BONUS CONTENT FROM LPN2009

Focusing on video surveillance to reduce falls
By Debbie Goodlett, RN, BSN; Christi Robinson, RN, CMSRN; Patricia Carson, RN, CMSRN; and Linda Landry, RN, CMSRN

Who’s falling in your hospital and what are you doing about it? According to the CDC Injury Center, in 1 year about 1.8 million older adults sustained nonfatal fall injuries. More than 433,000 were hospitalized and 15,800 died from unintentional fall injuries.¹ The Joint Commission found that falls accounted for 6.1% of all sentinel events as of 2008.²

As part of the National Patient Safety Goals, The Joint Commission requires organizations to implement a fall reduction program that will best serve their patient population. Fall reduction plans should involve healthcare team members, families, and patients and consider the inclusion of sitters, companions, and direct observation interventions.

In this article, we’ll discuss how and why we initiated an innovative fall reduction plan that included 24-hour camera surveillance. Our plan has helped us keep our patients safer despite a challenging staffing shortage. Let’s start by considering how staffing levels influence fall rates.

Fewer nurses, more falls
According to a study using the National Database of Nursing Quality Indicators, higher fall rates were associated with fewer nursing hours per patient day.³ Because fall rates were highest in medical units, increasing nurse staffing in these units could have the greatest impact on fall reduction.

But what happens when nursing hours can’ be increased or nurses aren’t readily available? After Hurricane Katrina, the 34-bed internal medicine unit at Ochsner Medical Center in New Orleans, La., was faced with both staffing challenges and increased patient falls, particularly those resulting in injury. We needed to observe high-risk patients without increasing nursing hours.
We decided to use a designated sitter staff, but we needed to address many other factors. Our unit’s spread-out design wasn’t conducive to close patient observation. Shortly after Katrina, our patient population changed, with a significant increase in patients with psychiatric diagnoses, patients admitted as psychiatric emergency commitments, and those on suicide precautions. These patients required one-on-one sitter observation, which depleted our in-house sitter pool. Although we encouraged relatives of confused patients to stay, some had been displaced by the hurricane. With these challenges, we had to look for creative solutions to keep high-risk patients safe. We started a performance improvement project, and we accomplished it in phases.

Initiating our project
Our initial step was to clearly define the problem using outcomes that could be benchmarked: the number of falls per 1,000 patient days. Next, we identified key players and set up meetings to analyze the problem comprehensively. Our key stakeholders included unit personnel, a geriatric nurse specialist, and representatives from performance improvement, risk management, and security. The performance improvement and risk management stakeholders provided recommendations for outcome measures and the consent process. We consulted security early on about the feasibility of using camera equipment for patient observation.

After much discussion, the team concluded that the best solution was to design an innovative fall reduction plan using 24-hour camera surveillance to monitor patients at high risk for falls.

Assessing our plan
We next explored the feasibility of implementing the project based on available human and financial resources, time constraints, and the recommendations of key stakeholders. We were able to fast-track this project because it was a safety issue. A comparative cost analysis that showed using video surveillance was more cost-effective than using sitters provided further support for the project.

Security experts recommended the most appropriate surveillance equipment, such as cameras capable of visualizing the patient’s bed and immediate surroundings in low lighting.

We also reviewed the performance improvement initiative with our risk management department. The hospital’s legal counsel told us the consent form for treatment includes the use of cameras for patient-monitoring purposes. They concluded that we wouldn’t need a separate consent or a prescriber’s order to use cameras for fall monitoring.

Developing and implementing the program
Next, we developed program guidelines for selecting video sites for surveillance and monitoring, identifying patients, and choosing monitoring procedures.

We selected four rooms adjacent to a remote nurses’ station, where the TV monitor would be located. The monitor screen had to be in an area where we could protect patient privacy. The four patient rooms were chosen because they were close to one another, easily accessible by monitoring staff, and in a quiet, low-traffic area. We planned to equip additional rooms with cameras using the same monitoring system later.

For placement in a camera room, we chose patients at high risk for falls based on historical data. These patients had to meet criteria for cognitive dysfunction or nonadherence to safety instructions. We targeted older patients but excluded patients on suicide precautions and those requiring physical restraints. Because the success of this project required interdisciplinary collaboration in bed assignment, we shared our camera room guidelines with nursing administration, bed control coordinators, emergency nursing staff, physicians, social workers, physical and occupational therapy, and respiratory therapy.

We trained unlicensed assistive personnel (UAPs) on fall reduction interventions and video surveillance equipment use. Monitoring procedures included assigning the trained UAPs to watch the camera room monitor 24 hours a day. Their responsibilities included participating in shift reports for camera-room patients, directly visualizing the monitor, and intervening to prevent falls. Intervention could mean going to the bedside, speaking to the patient through the call system, or alerting other staff by using SpectraLink wireless phone systems or intercom messages (for example, immediate assistance to room 8088). Other effective interventions included notifying the nurse of increasing restlessness, agitation, or other potentially unsafe behavior.

Evaluating outcomes
The goal of this project was to reduce falls. Because appropriately identifying patients for camera rooms was vital, we also expected overall improvement in fall risk assessment. We analyzed the fall rate for the entire unit before and after the video surveillance project began. We also tracked the number of falls that occurred in the camera rooms.

We reduced the mean annual unit fall rate by 6% after implementing the project. However, when we compared the patients in the entire unit to those in the camera rooms using paired Student’s t-test (p=.548), the difference was statistically insignificant. Only one fall occurred in the 417 patients admitted to the camera rooms over the 12-month evaluation period (0.68 falls per 1,000 patient days). This fall, which didn’t injure the patient, was related to failure of the monitoring staff to respond because the patient’s behavior was misinterpreted.

The cost analysis supported continuing the project. Before using video surveillance, individual sitters would have been used to prevent falls at a cost of $240 per day per patient. The one-time cost for surveillance and monitoring equipment, including installation, was about $3,000; it requires only one monitoring person per shift. This intervention cut our sitter cost from $960 for four patients to $240 for four patients.
This performance improvement project suggests that video surveillance may be an acceptable strategy in reducing falls in hospitalized patients.

Lessons learned
Based on what we learned during the first year of this project, we offer this advice to others considering a camera surveillance program.

Performance improvement design

• Define goals and metrics early in the project design.
• Conduct a cost analysis.
• Identify inclusion and exclusion criteria for camera-room occupancy.
• Establish checkpoints to evaluate progress.
• Maintain and frequently prioritize a formal camera-room waiting list.

Patient and family

• Include the use of cameras for patient monitoring in the hospital’s general consent form.
• Include the use of video surveillance in the patient’s plan of care.
• Include the patient and her family in the plan of care and educate them about camera guidelines.
• Post notification of video surveillance in camera rooms to alert visitors.
• Ensure privacy for the patient and her family as needed.

Optimizing clinical outcomes

• Use a process, such as a fall risk tool and interdisciplinary discussions of fall risk, to identify appropriate patients for the camera rooms.
• Provide frequent staff-development sessions to increase fall risk awareness, improve consistency in fall risk asssessment, and identify patients who are most appropriate for video surveillance. Cross-train staff.
• Use consistent monitoring personnel who are knowledgeable about interpreting behaviors that may lead to a fall.

References
1. CDC Injury Center. Falls among older adults: an overview. Updated April 25, 2008. http://www.cdc.gov/ncipc/factsheets/adultfalls.htm.
2. The Joint Commission. Sentinel event statistics. Updated September 30, 2008. http://www.jointcommission.org/SentinelEvents/Statistics/.
3. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on acute care hospital units. Nurs Outlook. 2004;52(1):53-59.

Source: Nursing2009. February 2009.