Fall Prevention and Safety: Creation of Sitter Discontinuation Guidelines

Medical-surgical nursing staff have a significant impact on preventing patient falls and maintaining patient safety. One way hospitals can mitigate patient falls in the confused population is by utilizing sitters at the bedside. A sitter is a staff member who remains at the patient’s bedside based on their condition to keep them safe while hospitalized.

After a high-harm event, a hospital’s fall prevention committee members found a gap in knowledge regarding when to maintain or discontinue a sitter. Further, bedside staff did not always feel they had the autonomy to advocate for maintaining a sitter due to staffing needs. As medical-surgical nurses, it is a daily challenge to balance the needs and demands of unit staffing with patient care, which can ultimately lead to moral distress for nurses and poor outcomes for patients. The fall prevention committee knew they wanted to develop a tool that could help clinical nurses determine when it may or may not be appropriate to maintain or discontinue a patient sitter. Patient safety always comes first, so these tools are needed to support nursing judgment.

Members of the hospital’s fall prevention committee wanted to create a tool that would help clinical nurses decide whether a sitter was still necessary. Finding limited evidence in the literature, they collaborated with content experts. This interdisciplinary group included pharmacists, geriatric providers, neurologists, and nurses to create standardized guidelines. These guidelines incorporate assessment questions, safety interventions, and a pharmacology reference for frequently used medications.

After the guideline was created, it was decided that it should be trialed on a unit for efficacy. Due to patient complexity and a high fall rate, a neuroscience unit was chosen. Prior to the one-month trial, staff were surveyed for their perspective on the need for a guideline, and 100% reported that the guidelines would improve comfort in discontinuing a sitter. The survey results showed 83% of staff reported that staffing influences their decision-making when it comes to removing a sitter. Additionally, no staff member reported that they felt “very comfortable” independently deciding to discontinue a patient’s sitter.

The implementation plan included fall prevention committee members, the unit manager, and a clinical nurse specialist educating staff at unit huddles and through 1:1 education. The guidelines were made accessible by having laminated copies located at each nursing station and other care areas.

A copy of the guidelines that were created in collaboration with nursing, pharmacy, a geriatric specialist, and neurology.

At the conclusion of the one-month trial, an electronic survey was distributed to staff. The results showed that 100% of staff now consider medication changes prior to removing a sitter. All of the individuals who used the guidelines during the trial reported that it improved their comfort in decision-making when removing a sitter. Staff shared, “I liked the guidelines; they were helpful!” and “I really liked the list of medications on the guidelines; that was a great reference.”

Implementation improved staff satisfaction with sitter use decision-making. Incidentally, the number of falls among cognitively impaired patients decreased by 50% and falls with injury rate dropped from 1.41 to 0.93 when comparing pre-implementation to post-implementation quarters. Hospital falls occur for many reasons, achieving a reduction in patient harm represents a significant win. The guidelines are now used by nurses, hospitalists, case managers, and clinical nurse specialists in planning care, utilizing sitter resources, and addressing discharge needs.

There is always more work to be done regarding fall prevention and patient safety. Our next steps include ongoing efforts to ensure that all nursing units have access to and utilize the Sitter Discontinuation Guidelines. This is accomplished through standardized onboarding education and leveraging fall champions. Additionally, we will ensure that these guidelines are being used during multidisciplinary rounds. This has been done by collaborating with the case management team and unit level managers. Guidelines are used when a complex patient case arises. Future work also includes making this document electronic or placing it in the electronic medical record for ease of use.

When resources are limited and nurses lack experience, implementing a guideline that aids in decision-making puts patient safety first while supporting nurses’ critical-thinking skills. Proper allocation of resources should match the heavy demands of healthcare today, ensuring that patients truly have an individualized plan of care. The Sitter Discontinuation Guidelines do just that.