sitter usage

[babsRN]

I am in need of ya'lls experience with sitter usage on med-surg areas and telemetry areas. I am manager of about 70-ish total telemetry beds. Half of these are informally considered as step-down ICU beds. Our current nurse patient ratio is about 1:4-6 depending on acuity and shift and all the other usual variables. The patient population is mixed 50/50 medical/surgical, with half being open hearts, s/p MI's, CHF, acute CVA, post interventional caths.

My inquiry is this: How does your facility use sitters as a replacement for restraint use? Where do the FTEs come from?...are they paid out of your cost center and therefore a negative impact on your productivity? In my experience, we use alot of sitters...some pay periods in excess of 600-700 hours...with many of these sitters being used to keep patients out of the critical care areas, for example: an OD who otherwise would go to the ICU for 1:1 observation is placed with a sitter in my post interventional area where the n:p ratio is 1:2-3, or the patient who is siezing and without a sitter would be in the ICU. There seems to be an opinion higher up in the organization that these are cute little old folks with oldtimers disease...that if I put mittens on these patients, or close the door to their room so they won't wander that this will fix it. After I stop rambling here I'm going to write a data collection tool to provide meaningful information to convince those above me that their ideas may not meet our needs. I'd love to hear from anyone having similar experiences...thanks!!

[askater]

I worked at a local hospital 5 minutes away. I disliked that job for many reason's. Lack administration support. Poor staffing. Unable to give safe care due to staffing. It was a step-down unit/med. surgical. We had 6 patients per R.N.

We had many patient's fall out of bed. Pull out foley's etc.

Than I went to a larger hospital. 35 minutes away. I thought it was great. They had sitter's. If I had a confused patient I'd call the Dr. and get a sitter order. (renew every 25 prn) The shift that started to notice the confusion usually didn't get a sitter, but used one of the nurses aides to watch the patients. I don't know how the funds work.

Now they changed it. They totally gear away from restraints (4 side railings up to posey's) What we are to do is call family. Request a family member to stay with the patient. If they are unable the family has to pay for the sitter. Which is a charge of $20 an hour (or something like that)

Prior when sitter's were accesible I noticed A LOT less need of incident report's. And obviously a lot less injured patient's secondary to fall or pulling on lines etc.

Now our hospital changed the rules.

[P_RN, ADN, RN]

For confused patients family member would be contacted and would hire their own sitter from an approved list. Or they could come stay with them. This was a general floor not telemetry.

For suicidal patients physician would order sitters 1:1 and that came out of the floor's budget. Only suicidal patients though.

One year before this ruling sitters/agencies cost well over $100k. After the ruling that was down to just under $9k.

Restraints were really restricted - JCAHO you know. For 4 point, there was to be loosening q 15 mins, vitals q 1h and q 2h doctor order renewal. Not many restraints either.

[thisnurse]

we use sitters for suicide patients and patients whom restraints wont hold. otherwise known by me as the "houdini" patients. im not sure how its paid. i know the doc writes the order and the hospital supervisor gets the sitter.

[Furball]

I'm suprised that some facilities make the families pay for sitters? Wow. Most sitters on my floor are for pts suffering from post op comps mainly from CABG's. Cardiac bypass can cause temporary forgetfulness or confusion. Metabollic encephalopathy is another biggie. My hospital pays for all sitters regardless of why it's needed. Guess we're quite lucky eh?

[misti_z]

We too use sitters for the "houdini" patients and suicide precautions, but sitters come out of our cost center. Only heard of family paying for a sitter one time....very wealthy family very elderly pt.

[grouchy]

Our hospital provides sitters, but we never have enough. When JCAHO tightened the restraint rules, I immediately thought that they were creating standards that hospitals (and, ultimately, taxpayers, businesses, and employees) simply cannot afford. That is, noone can afford the sitters, increased staffing, and environmental accomodations needed to minimize or eliminate restraints without increasing injuries. They have mandated a standard, but by not mandating funding for that standard they have simply created a new source of liablity for hospitals.

By the way, we have been told that placing all 4 siderails up on a bed is now considered a restraint and requires a doctor's order. I remember when only a few years ago I would have been considered negligent by my colleagues if I did not do this. Is this the rule at other hospitals?

[babsRN]

Thanks all for your replies to my dilemma. At my facility we are supposed to tell the families that they will be charged for the sitter time, however, I've not known the hospital to actually bill for this. In many cases the family is not available or not able to come in. Having this expensive coming out of the department adds up fast, and pulls staff from patient care since we're supposed to take it out of the daily hours of care alloted to each patient. There are times when there are up to 3 sitters on the floor, and if the census is low enough...theoretically it could leave one or no staff left to care for the rest of the patients if one is really going to be hard nosed about productivity.

I've found some research done on this and will be pulling articles next week after the holiday.

Thanks again!

[thisnurse]

babs...are you saying that the sitters are also NOT covered by insurance? this is out of pocket?

if that is the case then the hospital is saying it can't provide the care the patient needs.

wow.

four side rails up are considered restraints? is this a policy at your facility or is it jcaho?

amazing.

i think we need to restrain the people at jcaho.

[Jenny P]

JCAHO set the rules about 4 side rails up = restraints. We have some beds that have different controls on each of the 4 side rails, but have to leave a pair of side rails down even if it makes the controls inaccessible to the patients and the nurses. My unit (CV-ICU) had a history of minimal restraint use, but we still got nailed by them last June or July (before they said 4 siderails were restraints). They didn't like the way we got our MDs to order restraints daily; it had to be EVERY 24 HOURS!! and the doc was to come in and evaluate the pt. themselves before we could apply restraints. YEAH RIGHT! I posted a thread on it at the time; later, JCAHO backed down and said we could restrain pts. before the doc saw them. We had quite a write-in campaign at the time, and I wrote to my state senators and congressmen about this rule. Something helped, but then the rule about the side rails came out (I doubt if they were connected, though). We use sitters frequently, but I don't think they count as part of our staff. I don't know how they are budgeted for.

[thisnurse]

the four side rails up was never mentioned as being a form of restraint. looks like ill be browsing the procedures manual today. lol

[babsRN]

To confirm...side rails are indeed a type of restraint in JCAHO's eyes...hard to swallow when you're an old fart who even two years ago used to shout from roof tops..."Get those side rails up, d*** it!!" . Also interesting twist that "thisnurse" puts into discussion...that by billing the patient's family suggests the facility is unable to meet the needs of the patient. I'll have to chew on that one a while. Thank you thisnurse, I love statements like this that make me think! b