It's Friday evening at Anywhere USA Children's Hospital, and on the hematology/oncology unit, a "threat of violence" code calls out from the overhead system. A patient with hyperkinetic behavior is attempting to harm his safety attendant.
One floor down, a patient admitted for suicidal ideation found and tucked away a safety pin while in the playroom with her safety attendant. Later in the evening, the security team thwarts an escape effort by a disgruntled teen when the safety attendant peeked her head out of the room to ask for a needed break.
The ripple effects of the increasing number of pediatric behavioral health boarders, technology-dependent patients, and medical patients with atypical development are being felt in children's hospitals across the country.
An estimated 1 in 10 hospitalized children over the age of 3 has both a medical and a psychiatric diagnosis, resulting in an increase in the number of pediatric psychiatric patients boarding in pediatric emergency departments and acute care facilities.
Trauma-informed programs, therapies and pharmaceutical management are invaluable tools, yet these patients often remain in acute behavioral crisis throughout their hospital stay and require additional measures to ensure their safety.
This has created an increased need for safety attendants, specialized training for providers and staff, additional security measures, and facility, patient and staff safety regulations.
Safety attendants have been used in a variety of health care settings for decades, however the training, use and efficacy of these programs vary.
Most existing literature supports the use of a regimented safety attendant program to prevent falls, but their efficacy and cost remain inconsistent for other diagnoses such as delirium, elopement or self-harm. Despite the unproven benefit, safety attendant use continues to be a high cost for hospitals to shoulder in these cases.
But the Joint Commission remains firm: The best practice for patients with acute suicidality is one-on-one, in-person observation. Based on what we know, hospitals will continue to experience a demand for safety attendant staffing, but technology can assist.
Children's hospitals can embrace alternative methods for patient safety observation for diagnoses other than suicide ideation, allowing safety attendants to work in areas of highest need.
Recent nursing data shows that most hospitals do not use technology to assist with patient safety observation, though more than 50% of those surveyed thought it would be useful. With the increasing use of virtual technology in health care today, exploration of new or blended models for patient safety observation is a natural next step.
To implement such a system, the first step at Atrium Health Levine Children's Hospital in Charlotte, North Carolina, was to bring the right representatives to the table.
A behavioral health task force included representatives from medical, nursing, hospital administration, risk management and information services teams, as well as patient family representatives.
This team completed a review of the current care model, knowledge gaps, risk assessments and national best practices. With this assessment, the team created a blended patient safety observation bundle using video and in-person observation. After purchasing the video technology, the team went to work in phases.
Educating the team
The task force created a short, educational series for each of the top pediatric diagnoses that use patient safety observation. These diagnoses included technology dependence, eating disorders, non-accidental trauma, aggressive or hyperkinetic behavior, fall risk, suicidality and homicidality.
Staff were required to complete the online educational training and quiz to be eligible for patient observation duties within Levine Children's Hospital.
Additionally, those specifically hired for the video patient observation (VPO) team underwent further training on the technology, clinical notification and response algorithms, and maintaining professional boundaries. These have now become an annual, system-wide patient safety attendant competency.
The next step was to educate the nursing and provider care teams to improve their comfort level with the new process. This was done through frequent hands-on demonstration of equipment, an open-door visitation policy to the observation suite, and opportunities to sit with the team, observe, ask questions and see the technology in use.
Formal educational presentations were also provided during faculty meetings, grand rounds, nursing huddles and new hire orientation. Through this upfront work, medical teams, patients and families gradually built comfort and confidence in the technology.
Building a process for observation
The task force created a decision tree to guide providers and nurses in determining who qualifies for in-person observation, video observation or no observation at all.
This was done through surveying subspecialty teams, reviewing national best practices, and consensus agreement among pediatric providers. For example, patients with active suicidality always qualify for in-person observation, and those with fall risk or technology dependence may not.
This allowed team members to feel more confident in their decisions about safety. VPO qualification is now commonplace language among teams.
The Information Services Department partnered with the task force to quickly obtain and operationalize mounted video cameras on the cohort unit, as well as mobile video units for patients on alternate floors.
Once activated, the VPO team can quickly deploy their resources to set up and discuss the technology with families in the room, and then begin the patient safety observation process from a remote suite.
One VPO representative can monitor up to nine rooms, depending on patient acuity. Team members follow a strict algorithm for response that can include vocal cues for redirection, a phone alert to the bedside nurse, physical response by a VPO runner, security notification or initiation of a pediatric rapid response.
Finally, the VPO team keeps a detailed log throughout the shift that mirrors the in-person observation log, and both are included in the electronic medical record for care team review.
Once the video technology was purchased, the algorithms were in place, and the education was complete, a three-month dual trial began.
Levine Children's Hospital employed in-person safety attendants and video observers simultaneously to ensure the technology worked as anticipated and to perform head-to-head comparisons for safety and efficacy. This initial trial period and evaluation played a major part in achieving buy-in from providers.
Safety, efficacy and use
The head-to-head evaluations were conducted through intermittent trained bystander observation. Overall, the task force examined staff response time to event notification, safety attendant performance, and safety events related to attendants.
The task force was pleased to observe bedside nurses typically responded to events following remote VPO notification in less than 15 seconds.
Perhaps even more interesting, about 96% of the time, the VPO team made the first alert ahead of the in-person safety attendants.
Given that delayed documentation by the in-person attendant or nonverbal redirection may have contributed to these findings, the hospital conducted separate observation periods examining whether the in-person safety attendant was physically observing the patient at the time of the random spot check.
Further confirming support of the VPO program, the hospital found the VPO team to be actively observing the patient 26% more often than their in-person counterparts.
Next, the task force tracked the hospital's safety event reporting, pulling those out during the trial period that related to patient safety observation.
Most of the safety events reported during this time resulted in what the organization classifies as "no harm" and were primarily focused on observer inactivity more than wrong activity or failure to report. Consistent with earlier findings, approximately 76% of the events where attributed to in-person observation versus VPO.
Return on investment
While improvement and editing of this blended patient observation bundle are ongoing, the hospital has made strides from a staffing and financial standpoint.
By offsetting some in-person observation needs with a smaller, efficient VPO team, the hospital has demonstrated a decrease in patient safety attendant staffing needs of approximately 50% daily, an estimated decrease in labor costs of over $400,000 and achieved greater than 200% return on investment in 18 months.
Blended sitter models that include in-person and video patient observation are feasible and cost-efficient options for patient safety in most children's hospitals. When considering such a program, gather multidisciplinary input, ensure fidelity to observer education and re-education, create clear documentation, and monitor ongoing safety plans.