Southcoast Health System: Reducing the Use of Safety Sitters

Southcoast Health System's well thought-out program to reduce patient "sitters" - the individuals who spend time with patients to ensure that they do not fall and injure themselves - makes sense financially for the system, but has its genesis in improving patient safety and strengthening the caregiving team.

"They're not just sitting there. They are now interacting with the patients" says Joyce Dolin, R.N., the director of patient services at Southcoast. "So we changed the name."

But the changes go far beyond the two new titles - Patient Care Observer and Therapeutic Assistant. Southcoast, which is the parent of Charlton Memorial Hospital (Fall River), St. Luke's Hospital (New Bedford), and Tobey Hospital (Wareham), instituted a whole new program of re-training, clustering of fall risk patients, more coordinated handoffs between caregivers, plus new equipment, and a new "culture" among the observers and assistants and the other caregivers with which they work.

ASSESSING THE ISSUE

Southcoast hospitals each had their own fall prevention team, but beginning in 2009, hospital officials put together a falls team across the entire system. They also hired a consultant, assessed all the numbers at the various-sized hospitals, reviewed new equipment, assessed alarm systems, and more, ultimately coming up with a multi-pronged plan.

"An overriding goal was to move away from the use of restraints - which are used as a last resort," says Karen Pehrson, psychiatric clinical nurse specialist at Southcoast. "So we had to see what was out there, while reducing the amount of sitters, which was a tall order."

NEW EQUIPMENT

The falls team looked at acquiring a new form of patient beds that are constructed very low to the floor; they're about six inches high with a two-inch pad next to them, so if patients roll off the beds, they only have a four-inch fall. But re-fitting 750-beds in the entire Southcoast system proved to be very capital-extensive and  not necessary for all patients, so  the beds are used on select patients.

Southcoast then looked at various alarm systems before finally settling on one manufactured by Posey Healthcare Products.

"Their alarm is very clear so you can hear them outside of the room, plus they don't need to be reactivated," Pehrson said. "Every time you add another layer of decision making, you add another layer of potential error, which is why Posey's auto-reactivation capabilities appealed to us."

Plus the new alarm, which warns patients that they may be at risk of falling, is able to be recorded in the patient's native language, using the voice of a relative or loved one.

And rather than use restraints to stop, say, an elderly, mentally-impaired patient from pulling out their IV (a common occurrence at hospitals), Southcoast uses a knit sleeve which runs over the thumb and almost up to the shoulder. It not only covers the IV site, but elders like it because it is warm and protects frail elbows as well. Southcoast is also experimenting with a "freedom splint," a large blue, plastic balloon arm covering that gives people a large range of motion but, again, prevents damage to the IV area.

Patients with dementia are also outfitted with an activity apron, which contains many zippers, buttons, Velcro tabs, and more to occupy those patients who have a need to be busy.

"Some people are very fidgety and their attention is turned to the apron," Dolin says. "For those with dementia, it's good to redirect their attention."

Other patient safety and fall preventers include torso support that holds patients upright in their chairs. It's not a restraint because they can easily release themselves - at which point they hear a recorded voice reminding them they may be at risk.

"It's all about finding humane ways to give people reminders and cues," Pehrson said. "You don't restrain people just because they are at risk of a fall".

NEW SAFETY ZONES

Aside from the use of new equipment, Southcoast began to coordinate how high-risk fall patients are served in the hospital. First, they clustered patients so that one observer could watch four people at once. But gradually they took their concept to the next level, creating "safety zones," which are two semi-private rooms (four patients) staffed by personnel who are trained in dementia and psychiatric issues.  A brochure developed through the hospital's education department explains the safety zone to patients and their families.

Admissions criteria was created for the safety zone and patients are reassessed every shift to see if they still should be located there.

Attempts are made to make patients in the safety zone as comfortable as possible, meaning Southcoast attempts to find out from family members the person's daily routines. What time do they usually go to bed and get up? When do they eat? Do they play cards? By keeping patients to a familiar routine and surrounding them with familiar touchstones, such as pictures of family, the patient feels less compelled to move around and risk a fall.

One of the biggest fall risks is the transition from one area of the hospital to another, so Southcoast assessed the entire handoff hierarchy. Like other hospitals, Southcoast uses the "red slipper" logo on charts (and actually provides them to patients) so everyone, from nurses, to patient transporters, to technicians in the radiology department, knows that a patient is a fall risk.

IT'S ABOUT THE PEOPLE

Even though Southcoast reconsidered the equipment it uses, the places in the hospitals where fall risks are clustered, and more, the biggest change - and the one that goes to the heart of care at the hospitals - involves the people it hires as Patient Care Observers and Therapeutic Assistants.

"In the past we had unlicensed people with only three hours of training serving as sitters," says Karen Pehrson. "This wasn't good enough. People dealing with patients who have drug and alcohol issues, or who are suicidal, really need more in-depth training."

Southcoast surveyed the literature from Chief Nursing Officers and others throughout the U.S., and developed two new job descriptions - Patient Care Observers for those who have a high-risk of falls, and Therapeutic Assistants for those dealing with patients with psychiatric or drug abuse problems.

"People are not always adept at dealing with both populations," Dolin notes.

Patient Care Observers (PCO) are given 8.5 to 9 hours of classroom training. They learn a great deal about elders, about Alzheimer and dementia. "We do role playing where they have to intervene with someone who is escalating," Pehrson says. "We want them to I.D. an escalating situation and know how to diffuse it." The PCOs can help someone from bed to chair or from chair to bathroom but they don't handle any blood or fluids.  However, Pehrson says they are taught core emergency skills - CPR, how to recognize stroke symptoms and, most importantly, how to get help fast.

"I've seen our people do wonders by just using a soothing voice to really keep patients  safe," Dolin says.

Training for the Therapeutic Assistants is the same for the first five hours of the classroom but then they focus on behavioral issues and psychiatric patients.

"These are much more aggressive types of behaviors," Pehrson says, and it takes a different type of personality.

One of the training exercises Southcoast does is to put the TAs in full four-point restraint so that they can "experience that situation and have compassion for what it is like for patients," Pehrson says. "We don't want them to stigmatize people because they have a brain disorder."

THE RESULTS

Southcoast's fall rate per 1,000 patient days fell from 3.01 to 2.98 - a small drop but a drop nonetheless. "Plus there's better patient care," Dolin notes.

The system's next steps are to try to find flexibility between the PCO and TA positions so that one can fill in for the other at peak times.  (There's a peak time for elder care, during flu season, for example, and even a peak time for suicides around the holidays, the hospital has found.)

But no matter who they work with, or at what times, the PCOs and TAs are making a difference, Southcoast's Pehrson says. "When our observers and TAs have compassion for patients, it's really good to see what they can do. It's not so much what you do with your hands to help someone, but what you do with your whole person. They really get the message that they are a key part of the caregiving team. They have an important role," she says.

--by John LoDico