ABSTRACT LEADING FOR ACCOUNTABILITY FROM THEORY TO PRACTICE!

Introduction: Patient safety remains a primary focus for better healthcare. The use of patient sitters delivers direct surveillance of patients with the goal of providing a safer setting for the patient. The cost associated with staffing additional resources places a taxing burden on healthcare institution. Additionally, little evidence exists to support the use of sitters as fiscally responsible or reducing patient harm (Harding, 2010). Background: High rates of sitter utilization have occurred for multiple years without demonstrated improvement to patient safety. Multiple initiatives to bring sitter utilization in line with budget have been implemented, such as limiting the number of scheduled sitters per shift or utilizing “roamers” to travel from patient area to patient area checking on high risk patients every fifteen minutes. Unfortunately, sitter utilization remained high, costs soared and no improvement in patient safety was achieved. At the pinnacle of despair, the facility reached an all-time high patient fall rate and high sitter utilization. Project: The nursing leadership team developed a sitter algorithm to guide critical thinking and decision making. Additionally, Vanderbilt’s ABCDE critical care algorithm for delirium assessment and early mobilization was implemented and later adapted for general practice areas (www.icudelirium.org). Multidisciplinary education was provided to physicians, nursing and ancillary departments. Best-practice restraint and fall safety alternatives to protect patient from harm were implemented. Despite all these efforts, sitter utilization was still significantly above budget. To this point, attention and energies focused only on the number of sitters and dollars. However, as the facility embarked on a Relationship Based Care (RBC) journey, the focus changed to the relationship between the healthcare professional and the patient and the mutual contract of keeping the patient safe. Methods: Identification of sitter utilization through a RBC lens led to the question of what relationship needs repair. The key dysfunctional relationship was between the healthcare professional and the patient in which the healthcare professional perceived the inability to keep patients safe and free from harm. Since high sitter usage was a symptom of the broken relationships then theoretically if the relationships are repaired, sitter usage should go down without an increase in harm to patients. This ignited a shared vision and inspiration because as healthcare professionals, we all want to keep patients safe. Through several nursing leadership meetings the model of Leading for Accountability© was transformed into a living action plan that guided the newly established vision (Wright, 2007). Each step designed by the nursing leadership team is outlined in Figure 1 Leading for Accountability©. A pivotal moment that transformed the “how it had always been done before” mentality was during individual eye to eye (E-E), knee to knee (K-K) sessions between the Chief Nurse, the directors and managers in which expectations were clearly articulated.

Results: 2012 (January to June) and 2013 (January to June) data was compared for sitter cost, sitter hours, acute care falls, acute care falls with injury and restraint hours. Total dollars spent on sitters has decreased by $20,000 to $40,000 per month (2013 YTD) as compared to same time period in 2012. The daily use of general risk sitters (sitters not assigned to patients identified as suicidal or homicidal) has been maintained below the budgeted daily allotment. Acute care falls have decreased from 3.46 to 3.22. A modest increase was noted for acute care falls with injury from 1.06 to 1.09. However, the total number of restraint hours decreased nearly 5% and the number of prolonged medical/surgical restraint use (>72 hours) decrease by 15%. Also, the total number of med/surgical patients in any type of restraint increased by 67 patients in 2013 YTD as compared to same time period in 2012. Conclusions: The model Leading for Accountability© served as a valuable roadmap to guide the project. Significant improvements have been achieved with patient safety metrics and cost benefits. Additionally, the change in culture from the once automatic request of a sitter to collegial dialogue is paramount. This cultural change was demonstrated during a random evaluation of sitter utilization conducted by the Clinical Nurse Specialists post program implementation, a staff nurse eagerly reported what she had done to prevent sitter use and how she protected her patient from harm (Pictures 1-3 are a re-enactment of that experience with Nurse Nancy). The facility is confident that Leading for Accountability© model to keep patients safe and free from harm will have a lasting impact on care delivery.

RESTRAINT RESULTS

Translation from Theory into Practice: One Hospital’s Journey to Keeping Patients Safe and Free from Harm

Jennifer Ernst MSN, RN, GCNS-BC, Tara Nichols, MS, RN, CCRN, CCNS, ACNS-BC, and Josephine Wahl, RN, MS, NE-BC, FACHE & HFWH Nursing Leadership Team

Henry Ford Wyandotte Hospital, Wyandotte (HFWH), Michigan, USA

REFERENCES

RESOURCES

•Baron, M. (2009) Journal abstracts: strategies to minimize the use of sitters. Massachusetts Organization of Nurse Executives. P 1-10.

•Boswell, D.J., Ramsey, J., Smith, M. A. & Wagers, B. (2001). The cost-effectiveness of a patient-sitter program in an acute care hospital: attest of the impact of sitters on the incidence of falls and patient satisfaction. Quality Management in Health Care. 10(1), 10-16.

•Harding, A. D. (2010). Observation assistants: Sitter effectiveness and industry measures. Nursing Economics. 28(5), 330-336.

•Vanderbilt University ABCDEs of prevention and safety www.icu delirium.org

•Weeks, S.K. (2011). Reducing sitter use: decision outcomes. www.nursingmanagement.com . 37-38 DOI-10.1097/01.NUMA.0000407582.12602.21

• Wright, D. Establishing a system of accountability: The manager’s role 453-460. In Koloroutis, M. Felgen, J., Person, C. and Wessel, s. (eds.) (2007). Relationship-based care field guide: Visions, strategies, tools, and exemplars for transforming practice. Minneapolis, MN: Creative Health Care Management. •A reference list with these and additional reference available upon request

Figure 1. Leading for Accountability © model transformed to keep patients safe and free from injury, depicts the action plan developed by the nursing leadership team as they operationalize the language of RBC into the process.

SITTER COST/ACUTE CARE FALLS

Product Picture Suggested UsageSkin Sleeve PS#253544 S PS#253530 M PS#253534 L PS#253537 XL

Elbow Immobilizer PS#253539 Infant

PS#253547 Infant Large PS#253546 S PS#253545 M PS#253529 L

Activity Apron PS#253531

Non-slip Grip PS#253542

Personal Alarm PS#225577 (alarm)

PS#253536 (replacement cable)

Bed & Chair Alarm PS#253538 (alarm)

PS#251240 (bed pad) PS#253532 (chair pad)

PS#253538 (replacement cable)

Self-releasing Lap Belt PS#253541 S/M PS#253535 M/L PS#253528 XL PS#253533 XXL

Wedged Seat Cushion PS#253540

RESTRAINTS RESTRAINTS RESTRAINTS

Any restraint use requires a physician order!

Safety equipment chart created by Jennifer Ernst MSN, RN, GCNS-BC

Veil Bed• Least restrictive• Considered restraint-free onlyif unzipped

Mitts• Prevents grabbing, scratching, hitting

• Prevents disruption of medical treatments by camouflaging IV sites & wound sites• Helps protect thin, fragile skin

• Prevents disruption of medical treatments by camouflaging IV sites & wound sites• Immobilizes elbow joint

• Alerts staff to attempts to exit bed, chair or toilet seat unattended

• Alerts staff to attempts to exit bed or chair unattended• Used w/ bed or chair pad sensor

• A reminder aid to prompt patient before ambulating independently• Restraint-free if Velcro in front• For limited upper trunk control

Hard Restraint• For aggressively combative, agitated • Extreme risk for self injury

Soft Restraint• For moderately combative, agitated• At risk for self injury

• Reduces potential for forward slide• Improves posterior pelvic tilt

Lap Belt• Less restrictive• Belt is a restraint if velcro to back

• For patients with decreased cognitive function• Provides visual and tactile stimulation

• Reduces potential to slip from chair or foot rests• Improves grip for assistive

Figure 7. Safety algorithm and equipment guide for safety assessment and intervention

Figure 3. Comparison of 2012 and 2013 total number of general risk sitters per shift..

Figure 2. Comparison of 2012 and 2013 total sitter costs.

Leading for Accountability© Model Implementation

Picture 2. Nurse mobilizes patient to recliner chair, secure lap belt and makes sure the belt is not to tight.

Picture 1. Nurse relocates patient to doorway to orient patient to surroundings and allows engagement with the staff.

Picture 3: Yellow socks alert staff that the patient is at risk for falling.

Figure 6. 2012 and 2013 restraint data. Figure 5. 2013 acute care falls and falls with injury after implementation of Leading for Accountability© Model.

Figure 4. 2012 acute care falls and falls with injury prior to implementation of Leading for Accountability© Model.

Wright, D. 2007

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