After reading this article, you will be able to:
- Describe a nursing toolkit that helped one facility reduce falls and save more than $400,000
- Identify the components of the toolkit’s three-pronged approach to patient safety
- Explain how to educate physicians about new patient care models
Editor’s note: This article was written by Corrine Haviley, RN, MS, associate chief nurse at Central DuPage Hospital in Winfield, IL, and is based on her experience as the former director of medicine nursing at Northwestern Memorial Hospital in Chicago.
At Northwestern Memorial Hospital in Chicago, the use of sitters (staff members who sit with patients) had increased 30% without an associated decrease in the patient fall rate.
When I looked at the data and ran a regression analysis, the results were the same—which raised a red flag: Why do we order sitters?
Understand the need for sitters
I asked physicians and nurses why they had historically used sitters. I found that 80% of the time, sitters were ordered because patients were at risk for falls or line pulling, whereas 20% of the time, they were ordered because patients were in alcohol withdrawal or at risk for suicide. Other feedback I received regarding the ordering of sitters was: “The family wants them,” or “We’ve always used them,” but there wasn’t any real methodology behind the process.
I also noticed that sitters were ordered and weren’t told what to do, or were never told to go home, allowing them to stay on the unit for days. That was an expense the hospital was absorbing, because there is no reimbursement for sitters.
Develop a new safety model
I wanted to create a new model that took the decision for ordering sitters out of the physicians’ hands and gave more care opportunities to the nurses. So I began with two questions: “What can we do to better teach sitters and tell them what we expect?” and “How can we reduce the number of sitters and give staff nurses another opportunity to provide excellent care?” These questions made it clear that I needed a team to help build a new safety intervention model.
Intervene with a toolkit
Working with an interdisciplinary team of physicians, patient care technicians, nurses, pharmacists, advanced practice nurses, physical therapists, and administration, I developed a toolkit to help staff nurses intervene earlier with at-risk patients.
The toolkit included:
- An algorithm delineating the process for identifying interventions related to suicide or homicide, severe alcohol withdrawal, fall risk, elopement, and line pulling.
- The confusion assessment method survey, which screens for overall cognitive impairment and helps distinguish delirium or reversible confusion from other types of cognitive impairment.
- A 10-question, portable mental status questionnaire that detects the presence and degree of intellectual impairment.
- A three-pronged approach to safety: rooms, rounds, and relatives. This model was developed by staff nurses to ensure that the right questions were being asked during hourly rounding and that rooms were safe for patients. The model includes the following practices:
Rooms. Conduct room sweeps that include eliminating clutter, ensuring that personal items are in reach, checking that the bed is in low position with side rails up, and ensuring that the bed alarm is in use when indicated.
Rounds. During hourly rounding, ask the three Ps:
1. Do you have to go potty?
2. Do you have any pain?
3. Can I reposition you?
Relatives. Speak with patients and family members about the importance of patient safety. For example: “Your mother is at risk of falling, so please do not take her to the bathroom without us.”
- A scripting guide. Before a nurse leaves a patient’s room, he or she will say, “Is there anything I can do for you before I leave?” and “Someone will be back in about an hour. However, if you need something, please press the nurse call button.”
Educate physicians on change
Our team educated physicians about our new model by giving presentations with one simple idea: “This is our new approach to falls and patient safety. We don’t want you to order sitters. If you are worried that a patient is going to fall, talk to the unit manager so it can be decided as a team what would be best for the patient.”
The interdisciplinary team also wrote a letter to the chief of medical staff, who then distributed it to all physicians.
The letter stated: “The new model is a nursing function. As nurses, we are concerned with safety, and we want physicians to partner with our nurses because we don’t want to do anything in silos.”
Lastly, there was a control mechanism in the sense that a physician couldn’t simply order a sitter. If a physician tried, a supervisor would come to the floor and ask, “Can I help you with evaluating this patient?”
See a rise in success
Since the new model’s implementation in 2006, Northwestern has seen a savings of more than $400,000 from reducing the use of sitters. And fall rates have decreased from more than three to less than two per patient day.
Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, April 2009, HCPro, Inc.