Sitter Utilization Issues - Essay Example

Module Sitter Utilization A common phenomenon is observed in many patients where they lose their sense of judgment, and intentionally become a danger to themselves and others. In this regard, many of these patients are put under the care of a sitter who keeps an eye on them at all times to ensure the patients do not hurt themselves or those around them. These companions could either be in the institution where the patient is, in a private home that offers care to such patients, or could be family members or other people paid to care for the patient (Klonsky 1039). Statement of the Problem Many factors result in a patient harming oneself including mental illness, psychological factors, genetics, and drug use among other factors. According to Cleary (143), some people who do not suffer from any mental illness hurt themselves and others; however, suffering from psychiatric conditions increases the likelihood of a person doing self-harm. Individuals with personality disorders of any kind are at high risk of hurting themselves; including dual personality disorder and borderline personality disorder. In addition, phobias to various common phenomena cause people to harm themselves in one way or the other, as is depression caused by many pressures of daily living. Schizophrenia reduces a person’s ability to distinguish between real and imagined things, thereby causing a person to harm self or others. In addition, schizophrenic patients tend to be suicidal especially if the patients are young and know what the disease will do to their lives. Final in the list of mental disorders is Munchausen Syndrome, though it results in self-harm to a lesser extent. Recent studies have shown that terminally ill patients are also at risk of committing self-harm or suicide in extreme cases, for instance, HIV/AIDS patients. Psychologically, self-harm is caused by any form of trauma including childhood abuse, bereavement, and abusive relationships. Autism may cause patients to harm themselves, while other factors in life in may also contribute, including poverty and unemployment. Lesch-Nyhan syndrome is the only genetic conditions that result in self-harm; however, genetics predisposes a person to conditions like stress and depression that may cause a patient to self-harm. Alcoholics are the most predisposed drug users to self-harm, accounting for over 60 percent of drug users who do so. Harming oneself due to drug influence may occur when a person is abusing the drugs, due to the addiction, or because of withdrawal symptoms resulting from attempting to stop the habit (Laye-Gindhu and Schonert-Reichl 451). Self-harm takes many forms and includes biting, scratching, poking of eyes, banging the head, burning oneself, and piercing of the skin among others. While these are dangerous, they are not immediately life threatening except if the patient is attempting suicide. On the other hand, many patients may self-harm with the intention of committing suicide, especially by swallowing poisonous substances and other actions that are life threatening. While the treatment of these patients is results in healing that keeps them from self-harm, before full recovery the patient should be under close watch by a sitter to prevent self-harm of any form (Schoppmann 588). The Strategy The aim of this strategy is to guide patient caretakers on how to care for patients who are prone to self-injury depending on the level of risk that the condition puts the patient. In addition, it aims at defining if keeping watch of a patient improves the patient’s condition or makes it worse; if it is the former, a procedure is provided to measure the degree of improvement. A physician should specify all the requirements for a sitter depending on patient condition, and these orders should be given in daily to allow for necessary adjustments depending on patient condition. These orders should specify reasons such that the sitter can know why he or she is doing it, and to allow him or her to adjust conditions to suit the patient (Cincinnati Childrens Hospital Medical Center 4). The strategy described in the paragraph above was obtained from the National Guideline Clearinghouse website and is given in the appendix. According to the AHRQ, the website gives guidelines to professionals in the medical field on appropriate patient care. This webpage describes clearly how professionals should analyze patients effectively to know if patient condition is improving as they are being treated and catered for by a sitter, or otherwise. The information presented on this webpage is dependable because it belongs to a respectable government agency, and it uses information derived from peer-reviewed journals. This means that the best and most knowledgeable minds in the field would recommend this information as viable; especially since it uses professionally approved ideas (Farber 290). Implementation Approval. In the hospital, the strategy has to be approved by all stakeholders in the management and workforce before it can be used on patients. First, the senior hospital management will meet with the person coming up with the proposal. These leaders will want to know the efficiency and effectiveness of the approach, the cost of implementation and the likely returns. However, this team will not be interested in the medical aspect of the system as there is another group for that; theirs is to know the impact of any new project on the overall hospital management without worrying about the technical details. Once the high administration gives a go ahead to the strategy, department heads for the affected departments will then pick up the matter for discussion with group leaders and team players at the department level. The final stage in the approval of the strategy of patient improvement analysis will be consultations with the people who will implement the strategy, who are the employees in various departments. These consultations will involve an analysis of the system for various factors, including the time required for implementation, how duties will be shared, and what the employees think of the strategy among other factors. If these consultations result in suggestions for modification or abandonment of the strategy altogether, the information would be communicated to managers for consideration. Once employees agree to the project as it is, strategy implementation starts with immediate effect (Dodds and Bowles 183-188). Orientation and Training. Though employees already have the skills to perform all routine procedures related to patient care, they have to be oriented on standard ways of doing this, and get training on the part involving analysis for efficiency. Training employees in a standardized manner enables the institution to maintain uniformity for quality assurance, and ensure that failure of the strategy will be due to factors within the strategy and not employee incompetence. Since all employees at the hospital have their duties and responsibilities at their departments, training will be done in shifts whereby each department will make a schedule for its employees’ attendance of trainings. This will ensure that strategy implementation does not interfere with hospital operation in a bad way. These trainings should be spaced out to avoid overloading employees with excessive tasks. In addition, the hospital usually has forums where employees meet for academic or other purposes. These forums should also be used such that trainers can train employees on the strategy. If the hospital does this, then it is likely that the strategy will be implemented in a remarkably short time (Vrale and Steen 515). As regards to trainers, the senior medical professionals in the hospital could assist in topics in the strategy they are conversant with; such that each of them gets the topic that he or she is most suited. In addition, before employee training starts, these professionals will be trained to give them the necessary skills and act as a refresher course for those skills that they already have. Various trainers will handle employees to ensure they get a clear picture of the task by hearing it from different perspectives. These trainers will be the hospital-based professionals, and other trainers outsourced from other institutions, preferably those that deal with implementation of this genre of strategies. All these trainings will be continual such that the hospital will adopt them as part of its culture to ensure optimal performance (Skegg 1471). Effectiveness and Cost. On a monthly basis, quality assurance staff in conjunction with department heads will analyze the strategy for effectiveness and efficiency; using the methods explained in the appendix. First, they will check if the rates of patient self-harm will have reduced, including change in the rate of suicide attempts and mortality rate. In addition, the team will screen patients for data on change in intensity of self-harm, a portion of which will be provided by the patients’ caretakers. Data will be collected this way for six months and then analyzed for improvement trend; if improvements are recorded then the strategy is effective and should be used as it is. However, if the results do not show improvements, then the committee overseeing the strategy should meet to rethink the strategy for improvements or modifications. Moreover, if improvements are recorded, meetings should be held to deliberate on ways of making the strategy even more successful (Duffy 946). On the costs to the hospital by the project, there will not be much required of the hospital since employees will be used to implement the strategy, unless the management decides to give them extra allowances for motivation purposes. For patients whose families decide to provide care by private means, the cost of professional sitters varies from $15 to $35 per hour depending on the institution and the quality of care. The other expense that the hospital must incur is that of training, but this will not be a hefty burden especially if the strategy succeeds. Timeline Activity Start Date End Date (Where applicable) Formation and meeting of strategic committee March 1, 2012 Discussion with the management March 6, 2012 Memo detailing proposed strategy and meetings schedule March 10, 2012 Meeting with department heads March 15, 2012 Consultations with employees and representatives March 20, 2012 March 31, 2012 Training of instructors April 1, 2012 Continuous (on a monthly basis) Training of employees April 6, 2012 Continuous (on a monthly basis) Start applying strategy to hospital and home-bases patients April 15, 2012 Continuous Hospital newsletter: Self hurt and the various available remedies May 1, 2012 Continuous (monthly basis) Other topics to be suggested later Hospital awareness months for causes of self-harm and the available remedies Alcohol April 1, 2012 April 30, 2012 Mental health May 1, 2012 May 31, 2012 Stress and distress June 1, 2012 June 30, 2012 Bereavement July1, 2012 July 31, 2012 Suicide and its prevention August 1, 2012 August 31, 2012 Analysis for effectiveness Monthly since the start of implementation Retraining or strategy modification Whenever deemed necessary Works Cited Agency for Healthcare Research and Quality. Best evidence statement (BESt). Preventing patient self-harm. 2012. Web. 10 February 2012. Cincinnati Childrens Hospital Medical Center. “Best Evidence Statement (Best). Preventing Patient Self-Harm.” Cincinnati (OH): Cincinnati Childrens Hospital Medical Center 6 July 2011: 4. Web. Cleary, M. “The Challenges of Mental Health Care Reform For Contemporary Mental Health Nursing Practice: Relationships, Power and Control.” International Journal for Mental Health Nursing 12.2 (2003): 139-47. Web. Dodds, P., and Bowles, N. “Dismantling Formal Observation and Refocusing Nursing Activity in Acute Inpatient Psychiatry: A Case Study.” Journal Psychiatry and Mental Health Nursing 8.2 (2002): 183-8. Web. Duffy, D. “Out of the Shadows: A Study of the Special Observation of Suicidal Psychiatric In-Patients.” Journal Advanced Nursing 21.5 (2005): 944-50. Print. Farber, S. "Death and annihilation anxieties in anorexia nervosa, bulimia, and self-mutilation", Psychoanalytic Psychology 24.2 (2007): 289–305. Print. Klonsky, E.D. "Non-Suicidal Self-Injury: An Introduction." Journal of Clinical Psychology 63.11 (2007): 1039 Laye-Gindhu, A., and Schonert-Reichl, A. "Nonsuicidal Self-Harm Among Community Adolescents: Understanding the "Whats" and "Whys" of Self-Harm." Journal of Youth and Adolescence 34.5(2005): 447–457. Print. Schoppmann, S, Schrock, R., Schnepp, W., and Buscher, A. “Bodily Sensations in Moments of Alienation Related to Self-Injurious Behavior: A Hermeneutic Phenomenological Study.” Journal Psychiatry and Mental Health Nursing 14.6 (2007): 587-97. Web. Skegg, K. "Self-harm." Lancet 336 (2005): 1471. Print. Vrale, G. B., and Steen, E. “The Dynamics between Structure and Flexibility in Constant Observation of Psychiatric Inpatients with Suicidal Ideation.” Journal of Psychiatry and Mental Health Nursing 12.5 (2005): 513-8. Print. Appendix Guideline Summary NGC-8635 Guideline Title Best evidence statement (BESt). Preventing patient self-harm. Bibliographic Source(s) Cincinnati Childrens Hospital Medical Center. Best evidence statement (BESt). Preventing patient self-harm. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2011 Jul 6. 4 p. [13 references] Guideline Status This is the current release of the guideline. Scope Disease/Condition(s) Suicidal ideation Previous suicide attempt Self-injurious behaviors including suicidal and non-suicidal self harm Guideline Category Management Clinical Specialty Pediatrics Psychiatry Intended Users Advanced Practice Nurses Nurses Physician Assistants Physicians Psychologists/Non-physician Behavioral Health Clinicians Guideline Objective(s) To evaluate, among inpatient psychiatric patients, if constant observation beginning at admission compared to routine safety checks reduces the incidence of self harm Target Population Children and adolescents ages 6-17 admitted to an inpatient psychiatric unit, with suicidal ideation, previous suicide attempts, or self-injurious behaviors including suicidal and non-suicidal self harm at serious risk of self harm Interventions and Practices Considered Constant observation of inpatient psychiatric patients beginning at admission versus routine safety checks Major Outcomes Considered Incidence of self harm Methodology Methods Used to Collect/Select the Evidence Searches of Electronic Databases Description of Methods Used to Collect/Select the Evidence Search Strategy Databases: CINAHL, Medline, Cochrane Review, PsycINFO, Google Scholar Keywords: observation, self harm, suicidal behavior, self injurious behavior, adolescents, inpatient, psychiatry Limits: English language, time frame included articles published in the previous 20 years Retrieved: July 29, 2010; November 22, 2010 Number of Source Documents Not stated Methods Used to Assess the Quality and Strength of the Evidence Weighting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence Table of Evidence Levels Quality Level Definition 1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies 2a or 2b Best study design for domain 3a or 3b Fair study design for domain 4a or 4b Weak study design for domain 5 Other: General review, expert opinion, case report, consensus report, or guideline †a = good quality study; b = lesser quality study Methods Used to Analyze the Evidence Systematic Review Description of the Methods Used to Analyze the Evidence Not stated Methods Used to Formulate the Recommendations Expert Consensus Description of Methods Used to Formulate the Recommendations Not stated Rating Scheme for the Strength of the Recommendations Table of Recommendation Strength Strength Definition "Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations). "Recommended" There is consensus that benefits are closely balanced with risks and burdens. No recommendation made There is lack of consensus to direct development of a recommendation. Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below. 1. Grade of the body of evidence (see note above) 2. Safety/harm 3. Health benefit to patient (direct benefit) 4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time) 5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis) 6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome]) 7. Impact on morbidity/mortality or quality of life Cost Analysis A formal cost analysis was not performed and published cost analyses were not reviewed. Method of Guideline Validation Internal Peer Review Description of Method of Guideline Validation Reviewed by Cincinnati Childrens Hospital Medical Center Evidence Federation Recommendations Major Recommendations The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a-5) are defined at the end of the "Major Recommendations" field. 1. It is recommended that direct care providers working on inpatient psychiatric units and performing constant observation use a therapeutic relationship approach. It has been found that a therapeutic relationship is interpreted as more effective than a controlling or isolating approach (Cleary, 2003 [4a]; Duffy, 1995 [4a]; Vrale & Steen, 2005 [4a]). There is insufficient evidence, due to a lack of quantitative studies regarding constant observation, to make a recommendation answering the clinical question; due to safety purposes this is an accepted practice. How this is carried out however, varies. A therapeutic relationship approach can be more successful in maintaining patient safety (Schoppmann, 2007 [4a]; Cleary, 2003 [4a]; Dodds & Bowels, 2001 [5a]). Definitions: Table of Evidence Levels Quality Level Definition 1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies 2a or 2b Best study design for domain 3a or 3b Fair study design for domain 4a or 4b Weak study design for domain 5 Other: General review, expert opinion, case report, consensus report, or guideline †a = good quality study; b = lesser quality study Table of Recommendation Strength Strength Definition "Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations). "Recommended" There is consensus that benefits are closely balanced with risks and burdens. No recommendation made There is lack of consensus to direct development of a recommendation. Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below. 1. Grade of the body of evidence (see note above) 2. Safety/harm 3. Health benefit to patient (direct benefit) 4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time) 5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis) 6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome]) 7. Impact on morbidity/mortality or quality of life Clinical Algorithm(s) None provided Evidence Supporting the Recommendations References Supporting the Recommendations Cleary M. The challenges of mental health care reform for contemporary mental health nursing practice: relationships, power and control. Int J Ment Health Nurs 2003 Jun;12(2):139-47. PubMed Dodds P, Bowles N. Dismantling formal observation and refocusing nursing activity in acute inpatient psychiatry: a case study. J Psychiatr Ment Health Nurs 2001 Apr;8(2):183-8. PubMed Duffy D. Out of the shadows: a study of the special observation of suicidal psychiatric in-patients. J Adv Nurs 1995 May;21(5):944-50. PubMed Schoppmann S, Schrock R, Schnepp W, Buscher A. Then I just showed her my arms . . . Bodily sensations in moments of alienation related to self-injurious behaviour. A hermeneutic phenomenological study. J Psychiatr Ment Health Nurs 2007 Sep;14(6):587-97. PubMed Vrale GB, Steen E. The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation. J Psychiatr Ment Health Nurs 2005 Oct;12(5):513-8. PubMed Type of Evidence Supporting the Recommendations The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field). Benefits/Harms of Implementing the Guideline Recommendations Potential Benefits Health benefits include maintaining a safer environment for patients and staff. Using a therapeutic approach to constant observation not only can lead to decrease in self-harm, but also decrease in aggression by having less confrontations resulting from a controlling approach. Potential Harms Utilization of constant observation is associated with large fixed costs. Not all patients should be placed at the highest level of observation; therefore a threshold determined by the Suicide Risk Assessment Tool (SRT) should be used to determine those patients who need constant observation as part of their care plan. The risk of patient self-harm increases when there is inconsistent practice in the use of constant observation, especially during new admission and/or transfer from medical units. Qualifying Statements Qualifying Statements This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure. Implementation of the Guideline Description of Implementation Strategy An implementation strategy was not provided. Institute of Medicine (IOM) National Healthcare Quality Report Categories IOM Care Need Staying Healthy IOM Domain Effectiveness Identifying Information and Availability Bibliographic Source(s) Cincinnati Childrens Hospital Medical Center. Best evidence statement (BESt). Preventing patient self-harm. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2011 Jul 6. 4 p. [13 references] Adaptation Not applicable: The guideline was not adapted from another source. Date Released 2011 Jul 6 Guideline Developer(s) Cincinnati Childrens Hospital Medical Center - Hospital/Medical Center Source(s) of Funding Cincinnati Childrens Hospital Medical Center Guideline Committee Not stated Composition of Group That Authored the Guideline Team Leader/Author: Jason Phibbs, BSW, Mental Health Specialist II, Adolescent Psychiatric/Medical Inpatient Unit Support/Consultation: Mary Ellen Meier, MSN, RN, CPN, Evidence Based Practice Mentor, Center for Professional Excellence, Research & Evidence Based Practice Financial Disclosures/Conflicts of Interest There are no known conflicts of interests. Guideline Status This is the current release of the guideline. Guideline Availability Electronic copies: Available from the Cincinnati Childrens Hospital Medical Center  . Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Childrens Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@chmcc.org. Availability of Companion Documents The following are available: Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Childrens Hospital Medical Center  . Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 1 p. Available from the Cincinnati Childrens Hospital Medical Center  . Table of evidence levels. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Childrens Hospital Medical Center  . Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Childrens Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@chmcc.org. Patient Resources None available NGC Status This NGC summary was completed by ECRI Institute on November 18, 2011. Copyright Statement This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions: Copies of this Cincinnati Childrens Hospital Medical Center (CCHMC)  Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. 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