Observation Assistants: Sitter Effectiveness and Industry Measures
Andrew D. Harding, RN, MS, CEN, NEA-BC, FAHA
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Purpose: The use of observation assistants (sitters) is a means for direct observation of patients for the purpose of providing a safer environment for the patient. There are no defined industry standards for the use, efficiency, or financial measure of sitters. This project sought to improve the effectiveness, utilization and financial costs of sitters.
Design: Performance improvement project prospective is designed to study and improve the processes of providing healthcare services to meet the needs of patients and stakeholders.
Setting: This performance improvement project occurred in a free standing 140 bed acute care hospital that receives 54,000 emergency department visits annually, in suburban Massachusetts.
Participants / Subjects: The subject was the process of sitter requests and utilization. The registered nurses with a bachelor of science in nursing or masters' degrees were only 31% of the active staff and 96% female.
Methods: Data were collected related to the unique patient visit requests for sitters per shift, the indication for the sitter request, the patient and hospital unit demographics, the financial costs of using sitters by patients visiting the emergency department (ED) and inpatient units (except the nursery). Interventions were implemented in March 2009 allowing comparisons between the first 5 months and the last 7 months of fiscal year 2009 (FY '09). After reviewing the literature and first five months data the project's interventions were selected. Comparisons of the data before and after intervention implementation were completed.
Eight interventions were implemented including an electronic intranet based requisition system for direct care providers. Indications for sitter use were limited to patients at risk to harm themselves or others and patients at high right to fall, per the SAD PERSON tool & Morse Fall Score respectively. Nurse manager & nurse supervisor in-person clinical review of patients prior to the next shift helped to identify alternative interventions. A sitter education program was provided. Increased hiring and use of per diem for all employees acting in the role was instituted. Scrutiny increased for using overtime. The construct of average daily census (ADC) was used to present the data in all forums and reports.
Results / Outcomes: No elopement or assaultive behaviors were documented for patients with a sitter. The fall rate had no relationship to sitter use. Actual sitter ADC increased 17% monthly on average in the last 7 months of FY æ09. The average hourly rate paid to sitters was reduced by $1.89 or 12.4%. The percent of overtime of monthly total dollars was reduced from 26.8 % to 15.6%. Average daily census is a useful construct for displaying the data about sitters for internal and external stakeholders.
Implications: The use of sitters had no relationship to fall rate, assaultive behaviors or self harm. There were no relationships between ED or inpatient volume and actual sitter use. The interventions used to reduce the cost of sitters were effective. The ADC construct is suggested for comparison and industry standardization. Research is needed to determine the effectiveness of sitters.
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