By Jamie Clendenin, Melanie Lee, Ashleigh Nurski and Stacey Overholt
COVID-19 has had a devastating impact on children. Many have experienced profound social isolation as a result of lockdowns and remote learning; others have had their home lives shattered by the death or debilitating illness of a parent or abuse by a family member. Even before the pandemic, suicide was the second-leading cause of death among adolescents; from 2007 to 2017 rates of teen suicide increased by 56%. After COVID took hold, the proportion of children seeking emergency mental health services who required immediate hospitalization rose 75%.
Suffice it to say, capacity to treat this need, including by inpatient children’s hospitals and within pediatric units of acute hospitals, has been tested. Nurse leaders are seeking solutions that will help keep patients safer while improving productivity, especially by reducing reliance on one-to-one sitters.
One solution that has shown promise for this challenging population is remote patient safety monitoring. Over the past three years, more than 4,000 pediatric patients have been placed under video surveillance using AvaSure’s TeleSitter solution. Fifty-seven percent of those patients present with low- to moderate-risk suicide ideation. The other 43% are placed on video monitoring for the prevention of elopement, falls, medical device interference and staff injury prevention.
The TeleSitter solution includes in-room monitoring devices with high-resolution video and digital audio, an invisible and automatic infrared light for low-light viewing and a virtual privacy curtain activated by the monitor staff when a caregiver is working with the patient. Room devices are either mobile (wired or wireless) or a permanent ceiling installation. The camera has 360-degree pan, tilt, zoom capability, allowing it to see minute details such as whether a patient is hiding something to be used later as a ligature. Each device is equipped with a loud and distinctive alarm used to alert staff that a patient is not responding to redirection or needs assistance. The average response time to the alarms nationally is 15 seconds.
The room devices connect via Enterprise software with centralized monitoring located in one hospital or in “hub and spoke” arrangements, with systemwide or regional centers watching patients in multiple hospitals, each tech with 12-16 patients on a large screen at their workstation.
Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had been using AvaSure for several years to reduce the use of safety attendants, also known as patient sitters. Later it was used to monitor pediatric patients considered to be risks for aggression and violence against staff and other patients.
As the need has grown, Helen DeVos Children’s has used TeleSitting to monitor suicide-risk patients. The hospital uses the Columbia Suicide Severity Rating Scale to screen patients who present as moderate risk of self-harm or harm to others.
Joint Commission regulations say that patients with low-to-moderate suicidal ideation must be placed under “demonstrably reliable monitoring,” a standard that can be met by “continuously monitored video” linked to the “provision of immediate intervention” by a qualified staff member when called for.
At Anne Arundel Medical Center in Annapolis, Maryland, the pediatric patient selection criteria are different from adults’. It uses the Joint Commission-validated, four-question Ask Suicide-Screening Questions (ASQ) tool to assess the level of risk the patient presents. If the patient is found to be low-to-moderate risk, he or she qualifies for telemonitoring. Though the hospital also monitors adult patients, staff are given specific training on handling pediatric patients.
One key factor in a hospital’s degree of success in adopting this solution is the effort expended on overcoming institutional resistance to change. With suicide ideation patients, providers are often adamant that a human sitter needs to be in the room at all times, even though the vast preponderance of clinical evidence shows inconsistent results, as many sitters have no medical knowledge or specific training. If sitters are not available, direct patient care staff, such as patient care technicians, are de facto sitters. Once nursing leaders see the benefit of keeping frontline staff at the bedside, the more patients are remotely monitored.
Helen DeVos Children’s has worked on establishing strong communication between the nursing staff and monitor staff to tailor the intervention to each patient’s need. One patient may be restricted to bed, while the next is allowed to get up and sit in a chair. If a patient starts pacing the room and/or exhibits signs of anxiety, the monitor tech will intervene.
For parents, video monitoring means there isn’t a stranger sitting in the room staring at their vulnerable child. Parents are also happy to learn that the video is not recording.
Another best practice is for the monitor staff to greet each patient and family through the audio, so they know a human being is watching over their child. They use a scripted introduction, letting the family know they are there to keep their child safe. We think of it as akin to “the face behind the camera.”
Last, but not least, there are the savings. As so many other organizations have discovered, monitoring 12 at-risk patients remotely versus using one-to-one sitters naturally lowers costs. Sitters are a little-known source of spending that can cost a health system millions of dollars annually.
For example, in the first 11,000 hours of monitoring of pediatric patients, Anne Arundel saved $212,000. Along with greater savings at the hospital level, this creates resources that can be put to better use in improving patient care.
Jamie Clendenin, BSN, RN-BC, is Supervisor, Nursing Operations, Anne Arundel Medical Center, Annapolis, Maryland; Melanie Lee, MSN, RN, CPN, is Clinical Director, Pediatric Emergency and Inpatient Unit, Anne Arundel Medical Center; Ashleigh Nurski, MSN, RN, ACCNS-P, CPN, is Clinical Nurse Specialist, Helen DeVos Children’s Hospital, Grand Rapids, Michigan; Stacey Overholt, RN, MBA is Clinical Director of Sales at AvaSure.