Some patients are unable or unwilling to follow directions from medical staff. They might attempt to get out of bed without assistance, or they might be apt to remove an oxygen tube or an essential IV.
In those cases, New Hanover Regional Medical Center employed sitters to provide one-to-one care. In Fiscal Year 2015, the cost of that care increased to over $1.4 million. In order to accommodate more patients, nursing assistants would have had to be moved off the floor, increasing the number of patients for the other nursing assistants to care for. Clearly, another approach was needed. In March 2015, Nursing Leadership challenged Patient Care Operations and Patient Safety to identify a new approach for caring for these patients at the hospital.
Our workgroup established a goal of enhancing the patient and family experience by investing in training and technology to create an environment of patient safety, while reducing overall labor expense for providing this service.
A workgroup of key leaders and staff was assembled. Working with a Lean coach, the team brainstormed ideas and concepts, which were categorized using Lean PDSA (Plan, Do, Study, Act) methodology. The team evaluated the plausibility of centralizing the monitoring of sitter patients by placing cameras in patients' rooms.
The NHRMC team first tried to solve the issue as quickly as possible. Funds were allocated for NHRMC to work with a local vendor to build a camera. But the camera, while functional, had two limiting factors – it took several weeks to build and it could not interface with the NHRMC Electronic Medical Record (EPIC). After donating the camera to Hospital Police, the team regrouped, performed additional PDSA cycles and used the Lean process to develop a proposal A3. This systematic problem-solving tool allowed the team to look at the issue from all sides before looking for the best solution.
Identifying those best served
After applying Lean thinking to the process and reviewing the categories of patient sitters, the team first ruled out which patients would not be suitable for remote monitoring:
- Suicide patients
- Infection Prevention and Control patients
- Involuntarily committed patients
That left one core group of patients for whom remote monitoring might be a good fit - medical sitter patients. They became the team's primary focus.
Based on data, the team knew that Cognitive/Medical and Transition from Restraint patients comprised, on average, 14 sitter requests per day. The hospital had begun to place these patients in adjacent rooms so that one sitter could watch both rooms. Their medical conditions, with some exceptions, could be monitored remotely.
A system and a plan
Patients who need continual supervision are not restricted to any particular nursing unit. Therefore, our team decided that mobile monitoring units were needed instead of cameras that were mounted in the patient rooms.
Additionally, the technology needed to be reliable and compatible with NHRMC's existing technology. The cameras also needed audio capabilities so that patients and staff could communicate. We contacted our partner of choice “AVASYS.” With their help and with feedback from the team, we developed the following proposal:
- Increase patient safety and reduce medical patient sitter costs by using virtual monitoring technology.
- Utilize 30 wireless virtual monitoring units from a pre-selected centralized location (Patient Placement Office).
The results have benefitted NHRMC in several ways:
- Financially: NHRMC recouped the cost of implementing the system within the first year and had a dramatic cost avoidance.
- Patient Safety: By using tele-sitters instead of bedside sitters, NHRMC is able to closely monitor more patients than before. As a result, NHRMC has seen a decreased fall rate among our rehabilitation patients since the tele-sitter program was adopted.
- Staffing: In an average month, 10 employees who had been used as sitters are being re-positioned in other areas of patient care.