WHY DO GOOD BUDGETS GO BAD?

291NURSING ECONOMIC$/November-December 2018/Vol. 36/No. 6

R EDUCING HEALTHCARE COSTS while improving patient outcomes and experiences are explicit goals for

healthcare organizations (Institute for Healthcare Improvement [IHI], 2016). In an era of cost contain- ment, healthcare organizations may be reluctant to invest in costly inno- vations to meet these goals without significant evidence that demon- strates efficacy of the intervention and timely return on investment. While randomized controlled trials are slow, expensive, and time con- suming, analyzing large amounts of data collected from clinical care environments can create opportu- nity for healthcare improvement (Haughom, 2018).

According to the Institute of Medicine (1999), “safety should be an explicit organizational goal” for health care (p. 4). Patient falls

have been identified as a threat to patient safety in hospitals and are the number one reported adverse event, with over 1 million falls reported in U.S. hospitals annual- ly. Fall reports indicate approxi- mately 33% of patient falls are preventable (Ganz, Huang, Saliba, & Shier, 2013). Injuries as a result of falls are costly from the patient, family, and healthcare system per- spectives. During the past decade, the Centers for Medicare & Medicaid Services (2008) have not reimbursed additional hospital costs associated with falls and fall- related injuries. Hospitals are required by The Joint Commission to have a fall-reduction program as a national safety standard (Jorgensen, 2011). Fall risk tools, such as the Morse Fall Score Tool, are utilized to identify patients at high risk of falling and direct a protocol of standard interven- tions. Many hospitals have attempted to reduce falls by plac- ing sitters at the bedside of patients at high risk of falling (Burtson & Vento, 2015; Jeffers et al., 2013; Votruba, Graham, Wisinski, & Syed, 2016). Using available assessment tools, hospi- tals may determine which patients should be provided with a direct observation sitter; however, there is little evidence the intervention

Sonya L. Kowalski Rosanne Burson

Elaine Webber Margaret Freundl

Budgeting for a Video Monitoring System to Reduce Patient Falls

and Sitter Costs: A Quality Improvement Project

SONYA L. KOWALSKI, DNP, RN, ACNS-BC, is Associate Clinical Professor, University of Detroit Mercy, College of Health Professions, McAuley School of Nursing, Detroit, MI. ROSANNE BURSON, DNP, RN, ACNS-BC, CNE, CDE, FAADE, is Associate Professor, University of Detroit Mercy, College of Health Professions, McAuley School of Nursing, Detroit, MI. ELAINE WEBBER, DNP, RN, PPCNP-BC, IBCLC, is Associate Clinical Professor, University of Detroit Mercy, College of Health Professions, McAuley School of Nursing, Detroit, MI. MARGARET FREUNDL, MSN, RN, is the retired Associate Chief Nurse for Research, Education, Recruitment, and Professional Practice, John Dingell VA Medical Center, Detroit, MI.

EXECUTIVE SUMMARY A review of available evidence

for the use of video monitors to reduce patient falls and bedside sitter costs revealed few evi- dence-based, peer-reviewed articles.

Large numbers of clinically based reports in the form of poster and podium presenta- tions were found.

Available data were used to stimulate interprofessional sup- port and collaboration for a video monitoring budget plan as a quality improvement proj- ect intended to reduce patient falls and sitter costs at one gov- ernment healthcare facility.

The process of data collection and analysis is detailed, provid- ing a blueprint for nurse lead- ers.

NURSING ECONOMIC$/November-December 2018/Vol. 36/No. 6292

is effective in reducing fall-related injuries (Harding, 2010). Never - theless, inpatient sitter costs have been rising and may be as high as $3 million per year (Rochefort, Ward, Ritchie, Girard, & Tamblyn, 2011).

Problem Description A Midwest medical center has

had an interprofessional fall pre- vention taskforce in place for sev- eral years. The group formulated a fall prevention protocol based on findings from the Morse scale assessment scores. Additionally, bedside sitters were utilized to monitor patients identified as hav- ing the highest risk of falling. The taskforce accomplished early gains in fall prevention, but over time fall rates began to level out with minor variations over several years, based on data from this facility’s incident report tool. It was determined that use of bed- side sitters did not lead to an appreciable decrease in patient falls, and aggregate fall rates fluc- tuated between 1.09 and 5.30 falls per 1,000 bed days of care be - tween January 2013 and June 2016. Patient fall injury rates were also noted to be among the highest among comparable facilities ac - cording to the quality data reports within this large healthcare sys- tem of demographically similar medical centers. Bedside sitters were typically utilized after the patient’s first fall if fall prevention measures were considered likely to be ineffective due to patient characteristics, such as impulsivi- ty or dementia. Incident reports indicated patients continued to fall even with 1:1 bedside sitters in attendance.

The medical center did not have a pool of available bedside sit- ters and therefore utilized existing staff to function as sitters. The per- sonnel utilized were nurse techni- cians, licensed vocational nurses, or registered nurses. When a staff member was used as a sitter, either the employee worked overtime or was removed from the unit’s staffing model. The latter option reduced the staff available for patient care and made unit nurses

reluctant to request a sitter except in the most severe cases. The annu- al sitter costs at the institution were estimated to be $284,488.00 for acute care, $21,053.20 for long-term care, and $116,544.50 for mental health units (total $422,086 annual- ly). These estimates were obtained by utilizing staffing records and sit- ter salaries from an average month, dividing by the number of days in the month to determine an average daily cost, then annualizing by multiplying average daily cost by 365 days. The use of staff as direct observation sitters was ineffective and expensive, contributing to staff fatigue and dissatisfaction. The use of video monitoring to replace direct observation bedside sitters to reduce patient falls was identified as a possible solution.

Available Knowledge A literature review was con-

ducted searching for fall-reduction technologies, including video mon- itors. The Cochrane Library, CINAHL, and PubMed Central were searched for peer-reviewed articles within the last 10 years with key- words fall risk, fall reduction, fall prevention, technology, video moni- tors, video surveillance, and video cameras. Several technologies to reduce patient falls, such as smart shoes, smart carpet, floor sensors, necklace sensors, and personal airbags, have been developed, but liability and practicality issues have not led to market availability (Comstock, 2013). Only a few peer- reviewed, evidence-based articles were available to support use of video monitors to improve patient safety and reduce fall rates. The use of video monitoring within health- care systems to address the impor- tant issue of patient fall reduction has been of interest to nurse leaders since Denver Health described the use of video monitors as part of a Lean journey (Jeffers et al., 2013), but evidence has been lacking. Available peer-reviewed evidence included that Burtson and Vento (2015) implemented a mobile video monitoring system (VMS) to reduce the use of bedside sitters. The results of the study found decreased falls, fall-related injuries, use of

restraints, and sitter-related costs. Additionally, Votruba and co- authors (2016) found use of video monitors to be not only cost effec- tive, but also safe for use in fall pre- vention. After understanding poten- tial cost savings and safety of utiliz- ing a VMS to replace bedside sitters, the next logical step was developing a plan to demonstrate the potential benefits within the local healthcare facility.

The literature search was then expanded to include gray litera- ture, such as non-refereed sources and healthcare websites. A large number of poster and podium-pre- sented data was available. These data reports indicated that with use of video monitors sitter use declined, patient fall rates were reduced, fall injuries were re - duced, return on investment was rapid, and sitter cost avoidance was substantial, with the lowest annual site-specific savings esti- mate reported at $77,200 (Votruba et, al., 2016). No reports indicated regret over adopting the system. A VMS utilized by a healthcare sys- tem was demonstrated at a nation- al conference (Lee, 2016). Nurse managers and nurse users of the system gave testimonials about benefits of the system and shared facility data outcomes reports. Similar positive outcomes were reported during several site visits to hospitals where video systems were being utilized.

Specific Aims Video monitoring technology

is expanding rapidly and becoming a standard of care among the healthcare systems in this Midwest region. Facility adoption of a VMS was viewed as necessary to provide regionally equitable levels of mon- itoring for at-risk patients. An analysis of costs and benefits of the VMS to the hospital was intended to demonstrate the feasibility of adopting this technology as a qual- ity improvement project. The pur- pose of this project was to utilize available evidence to create a budg- et proposal and work with an inter- professional team to prepare for implementation of a VMS in a healthcare organization in the

293NURSING ECONOMIC$/November-December 2018/Vol. 36/No. 6

Midwest. Due to this hospital sys- tem’s budget planning constraints, it was anticipated that if the budget proposal was accepted, the time frame until implementation could be greater than a year or longer. Because the budget proposal por- tion of the project did not involve any patients and the expected time frame was lengthy, it was agreed by all participants to defer institution- al review board approval for the quality improvement study until the budget proposal was accepted, funding was approved, and a pur- chase in progress.

This article is designed to cre- ate a blueprint for assembling clini- cally based data and working with an interprofessional team including medical center leadership, nurse managers, fall-prevention commit- tee, biomedical engineering, and quality and safety managers, to cre- ate a budget proposal for this healthcare innovation aimed at reducing patient falls. The clinical questions proposed were:

If the typical sitter model of staffing were to be replaced with the video monitor model of staffing at this medical center: 1. What could be the sitter and

fall-related cost savings to the facility?

2. How could fall rates and fall injury rates be affected?

3. How much staff could be returned to the unit?

Methods Facility fall rates have been

trended on an ongoing basis. The fall and fall-related injury costs were estimated by annualizing a 6-month record of falls and fall- related injuries and multiplying the most recent and conservative cost estimates from the literature within the injury categories of none ($1,139), minor ($7,136), and major ($30,931) by the number of falls within each category (Spetz, Brown, & Aydin, 2015). Patient falls with no reported injury were estimated utilizing the no-injury cost calculation. The cost estimate total for combined non-injurious falls and fall-related injuries was $403,728. Gray literature reports video monitoring fall reductions

ranging from 6% to 99% with a 50% reduction near median. A 50% reduction in non-injurious falls would result in an estimated annual cost savings of $61,506 (54 falls with no injury or no injury reported multiplied by lowest cost estimate of $1,139 from the litera- ture and reduced by 50%). A 50% reduction in fall-related injury costs would result in an estimated annual cost savings of $140,358 (11 falls with minor injury multi- plied by lowest cost estimate from the literature of $7,136 plus two falls with major injury multiplied by lowest cost estimate from the literature of $30,931 and reduced by 50%). The 1-year facility sitter costs were estimated to be $422,086 and were calculated by annualizing the daily sitter costs from an average month of actual staffing records using average salaries for the categories of staff utilized.

Financial Narrative A financial narrative was

completed and presented to facili- ty stakeholders to gain support for the project. The cost of the VMS was estimated to produce an over- all savings to the facility within less than a year after implementa- tion. The estimated cost of the VMS was projected to be less than $150,000 for an initial purchase of eight video monitors, including equipment, installation, and staff training. The monitors were esti- mated to be $10,000 each for a total cost of $80,000 for eight mon- itors (verbal statement by a region- al healthcare system user). The cost of establishing a central mon- itoring area was estimated to be $30,000 (Browne & Sterne, 2015). The cost of licensing and system support was not available until the formal bid process but was estimated to be approximately $20,000 annually.

The subsequent staff costs were projected as cost neutral because existing nursing staff would be uti- lized as trained video monitor tech- nicians in the same monitoring sta- tion as centralized cardiac teleme- try. The number of full-time equiv- alents (FTEs) to staff 24/7 would be

five, and the average hourly wage of certified nursing assistants was $19.10. (Use of unit managers, tech- nology, and biomedical support was considered a part of normal job duties and not included in calcula- tions.) Based on the facility reports, approximately 25% of bedside sit- ters are utilized in the mental health units and direct observation for many of those patients will con- tinue to be required. Therefore, a reduction of bedside sitter use of 75% was anticipated. Using the cal- culated bedside sitter cost to the facility of $422,086, a 75% reduc- tion in bedside sitter costs would result in an estimated $316,564 annual savings. Total annual cost savings of the VMS for both avoid- ed sitter costs ($316,564) and avoid- ed fall-related costs ($61,506 + $140,358 = $201,864) was estimat- ed to be $518,428. After adjusting for costs of the system, the first-year cost avoidance for the VMS was estimated to be $368,428 ($518,428 - $150,000) for the facility. Total 3- year estimated fall-related costs of using a VMS were $1,093,531 (see Table 1). Total 3-year estimated costs of continuing current bedside sitter practice was estimated to be $2,477,442. Estimated 3-year fall- related cost savings with the use of the VMS was $1,383,910 (see Table 2).

Proposed Intervention The proposed intervention was

to implement a VMS with three- way communication to replace bedside sitters for all patients not on suicide precautions within the inpatient units of the medical cen- ter. This intervention was designed as a quality improvement project. The Plan-Do-Study-Act cycle was utilized to implement the project (IHI, 2016).

After budget approval, system installation, staff training, and pre-implementation data collec- tion, the VMS would be imple- mented with an initial capacity of eight patients. The eight video monitors would be on a single screen placed in the telemetry monitoring station, which then utilized existing staff (one person already being used for telemetry

NURSING ECONOMIC$/November-December 2018/Vol. 36/No. 6294

Table 1. Comparative 3-Year Cost of Video Monitors and Current Sitter Practice

Budget Item Year 1

VM Year 1 Sitters

Year 2 VM

Year 2 Sitters

Year 3 VM

Year 3 Sitters

Eight monitors at $10,000 each

$80,000 0 0 0 0 0

Central monitoring station

$30,000 0 0 0 0 0

4.2 FTE VMT staffing (pulled from existing model)

(0) (0) (0) (0) (0) (0)

8 hours of training for five CNAs as VMTs

$764.00 0 0 0 0 0

8 hours of training for two CNAs as VMTs

$0 0 $305.60 0 $305.60 0

Licensing/System support contracts

$20,000 0 $20,000 0 $20,000 0

Managers, technical, biomedical support

(0) (0) (0) (0) (0) (0)

Use of direct observation sitters (Avg daily sitter cost x 365)

$422,086 $422,086 $422,086

Use of VM observation

$105,521.50 $105,521.50 $105,521.50

Fall-related injury costs

$201,864 (50% reduction)

$403,728 $201,864 $403,728 $201,864 $403,728

Total estimated costs

$438,149.50 $825,814 $327,691.10 $825,814 $327,691.10 $825,814

CNA = certified nursing assistant, FTE = full-time equivalent, VM = video monitoring, VMT = video monitor technician

Table 2. Cost Savings Summary

Sitter Model Video Monitor Model

3-year estimated direct observation cost $1,266,258 $316,564.50

3-year estimated fall and fall-related injury cost $1,211,184 $605,592

3-year video monitor system cost 0 $171,375.20

3-year total cost $2,477,442 $1,093,531.70

3-year cost avoidance 0 $1,383,910.30

and an additional person taken from the utilized sitter model) to monitor the video camera screens and did not require additional staff FTEs. Based on reports from other facilities, it would be benefi- cial to utilize staff with experience in bedside care, such as nurse aids or caregivers on physical work restrictions, to monitor video sys-

tems because staff with bedside experience can better anticipate patient activity and are already skilled in direct communication with patients.

The inpatient units would share the portable video monitors. The mental health units require station- ary monitors for patient and staff safety. Charge nurses would work

with nurse supervisors to prioritize patients for monitoring based on a history of falls, impulsive behavior, cognitive impairment, recent ampu- tation, recent cerebral vascular acci- dent, hospice patients in the last stages of life, and alcohol withdraw- al patients on the Clinical Institute Withdrawal Assessment protocol. Patients in these categories are at the

295NURSING ECONOMIC$/November-December 2018/Vol. 36/No. 6

highest risk of falling based on this facility’s incident reports.

Implementation A presentation for the VMS

proposal was prepared and shared with the facility management ana- lyst and major nurse stakeholders. Data obtained from a literature review and attendance at a confer- ence presentation were included. A product demonstration was held to obtain management sup- port for the project. The budget proposal was created with the input of facility stakeholders to determine numbers and types (wall mount, ceiling mount, or portable) of video monitors that would be requested for the various inpatient units. The budget pro- posal was presented and accepted by the facility management team. Subsequently a facility walk- through was conducted with the vendor and biomedical engineer to obtain a formal quote to move forward with procurement and implementation of the VMS.

The video monitoring compa- ny included staff training and tech- nology support as part of the instal- lation package. The support pack- age included on-site support as the system is rolled out and support resources for any subsequent tech- nology issues that may arise. The package also included updates on best practices and unlimited fol- low-up support and re-education. The company provided templates for patient selection inclusion and exclusion criteria, event logging, video monitor technician job descriptions, policies and guide- lines for communication, and inter- ventions that could be tailored to meet the needs of the facility. Product design allows for cost- effective monitor expansion capa- bilities if needed. The interprofes- sional team would continue to work collaboratively to develop policies and procedures related to the use of the VMS for this medical center during installation and would assist with staff training.

Measures Data collected prior to video

monitor implementation were monthly and annual fall rates per 1,000 bed days, fall injury rates, sit- ter costs, facility aggregate staff sat- isfaction, and patient/family satis- faction. Data will be collected again at designated intervals, and pre and post-implementation measures will be compared to evaluate reduction in falls, fall-related injuries, bedside sitter costs, and improvements in staff and patient/family satisfaction.

Conclusion It is anticipated the VMS will

improve the measured outcomes and become a part of the cycle for continuous quality improvement. Implementation of the video moni- toring technology has the potential to improve nursing practice through improved safety. Improving patient safety may improve patient and family satisfaction. Returning assis- tive personnel to the unit staffing matrix and improved patient safety may enhance staff satisfaction. After implementation, safety improve- ments may lead to further research, which may reveal additional bene- fits of the VMS, such as improved patient and family feelings of secu- rity. Additional research may also lead to additional quality improve- ment initiatives.

This budget proposal process demonstrated a successful evi- dence-based approach using clini- cal evidence to reduce costs and promoted use of new technology to reduce patient falls and use of sitters. Involvement of interprofes- sional team members at various stages of the proposal develop- ment, including management ana- lyst, chief nursing officer, and nurse managers, was crucial for proposal acceptance. The authors anticipate use of clinical data for this project may be a useful blue- print for others to promote innova- tion utilizing clinical evidence. $

REFERENCES Brown, S., & Sterne, P. (2015). Keeping

watch: enhancing fall prevention through targeted video surveillance. American Nurse Today, 10(12).

Burtson, P.L., & Vento, L. (2015). Sitter reduction through mobile video mon-

itoring: A nurse-driven sitter protocol and administrative oversight. The Journal of Nursing Administration, 45(7/8). doi:10.1097/NNA.000000000 0000216

Centers for Medicare & Medicaid Services. (2008). Medicaid director letter. Baltimore, MD: Author.

Comstock, J. (2013). Slideshow: 7 tech- nologies working to prevent falls. Mobihealth news. Retrieved from https://www.mobihealthnews.com/2 0351/slide-show-7-technologies- working-to-prevent-falls/

Ganz, D.A., Huang, C., Saliba, D., & Shier, V. (2013). Preventing falls in hospitals: A toolkit for improving quality of care. (Prepared by RAND Corporation, Boston University of Public Health, and ERCI Institute under Contract No. HHSA2902010000171 TO #1) Rock - ville, MD: Agency for Healthcare Re - search and Quality.

Harding, A.D., (2010). Observation assis- tants: Sitter effectiveness and indus- try measures. Nursing Economic$, 28(5), 330-336.

Haughom, J.L. (2018). The rising health- care revolution: The future is already here. Health Catalyst. Retrieved from https://www.healthcatalyst.com/in novation-in-healthcare-why-needed- where-going

Institute for Healthcare Improvement (IHI). (2016). IHI triple aim initiative. Retrieved from http://www.ihi.org/ engage/initiatives/tripleaim/pages/de fault.aspx

Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.

Jeffers, S, Searcey, P., Boyle, K., Herring, C., Lester, K., Goetz-Smith, H., & Nelson, P. (2013). Centralized video monitoring for patient safety: A Denver health lean journey. Nursing Economic$, 31(6), 248-306.

Jorgensen, J. (2011). Reducing patient falls: A call to action. American Nurse Today, 6(Suppl. 2).

Lee, A. (2016, February). Setting a clear vision for patient safety: Utilizing mobile virtual monitoring to prevent falls and improve patient outcomes. Symposium conducted at Memorial Hermann-Texas Medical Center, Houston, TX.

Rochefort, C.M., Ward, L., Ritchie, J.A., Girard, N., & Tamblyn, R.M. (2012). Patient and nurse staffing character- istics associated with high sitter use costs. Journal of Advanced Nursing, 68(8), 1758-1767. doi:10.1111/ j.13 65-2648.2011.05864.x

Spetz, J., Brown, D.S., & Aydin, C., (2015). The economics of preventing hospi- tal falls. The Journal of Nursing Administration, 45(1), 50-57. doi: 10.1097/NNA.0000000000000154.

Votruba, L., Graham, B., Wisinski, J., & Syed, A. (2016). Video monitoring to reduce falls and patient companion costs for adult inpatients. Nursing Economic$, 34(4), 185-189.

Copyright of Nursing Economic$ is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.