Running Head: FALL PREVENTION USING TELEMONITORING

Fall Prevention Using Telemonitoring

Kei-Sha Dollard

Delaware Technical Community College

NUR 410-6W1 Nursing Informatics

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Fall Prevention Using Telemonitoring

According to The Joint Commission (2015) falls resulting in injury are a prevalent patient safety

problem. Elderly and frail patients with fall risk factors are not the only ones who are vulnerable

to falling in health care facilities. Any patient of any age or physical ability can be at risk for a

fall due to physiological changes due to medical condition, medication, surgery, procedures, or

diagnostic testing that can leave them weakened or confused. An estimated 25,500 Americans

died from falls in healthcare and community settings in 2013. Countless more suffered life-

changing injuries, and traumatic brain injury. Experts estimate that more than 84% of adverse

events in hospital patients are related to falls, which can prolong or complicate recovery

(Lunsford & Dodge Wilson, 2015). In October 2008, the Centers for Medicare & Medicaid

Services (CMS) stopped reimbursing hospitals for costs related to patient falls. The policy

change prompted all in-patient facilities to implement fall prevention practices including the use

of bed and chair alarms, safety sitters and physical restraints (Fehlberg et al., 2017). Falls are

expensive and detrimental adverse events that occur in hospitals. According to the Centers for

Disease Control and Prevention, it has been estimated that up to 1,000,000 inpatient falls occur

annually in the United States (US) with associated direct medical cost greater than thirty billion

dollars. CMS categorizes falls as “preventable” hospital-acquired conditions that they will no

longer provide reimbursement for. This has made hospitals focus more on patient safety by

creating new fall prevention programs and policies.

Ethical Dilemma with Telemonitoring

Nurses play a pivotal role in patient’s safety and fall prevention is a part of each and

every patient’s plan of care. There are times when ethical conflicts or dilemmas may arise in

keeping patients safe due to the interventions used which may limit a patient’s rights including
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autonomy, dignity and privacy. Nurses use ethical principles, clinical judgement and evidence-

based practice in tailoring fall prevention methods to each patient after assessing the patient’s fall

risks.

The nurse’s role in fall prevention is to initiate individualized care plans for each patient

they care for depending on the patient’s needs. They follow the evidence-based 3 steps in

preventing falls: 1. Fall risk screening and assessment, 2. Tailored/personalized care planning

and 3. Consistent preventative interventions (universal fall precautions and tailored interventions

to address patient-specific areas of risk). Risk factors for falls include a history of falls, gait

instability and lower-limb weakness, urinary incontinence, frequency, or the need for toileting,

agitation, confusion, or impaired judgment, and medications, especially sedative hypnotics (

Dykes et al., 2018). Fall risk screenings and assessments are done during patient admissions,

every 8 hours or shift, and with status changes. Once the nurse has determined the patients risk

factors and needs, a fall prevention plan and interventions are followed to keep the patient safe

from falls. The plan is communicated to the healthcare team, which includes the patient and

family. Research suggests that patient and family engagement in the three-step fall prevention

process is critical. Many hospitalized patients fall because they do not believe that they are at

risk and they do not follow their fall prevention plan. This is especially true for patients who are

independent at home and do not see themselves as vulnerable to a fall in the hospital (Dykes et

al., 2018). Patients that are confused and agitated and those whom choose not to follow the fall

prevention care plan are at a greater risk for falls and may require one on one observation or

telemonitoring to keep them safe. Moreover, this intervention may make the patient feel that

their rights are being violated.

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When the nurse determines a patient is a safety concern, he or she will contact the

physician to get an order for a one on one safety companion or a tele companion depending on

the patient’s safety risks which includes suicidal ideations or attempts, abusive behavior to self

and others, inability to follow safe directions, and pulling at IVs, Peg and Nasogastric Tubes.

Patients that have suicide ideations, attempts or are abusive to self and others require a one on

one safety companion in their room to prevent the patient from being harmed or harming others.

Other patients that are confused but can be redirected can benefit from a tele companion that is in

a remote location monitoring the patient through a camera in the patient’s room. The tele

companion can see if the patient is doing something they are not supposed to be doing and can

talk though a speaker to redirect the patient. If the patient still continues the unsafe practice; a

special alarm can be activated to alarm the healthcare team (nurse and patient care technician

PCT). Nurses are responsible for informing patients on the interventions they are being provided

and why they have been implemented in their care plan. The patient exercised their right to

autonomy by choosing not to follow the plan of care and/or have displayed a concern for added

interventions to keep the patient and others safe. The patient may also feel that their privacy is

being violated and that there are not being treated with dignity and respect by having someone

watching over them. On the other hand, the nurse follows a set of ethical principles including

beneficence which is the practice of doing what is best for the patient. The nurse is obligated to

provide safe competent care to his or her patients, families and coworkers. This can cause an

ethical dilemma because the patient feels that his or her rights are being violated and the nurse

feels that he or she is doing what is best for the patient by keeping them safe from harm. Safety

and tele companions are to respect a patient’s rights by providing privacy and treating the patient

with respect and dignity as much as possible, however there are situations that a patient may feel
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that his or her rights are being violated, but it only done to prevent harm to the patient and others.

These interventions include, monitoring a patient for safety concerns, assisting a patient with

toileting, and preventing a patient from pulling out IVs and PEG Tube and NG Tubes that are

needed to administer fluids, medications and nutrition to patients.

Current Method for Fall Prevention

A fall is defined as an unplanned descent to the floor with or without injury. This a major

concern on Stroke Treatment Units because every patient that is admitted to the unit is

considered a fall risk due to the acuity of their illness and cognitive function. Fall risk factors

include: previous fall history; gait instability and lower limb weakness; urinary incontinence,

frequency and the need for toileting; agitation, confusion, or impaired judgment; and

medications, especially sedative hypnotics. Universal fall precautions are used for all patients on

the unit. The universal fall precautions are:

 Familiarize the patient with the environment.

 Have the patient demonstrate call light use.

 Maintain call light within reach.

 Keep the patient’s personal possessions within patient safe reach.

 Have sturdy handrails in patient bathrooms, room, and hallway.

 Place the hospital bed in low position when is resting in bed; raise bed to a comfortable

height when the patient is transferring out of bed.

 Keep hospital bed brakes locked.

 Keep wheelchair wheel locks in “locked” position when stationary.

 Keep nonslip, comfortable, well-fitting footwear on the patient when ambulating.

 Use night lights or supplement lighting in patient rooms.

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 Keep floor surfaces clean and dry. Clean up all spills promptly.

 Keep patient care areas free from clutter.

 Follow safe patient handling practices.

 Hourly rounding.

Patients’ fall risks are assessed by the RN on admission to the unit and a care plan is

implemented with interventions tailored for the patients’ individualized fall risk factors. Patients

who are at high risk for falls; in psychiatric crisis, including those who have attempted suicide or

with suicidal ideation, or at risk for harming others; substance-abuse withdrawal with behavioral

problems; or experiencing delirium, confusion, or agitation are assigned a safety companion to

provide 1:1 observation. Using safety companions to directly observe patients at high risk for

falls is a practice suggested as part of several evidence-based fall prevention guidelines, however

the clinical and cost-effectiveness of sitter programs are being questioned.

I work on a 24-bed Stroke Treatment and Recovery (STAR) unit that is staffed by 7-6

nurses and 3 unlicensed assistive personnel UAP (patient care technicians and student nurse

externs). One nurse is in charge and the nurse-patient ratio is 1:4 or 1:5. The UAPs are split

between our three districts and they float to other districts when they are needed. When a patient

requires a safety companion; a UAP is pulled in the safety companion role, which leaves the

floor short with staffing. Inadequate staffing can lead to increase falls on the unit because every

patient on the unit is considered a fall risk. There is less staff on the floor to assist with

answering call bells and assisting patients with toileting needs. The RN has the additional

responsibility to round on the safety companion to make sure they are able to take breaks and to

assess for their safety as well as the patient. Preventing falls is a stressor on the unit and working
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short staffed can increase the unit’s stress levels. When there are several patients on the unit that

need safety companions; coverage is provided by the UAP float team. The safety companion can

also experience stress and anxiety when they are caring for a patient that is agitated, confused

and combative because they are at risk for physical and verbal abuse from the patient.

New Method for Fall Prevention

We have units in our hospital that are monitored by telesitters including the geriatric unit.

Our unit would benefit from having telesitters as well because a telesitter system would decrease

the rate of falls and would be cost effective in decreasing the extra staff needed to prevent falls

on the unit. The AvaSys is a portable remote patient observation and communications platform

that enables both visual and audio monitoring of patients at risk of self-harm, including falls, and

removing medical equipment and IVs. Telesitters can monitor up to 12 patients at a time and

redirect them if they are trying to get out of bed or are pulling at tubes, oxygen or IVs from a

remote location. The telesitter can call the nurse or UAP through our vocera system via the

iPhone to explain what the patient is doing; to have someone can go and check on the patient.

There is also the capacity to have a special alarm pulled to get someone to go in the room if the

RN or UAP was not reached on the iPhone. The use of the AvaSys remote monitoring system is

safe tool for fall prevention and can decrease safety companion use and costs while decreasing

falls on the unit. The average cost of using one in room safety companion for one patient is

about $350.00 per inpatient day. Effectively implementing the AvaSys remote monitoring

system with a telesitter-patient ratio of 1:12 would reduce the average cost to $29.00 per patient

inpatient day. The cost of a safety sitter for one patient per year is $127,750; with telesitters the

cost would be $10,585 per year. Christiana Care did a Safety Companion pilot program and
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showed the current budget for the program was $2,450,000 per year and was on target to be over

budget by $400,000 by the years end.

Inconclusion the AvaSys Telesitter monitoring system will help improve the quality of

care we provide on the unit by decreasing falls, improving staffing and reducing costs of

increased patient stays due to falls and pulled staff to sit with patients. This will decrease the

workloads of RNs and UAPs on the floor, which decreases burnout and alarm fatigue. Patient’s

privacy and dignity will be protected and the patient will be treated with respect at all times. The

patient and the family will be included in decision for monitoring and will be educated on the

process. Please see the following Flow Charts of the current and proposed fall prevention

process as well as the New Policy for Telemonitoring.

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Appendix 1

Patient admitted The Current Workflow

to the STAR unit or
reassessment
Patient is assessed for falls and
behavioral issues
Sitter Assessment Criteria
Schmid Assessment Score ≥ 3
History of Falls (YES)
Unilateral Weakness (YES)
Sensation Deficit (YES)
Able to Participate in Fall Prevention (NO)
Confusion/Agitation (YES)
Impulsive (YES)

Is the patient
suicidal/com
bative or at a Contact the Physician for a 1:1
high risk for Yes
Safety Companion order
falls?

NO

Safety Companion not needed.

YES

Change in
Revaluate as needed
status of
the
patient
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Appendix 2

Patient admitted The New Workflow

to the STAR unit or
reassessment
Patient is assessed for falls and
behavioral issues
Sitter Assessment Criteria
Schmid Assessment Score ≥ 3
History of Falls (YES)
Unilateral Weakness (YES)
Sensation Deficit (YES)
Able to Participate in Fall Prevention (NO)
Confusion/Agitation (YES)
Impulsive (YES)

Nursing order for Telesitter.

Yes
Obtain Pt/family verbal
Does the consent
patient meet
the above
criteria?

No

Is the patient Document the verbal

suicidal consent in the EMR

Yes Contact the Physician for a 1:1

Safety Companion order

NO

Safety Companion not needed

Telesitter not needed
YES

Change in
Revaluate as needed
status of
the
patient
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Appendix 3

Telemonitoring Policy

PURPOSE:
To describe the criteria and process of placing a patient with a telemonitor (telesitter) as a
strategy to increase patient observation and reduce patient falls resulting in improved patient
safety.

DEFINITION:
Telemonitoring is a nurse driven protocol that does not require a physician order, but it does
require patient’s verbal consent. It is a method by which a portable video camera is placed in the
patient’s room at the foot of the bed and monitored from a private location on the unit to provide
close observation for patient safety. This is a live feed on a closed-circuit television with real
time surveillance with no recording.

Policy:
1. Two AvaSys Patient Observer monitors will be located on 6C that is accessible only to
staff. Up to twelve cameras will display on each monitor.
2. Patient verbal consent is required and is documented in PowerChart.
3. Telemonitoring are for patients who respond to redirection/verbal cues appropriately.
4. If the patient/family refuses, standard care will be provided (i.e. encourage family to stay
with patient or obtain 1:1 safety companion.
5. Care will be provided by the assigned direct care providers. Telemonitoring is not a
substitute for frequent nursing assessments or interventions.
6. Telemonitoring will not replace other fall reduction strategies (i.e., low beds, chair/bed
alarms, toileting schedule and hourly rounding, etc.).
7. When the patient requires testing/procedures off unit, bedside testing as appropriate will
be considered.
8. When a member of the health care team is providing direct care, patient’s privacy will be
respected by placing system on privacy mode. Communication will take place between
clinical staff and monitor tech regarding privacy time for patient care.
9. Equipment will be kept at a designated area on 6C.
10. Equipment will be cleaned by department staff using appropriate cleaning agent prior to
storing (reference patient care equipment cleaning guide).

Appropriate patient for Telemonitoring:

 Patients who are mild to moderately confused
 Patients who are at high risk for fall with lack of safety awareness
 Patients who are impulsive requiring continuous observation that is responsive to verbal
cues/redirection
 Patients who are at high risk for major injury related to fall:
a. >75 years of age
b. Dementia
c. Osteoporosis/Osteopenia
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d. History of fracture in last 5 years

e. Patient on bleeding precautions
 Patients with a history of falling within the past 3-6 months
 Patients who are at risk for elopement
 Patients who are going through ETOH/drug withdrawal
 Patients with psychiatric disorders (excluding suicidal patients)
 Patients who are experiencing seizures, stroke/TIAs, syncope/dizziness
 Patients who are blind

Inappropriate patient for Telemonitoring:

 Patients who are on suicide precautions
 Patients who are not responsive to redirection/verbal cues
 Patients who are exhibiting aggressive/violent behavior

Discontinuation of Telemonitoring:
Discontinuation is based on nursing clinical judgement. The charge nurse will communicate
with the monitoring tech (telesitter) that monitoring with be discontinued. The order will be
removed from patient’s chart, and equipment will be cleaned appropriately by department staff
and stored in designated area. The Telesitter will discharge patient from central monitoring
station and will file documentation when indicated.

Charge Nurse:
In collaboration with the Nurse will determine which patients need Telemonitoring.
Shift accountability for the Telesitter (i.e. meal breaks, assignment, other issues that arise).
Enters order in PowerChart by ordering “Video monitoring” as a nursing order. Make sure
verbal consent is documented in PowerChart by the Nurse.

Nurse/PCT Responsibilities
 Assist with equipment set up for optimal viewing.
 Respond in a timely manner when notified by the Telesitter.
 Accompany patient in the bathroom and remain in the bathroom with them for safety.
 Remain with patient when on the beside commode.
 RN communicate with Telesitter for any new admissions, transfers, or discharges.
 PCT, encourage the use of diversional activities.

Telesitter Responsibilities:
 Ensure there is an order printed for each request.
 Introduce themselves to patient and family members and let them know that they will be
monitored.
 Play monitoring orientation video for patients and family members.
 Obtain report on patients from the patient’s nurse and off going Telesitter.
 Telesitters will work for 4- or 8-hour shifts.
 Monitor the patient continuously. Avoid distracting activities such as reading
making/receiving personal phone calls or text messages, etc.
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 Attempt to verbally redirect patient through the call bell system and encourage them to
stay in bed.
 Notify staff using Vocera and clinical alerting if any issues arises with the patient that
requires staff response.
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References

Dykes, P. C., Adelman, J., Adkison, L., Bogaisky, M., Carroll, D. L., Carter, E., ……..

Yu, S. P. (2018). Preventing falls in hospitalized patients. American Nurse Today 12(8),

8-13. Retrieved from: https://www.americannursetoday.com/preventing-falls-

hospitalized-patients/

Fehlberg, E. A., Lucero, R. J., Weaver, M. T., McDaniel, A. M., Chandler, A. M., Richey, P. A.,

…..Shorr, R. I. (2017). Impact of the CMS no-pay policy on hospital-acquired fall

prevention related practice patterns. Innovation in aging, 1(3), igx036. Doi:

10.1093/geroni/igx036

Lunsford, B. & Dodge Wilson, L. (2015). Assessing your patients’ risk for falling: A systematic

Process to address patients’ fall risk can decrease or nearly eliminate falls. American

Nurse Today 10(7), 29-31. Retrieved from: https://www.americannursetoday.com/wp-

content/uploads/2015/07/ant7-Falls-630_FULL.pdf

The Joint Commission, (2015). Preventing falls and fall-related injuries in health care facilities.

Retrieved from: https://www.jointcommission.org/assets/1/6/SEA_55_Falls_4_26_16.pdf