our care costs and staff resource use for one-to-one sitters had continued to escalate, our internal benchmark fall rates didn't decrease. This value-based care project focused on reducing sitter care costs while improving our system, process efficiencies, and quality of care related to falls.
Following a value-based project model, an interdisciplinary workgroup of key stakeholders was formed by the advanced practice registered nurse (APRN) manager for value-based care projects. The workgroup consisted of APRNs, RNs, nurse managers, a physician epidemiologist-strategist, the director of evidence-based practice (EBP) and research, education specialist, system analyst, nursing performance improvement staff, geriatricians, internal medicine physicians, and a process engineer. As a clinical team of experts, we recognized the current process for determining sitter need wasn't based on clinically sound assessment criteria. For nurses to practice at the top of their license, we needed to shift the culture to a nurse-led process and translate EBP into opportunities to improve care.1
We accepted that current clinical policies related to managing or identifying risk factors that contribute to the development of delirium weren't effective, contributing to resource waste and higher care costs, negatively impacting staff satisfaction due to disrupted unit workflows, and contributing to increased lengths of stay. From the onset, we recognized that the greatest barrier would be overcoming a long-standing organizational culture of using constant observation by one-to-one sitters to manage patients with signs of delirium.
Root-cause analysis showed a lack of knowledge about contributing risk factors, clinical assessments, and nonmedication nurse-led best practice interventions for patients with delirium. Filling gaps and taking advantage of opportunities could improve our care. We acknowledged the sitter role was limited to verbally or physically redirecting patient behaviors.12 The escalating requests to provide one-to-one sitters created a staff resource demand met by reassigning ancillary staff. Both the nurse staff advisory and night councils began to voice dissatisfaction because these ancillary staff reassignments were impacting unit workflow, workload, and efficiency.
We recognized that ensuring patient safety was a responsibility to be shared by all healthcare team partners. We searched the literature and networked to translate best practices into our policy and process revisions. Following Lean Six Sigma concepts, the Pareto chart for 2014 one-to-one sitter use showed that the three categories where waste could be reduced the most were delirium, impulsivity, and fall risk. The project goal was to reduce one-to-one sitters by 74 per month (from an average of 308 sitters per month to an average of 234.) The sitter reduction targets for 2015 were based on a 19% reduction from the 2014 usage. Internal sitter benchmarks were calculated by our physician epidemiologist-strategist from the 2014 sitter data.
We identified process inefficiencies, opportunities to improve care and patient outcomes, and outcome metrics to measure improvements. The opportunities we identified within our organizational processes included:
- shifting from a people-dependent process to an automated process by using electronic medical record (EMR) documentation to identify sitter needs by unit, based on patients' hyperactive delirium behaviors.
- establishing a standard operating procedure guide for team role accountability incorporating delirium management best practices.
- identifying internal sitter benchmarks to quantitatively determine internal improvement.
- establishing a standardized process for accountability to monitor, track, and sustain the practice change improvements.
- partnering with geriatricians to conduct housewide education on delirium risk factors, clinical assessments, and evidence-based interventions for patients with delirium and stratify delirium safety risk levels using clinical criteria.
The action plan implementation, which consisted of two phases, received unanimous support from all stakeholders. Before moving forward, we partnered with the geriatricians who initiated intensive education for APRNs, nurses, physicians, and involved departments on delirium risk factors, assessments, and pharmaceutical and nonpharmaceutical evidence-based interventions to prevent or improve delirium symptom management.
Phase one involved a 3-month transition phase to allow APRN coaching of staff RNs on assessment of delirium, identification of hyperactive delirium behaviors, and evidence-based nurse-led interventions.
Phase two involved implementing a nurse-led standard operating procedure to initiate and discontinue sitters, based on clinical criteria and stratified safety risk, that didn't require a provider order.
Starting June 29, 2015, when phase one began, hospital-employed inpatient APRNs were enlisted to take 24/7 sitter call to manage and appropriately address all nurse-driven sitter requests. This transition phase involved shifting accountability for provider one-to-one sitter orders to APRNs. This let the APRNs mentor and collaborate with the requesting nurse. Operationally, APRNs accepted 24/7 sitter ordering coverage for 19 units during this 3-month transition period. We excluded on-call for five units that already had combined APRN and physician assistant coverage, such as the ED, the surgical ICU, the cardiac ICU, and one surgical step-down unit. The behavioral health psychiatric unit was also excluded.
All on-call schedules were completed by the APRN team leader volunteers who coordinated the scheduling coverage with their peers. Daily, the assigned APRN would round on the assigned units to evaluate the need for sitter continuation based on collaboration with the assigned nurse. As unit rounds were made, APRNs reinforced education with the nurse, nurse manager, and administrative supervisor about contributing delirium risk factors, clinical assessments, and trialing nurse-led interventions for patient safety before making the clinical judgment to initiate a sitter. This was to prepare to move to the nurse-led initiation and discontinuation in phase two.
Phase one metrics showed that APRNs had a positive effect. The data demonstrated that one-to-one sitter use for safety risk management behaviors decreased by 41%, care cost decreased by 28%, and sitter use and falls declined. Restraint use levels remained unchanged, below national benchmarks.
The clinical nurses were expected to review the delirium risk checklist, complete assessments, and trial nurse-led interventions. If, in the nurse's clinical judgment, one-to-one sitter use was warranted and trialed interventions weren't effective, she or he would review the decision with the nurse manager or the administrative supervisor before initiating the call to the APRN. This was to reinforce the learning curve for those involved. When contacted, the APRN was expected to question the nurse about the contributing risk factors identified, assessment findings, and trialed nurse-led interventions and their outcomes.
Phase two involved implementing a nurse-led standard operating procedure to initiate and discontinue sitters, based on clinical criteria and stratified safety risk, that didn't require a provider order. As clinical leaders, the APRNs were successful in achieving the established goal for value-based care and quality outcomes.
Before the transition to phase two, the nurse-led sitter initiation and discontinuation policy and process were developed to clearly define a standard operating procedure guide with role accountability and monitoring and tracking processes for sustainability of the practice. RN representatives from night and staff advisory councils, nurse manager representatives, APRN representatives, and geriatricians all participated in the policy and process development.
Knowing nurses were already completing assessments for delirium, dementia, and fall risk, we integrated these assessments into a three-tiered risk stratification tool using a stop-light color coding system. (See Risk levels for sitter utilization.) The green assessment criteria reflect nurse-led universal safety interventions; amber or yellow assessment criteria reflect moderate safety behavior management risk with an increase in the nurse-led safety measures to be implemented; and red assessment criteria reflect the high safety behavior management risk with the most advanced nurse-led safety interventions to be trialed up to and including one-to-one sitter initiation.
The policy includes a process for sitter huddles at intershift report, sitter weaning, patient cohorts to create a safety zone, and revised EMR sitter orders.16 The safety zone assignment of up to four patients lets the assigned UAP round on the cohorted high-risk patient or patients every 15 minutes and provide interactive care consisting of mobility and diversionary activities.
From June 29, 2015, to October 1, 2015, care costs significantly declined and sitter utilization decreased while quality indicators for falls and restraints were maintained. (See Average number of sitters in 2015.) We've successfully transitioned from a reactive provider-led initiative to a proactive nurse-led sitter initiative empowering nurses to practice at the top of their license.1 The nurse-led sitter initiation and discontinuation policy constructed under the auspices of the interdisciplinary workgroup resulted in improvement in both systems and processes such as:
- a standardized operational procedure guide defining the accountability expectations for all team roles and expanding the role of the sitter to include best-practice interventions for delirium management.
- implementation of intershift sitter huddles, sitter weaning, patient cohorts of high-risk patients, every 15-minute staff sequential rounding assignments involving four staff members, and daily multidisciplinary rounds.
- revision of the sitter documentation tool to improve RNs' ability to evaluate the need to continue sitters based on the documented redirection needs.
- creation of internal sitter utilization benchmark measures to assess sustainability improvement.
- partnership with geriatricians to define the delirium risks, assessments, and nurse-led safety interventions within the policy and standard operating procedure.
- implementation of geriatrician-developed delirium educational programs for clinical staff.
- APRN provider pocket references on key points from the delirium educational presentations.
- partnership with the staff advisory and night staff RN councils to educate unit staff and monitor and track practice change.
- implementation of a sitter alert process, which automatically activates when the sitter numbers exceed internal benchmark measures for threshold or above threshold.
- partnership with our director for bed capacity management to incorporate our sitter volume into the bed report distributed to all administrative staff three times/day, 7 days/week.
Implications for nursing practice
Along the way, many lessons were learned. (See Tips for clinical nurses.) Because the reporting structure for APRNs is decentralized by departments, transparency of communication with administrative staff in the planning stage is paramount to project engagement from inception. Additionally, in the planning stages, anticipating the organization's culture and being ready to accept or embrace changes are essential.
Transitioning from process inefficiency and variations to process efficiency and consistency is a journey and not a destination. For each shift, we've assigned accountability to continue to monitor and track the number of sitters by department for meeting appropriate clinical use guidelines. By establishing a nurse-led practice for initiation and discontinuation of one-to-one sitters for managing safety risk behaviors associated with delirium, dementia, and fall risk, nurses can practice at the top of their license. By defining a sitter alert standardized process, integrating all levels of administrative accountability, we can demonstrate value-based care at its best, lower care cost for this population, and achieve higher-quality care outcomes with reduced falls and sustainable low restraint use. The organization's success and the sustainability of its value-based care are built around interprofessional partnerships with a common goal of improving patient outcomes.
Understanding Lean Six Sigma
Over 5 decades ago, the Toyota Motor Corporation's identification of the benefits of continuous improvement was visionary.17 Toyota's practice of Kaizen, or Lean, the continuous improvement of processes, demonstrated that the most important factor affecting process improvement and quality is standardization. Many industries, including healthcare, have adopted Lean because of its proven merits.18 Standardization can help reduce the waste of administrative and clinical inefficiencies, which most often are targeted by healthcare organizations striving to control costs.19
One tool sometimes used in Lean Six Sigma is a Pareto chart. This graph concisely shows the relative weight of the differences between groups of data.20
Source: Adapted from Thieret D, Clark E, Carbaugh DL. Electronic forms trump paper for surgical scheduling. Nursing. 2015;45(10):16-18.
Tips for clinical nurses
- Demonstrate collaborative nursing leadership skills by actively engaging in interprofessional partnerships that provide opportunities to continuously improve patient experiences and outcomes.
- Recognize system and process inefficiencies and opportunities that can be improved to support better clinical outcomes. For example, policies were developed or revised to ensure efficiency and to empower clinical nurses to practice at the top of their license based on education.
- Anticipate barriers to practice change and formulate strategies to overcome them.
- Recognize the significance of nurse-to-nurse peer review to support practice change sustainability and provide ongoing peer support.
- Utilize existing programs such as the HELP program (Hospital Elderly Life Program) to assist with evidence-based, safe care of these patients and sequential rounding every 15 minutes using support staff.
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