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Cincinnati VA Telecare Companion Project: Improving Veteran Safety Beth Ackerson RN, MSN, CNOR

Cincinnati VA Telecare Companion Project: Improving Veteran Safety Beth Ackerson RN, MSN, CNOR Chief Nurse Procedural Services and Chief Health Informatics Officer. Background Information. Fall prevention is a major challenge for all health care organizations

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Cincinnati VA Telecare Companion Project: Improving Veteran Safety Beth Ackerson RN, MSN, CNOR

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  1. CONFIDENTIAL & PROPRIETARY

  2. Cincinnati VA Telecare Companion Project: Improving Veteran Safety Beth Ackerson RN, MSN, CNOR Chief Nurse Procedural Services and Chief Health Informatics Officer

  3. Background Information • Fall prevention is a major challenge for all health care organizations • Estimated 1.3 to 8.9 falls per 1000 bed-days in acute care hospitals and 1.5 falls per bed year in nursing homes for aged people • 9-15% of all falls result in injury • Estimated costs: $17500 per incident and a total cost of $19.2 billion annually in the United States • 1:1 companions (sitters) are very expensive

  4. Goals of the Program • With increasing acuity and pressures for optimal productivity, reducing unnecessary patient companions (sitters) was a focus for our organization • As nursing leaders we were seeking to accelerate improvements in Veteran safety and meet the desired Quadruple Aim Results • Address those most at risk according to Institute for Healthcare Improvement

  5. Background Information • Not only was video monitoring a safe intervention, it was more effective than sitters alone in decreasing falls, by expanding the number of Veterans directly observed 24/7 • Studies demonstrated a decrease in 1:1 sitter usage and no corollary increase in falls. In fact, falls decreased as much as 35% at some sites • A significant number of major healthcare systems have incorporated the telecare companion into their care pathway

  6. Background Information • 66% reduction in falls and a 51% reduction in falls with injury • A site reported a 2.5 million dollar sitter cost savings in 2 years • On a brain injury unit 80% of staff report a positive benefit for themselves and patients • Returned nursing assistants to the bedside was a “huge win for staffing”

  7. Quadruple Aim Result • Bulls eye concrete return on investment (ROI) - sitter rate $15/hour vs. telesitter rate $3/hour • Where effectively deployed, adverse/disruptive event rates decimated • Patient/Family experience enhanced-faster response times/family breaks • Nurse experience enhanced

  8. Evidence Based • 30+ case studies - 4 result types (ROI, quality and patient/caregiver experiences) all with positive results • Behavioral Health study in progress • Workplace violence clinical study in progress • Current sites: Med-Surg, Critical Care, Rehab, Behavioral Health, Oncology, Long Term Care, Hospice

  9. Hardware (Permanent and Mobile) and Software (Local or Remote)

  10. Hub & Spoke One or More Central Monitoring Hubs Inter- Community Long Term Care Hospice Hospital A Hospital B

  11. Telesitter Adoption • Leadership Support is Critical-Results Not Realized If System is Not Used - Quadrad, Medical Staff, Nursing Service, Support Services (OI&T, Biomed and Social Work) • Project Kick-Off Presentation Goals, Performance & Expectations • Videos/Brochures/Letters/Media Releases, Staff Meeting Presentations • Review Best Practices in Healthcare

  12. Telesitter Adoption (cont.) • Space Design-Sit/Stand Desk, 46” Monitor, Privacy • Staffing Plan-Nursing Assistant 8 hr. Shifts -Best Practice-Monitoring Technician (MT)/Telemetry Technician Pool • Continued weekly meetings with Nurse Managers, NODs and Educators prior to Go Live

  13. Telesitter Adoption (cont.) • Downtime Contingency Procedures-Planned/Unplanned • E-Learning-Healthstream-1/2 hour for Nurses and 1 hour for MTs-train as many as possible prior to vendor visit • Integrate a process for ongoing education-educators as super-users • On site vendor MT and Social Work education

  14. Telesitter Adoption (cont.) • Establish Policy and Protocols based on Best Practice-MT reaction to potential falls and safety concerns • Appropriate Veteran Inclusion Criteria: Delirium/Restlessness, Drug/Alcohol Withdrawal, Confusion, Safety Restraints, Elopement Risk and General Safety Concerns (suspected contraband, medication diversion, self medication and inappropriate behaviors of Veteran and/or family)

  15. What is Telecare Companion Used For? • Fall Risk: fall risk assessment tool, history of falls, already fallen during their current stay or past stays • Veteran Behavior: escalating behavior, physically harmful actions, wandering/elopement, pulling at lines or tubes, property destruction, self medication and trial removal of restraints

  16. What is Telecare Companion Used For? • Medical Condition: CNS disorder, traumatic brain injury, altered mental state, medication side effects, detox, dementia, orthopedic and eating disorders • Quality and Satisfaction: peace of mind for loved ones, continuous monitoring, decreased alarm fatique, reduced sitter costs, protection of more patients and to mitigate risks

  17. Telesitter Adoption (cont.) • Exclusion Criteria: Suicide Risk, Behavioral Restraints, Failed Telesitter Monitoring Attempt (numerous redirections, excessive stat alarms 3 times in 30 minutes and ineffective re-direction) • Telesitter Failure Protocol: If all measures are unsuccessful, implement alternative measures (move Veteran closer to nurses station, review medications etc.) if unsuccessful notify charge nurse or NOD for telesitter removal/failure approval

  18. Telesitter Adoption (cont.) • Clinical Staff Responsibilities:Assess appropriateness, notify Veteran/family, provide education, document in CPRS, obtain equipment, introduce MT and call MT with report on Veteran, respond timely and respect privacy • Charge Nurse Responsibility:Check with staff nurses at end of the shift to clarify that Veterans meet criteria and assist the NOD in ensuring that all telesitter monitors are in use

  19. Telesitter Adoption (cont.) • NOD Responsibilities: Main gatekeeper for admissions and discharges, triage units when all in use, constant collaboration with the charge nurse, maintains a wait list of Veterans and assesses all Veterans in Failure Protocol

  20. Telesitter Adoption (cont.) • Monitoring Technician Responsibilities: Receive report from RN, places Veteran under visual monitoring, enters Veteran information into software and follows up at least every hour, introduces self to Veteran, logs all required information, redirects Veteran as needed, initiates stat alarm and Vocera broadcast as necessary, initiates privacy curtain and reports off to oncoming staff

  21. Telesitter Adoption (cont.) • Go-Live Support and Extensive Follow-Up with both the Vendor’s Clinical and Technical Team • Six month follow-up visit for mobile rounding, education and dashboard review • Hardwire clinical protocols into daily practice

  22. ORNAOnline Reporting Nursing Analytics • Combining Technology, Clinical Workflow and Comparative Data Analytics • ORNA is the only database of its kind in the United States • Hospitals can run comparisons on unit utilization, alarm rates, monitor staff interventions, effectiveness of monitor tech interventions and bedside staff responsiveness

  23. ORNA (cont.) • ORNA provides actionable intelligence reports monthly • The reports include many different performance snapshots for comparison by unit/hospital/MT/Veteran selection etc • Provides a unit by unit comparison with a long term plan to externally benchmark with other hospitals

  24. Lessons Learned • Software must be listed in the One-VA Technical Reference Manual as approved-AvaSys Telesitter • Mobile wireless units are not 508 approved (Standards for Electronic and Information Technology) • Communication between the nurse and the MT is critical-no assumptions about notification

  25. Lessons Learned (cont.) • The use of the telesitter does not replace alternatives and good nursing care: hourly rounding, not leaving the Veteran alone while toileting etc. • There is a learning and trust curve for both nurses and telesitters caring for video-monitored Veterans • Predicting which Veteran is likely to fall continues to be a complex challenge

  26. VAMC Cincinnati Quadruple AIM • Increase Veteran & family satisfaction • Less intrusive than 1:1 sitter • Relieve family member from sitter/safety role • Increase Nursing Satisfaction • CNA available for primary role • Quick alert thru Vocera when help is needed • Decrease cost: one person can monitor multiple Veterans vs. 1:1 sitters • Decrease Falls rate

  27. Outcomes • The Cincinnati VA demonstrated a 61% reduction in falls during the first 6 months of implementation • IPEC data-fall rate per 1000 BDOC-3.11 to 2.08 in med-surg • FY17 to FY18-9 falls to 1 fall in critical care • 0 unwitnessed falls • 0 falls with major/minor injuries • CLC-3 Veterans with 5-6 falls each-0 falls upon initiation of the telecare companion • 17% reduction in sitters since initial implementation

  28. ORNA Reasons for Monitoring • Fall Prevention: 68% • Safety of tubes/lines: 11% • Delirium/restless: 9% • Alcohol Withdrawal: 8% • Elopement: 4%

  29. ORNA - April & July 2019 • 345 Veteran admissions and discharges • 30,047 total monitoring hours $50/hour with benefits ($1,502,350)

  30. CONFIDENTIAL & PROPRIETARY

  31. CONFIDENTIAL & PROPRIETARY

  32. CONFIDENTIAL & PROPRIETARY

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