Frances M. Carr , MBChB
Internal Medicine Department, University of Saskatchewan, Saskatoon, SK
DOI: http://dx.doi.org/10.5770/cgj.16.29Purpose
The concept behind constant observation is not new. Whilst traditionally performed by nursing staff, it is now commonly performed by sitters. Details surrounding the usage, job description, training, clinical and cost effectiveness of sitters are not known; hence the reason for this review.
Methods
A literature search was performed in MEDLINE, Cochrane Database of Systematic Reviews, and PubMed from the years 1960 to October 2011. The definition for sitter used in the articles was accepted for this review.
Results
From this review, it is evident that sitters are being employed in a variety of settings. The question of which type of person would provide the most benefit in the sitter role is still not clear; whilst sitters have typically included family and volunteers, it may be trained volunteers who may offer the most cost-effective solution. The paucity of information available regarding the training and assessments of sitters and the lack of formal guidelines regulating sitters’ use results in a lack of information available regarding these sitters, and current available evidence is conflicting regarding the benefits in terms of cost and clinical outcome. The only strong evidence relating to clinical benefit comes from the use of fully-trained sitters as part of a multi-interventional program (i.e., HELP)
Conclusions
Current evidence supports a role for the sitter as part of the management of patients with delirium. The most cost-effective sitter role appears to be trained volunteers. Further research is needed to determine the specific type of training required for the sitter role. The creation of a national set of regulations or guidelines would provide safeguards in the industry to ensure safe and effective patient care.
Key words: delirium , constant observation , sitters , volunteers
Delirium is an extremely common problem occurring in over 50% of older, hospitalized patients, and is associated with both a decline in functional ability and increased morbidity and mortality. Consequently, it has been referred to as being ‘an independent marker of functional decline’.(1) In addition, the development of delirium is associated with higher rates of falling,(2) contributing to poor clinical outcomes. The hospital costs are considerably higher for these patients compared to those without delirium.(3)
Currently, the management for delirium is multifactorial(4) and should include the treatment of reversible conditions and addressing specific patient and care factors which may be contributing to the delirium.(4) A recognized component of this approach, both for the prevention and in the management of delirium, involves the employment of constant observation (CO) (also known as special observation).(4,5)
The concept of CO has been around for some time,(2,6) and associated definitions have ranged from ‘an intervention in which continuous one-to-one monitoring is used to assure the safety and well-being of an individual patient or others’,(7) to ‘direct observation of patients for the purpose of providing a safer environment for the patient’.(8) However, a more practical description for CO uses CO for the provision of one-to-one observation by a constant observer (a dedicated person employed to sit with the patient). Once mostly reserved for use within the psychiatric setting for patients at high risk of self-harm or suicide,(9) the role of CO has diversified and is now most commonly implemented for the management of delirious patients.(4) The term ‘sitter’ is used to refer to the person providing constant observation. Whilst numerous different terminologies exist for these constant observers (i.e., patient sitters, volunteers, client attendants, patient attendants, companions), for the purpose of this review they will be referred to as sitters.
Therefore, our primary objective for this literature review is to provide an overview of the current role of the sitter within the management of delirium in hospitalized patients by first addressing the current understanding of the role for sitters, the type of person employed in this role, indications for current usage, and the frequency they are used. Secondary objectives include the identification of key training requirements required for the sitter role and establishment of the cost-effectiveness of their role within delirium management.
A literature search was performed of MEDLINE, Cochrane Database of Systematic Reviews, and PubMed from the years 1960 to October 2011. The definition for sitter used in the articles was accepted for this review. The following search terms were used: sitter/patient sitter/companion/nurses’ aides/special care aides, confusion/delirium/acute confusional state, responsibilities/roles, constant observation/observation, outcomes, intervention, cost/cost analysis. A large number of search terms were used in order to ensure completeness, with identification and inclusion of all potential studies. Inclusion criteria required the articles (and abstracts) to be in the English language and contain relevant research involving at least one of the following: the roles of the sitter, people used for the sitter role, current usage of sitters, indications/assessment and/or tools/evaluation for sitter use, education/training requirements/pre-requisitions required for the role, costs associated with sitter use, sitter use/role within delirium setting including non-pharmalogical intervention models for delirium management. One additional article addressing accuracy of nursing staff for detecting delirium was also included due to the significant impact this could have for sitter usage. One reviewer was responsible for data collection, data analysis, and performing the literature review. Quality assessment was made based on: study design (and blinding), sample size, methodology, and validity of results. From a total of 147 citations initially identified, 50 full-text manuscripts were reviewed and 37 articles were included in the final analysis. A meta-analysis was not conducted due to clinical heterogeneity between included articles. Instead, a summary of the data is presented (Table 1).
TABLE 1
A summary of studies included in final analysis
The term ‘sitter’ relates to the person performing the one to one observation.(8) One of the first reports documenting sitter use was in 1985 as part of a nursing intervention for post-operative orthopedic patients, in which a ‘nurse visitor’ was employed to provide consistent contact with patient.(10) Whilst their presence may not have significantly influenced the rate or duration of delirium, it does provide evidence supporting the use of patient sitters in the management of delirium. Currently, there is no guidance available regarding who should be used in the sitter role, and no evaluation has been performed to assess the impact that the type of person in this role has upon the patient’s clinical outcome; as a result the type of sitter used is determined by the local health region.
The current literature describes a variety of people having been used in the sitter role. The use of skilled nursing staff or nurses’ aides as sitters has been well-described.(2,11) Whilst the experience and training they could offer is vast, their use is significantly restricted by an associated high-cost expenditure combined with limited staffing levels.(12) Family members or other relatives are used quite often, inadvertently, as sitters by health-care staff, which is supported by a study that looked at family participation in patient care in the hospital setting and showed their involvement ranging from direct provision of patient care to companionship.(13)
One study based in Australia used volunteers in the combined role of observers and companions for patients who had been highlighted as being at a high risk of falling. (14) These volunteers remained with them in the room and were involved in patient interaction, in addition to alerting nursing staff any time patients were identified as being about to fall. Whilst the results from this study showed significant reductions in patient fall rates, limited availability of these volunteers, combined with significant restrictions imposed from occupational health and safety regulations on their role, may limit their use in this capacity.
Although once used for observation of high-risk psychiatric patients, the use of sitters is now most commonly employed as part of the management for delirious patients. Another established, albeit less frequently recognized role, is the provision of companionship for patients in palliative care.(14) Alternative uses for the sitter role have been seen as part of a preventative strategy for ‘wandering’ patients(8) and in fall prevention.(15,16) An alternative role for the sitter has included their use for ‘rooming’ with patients. This is when a family member or close friend stays in the patient’s room, and has been shown to be effective for elderly orthopaedic patients, as described by one study on post-operative elderly orthopaedic patients to assess its clinical impact on delirium rates. (6) Although hospital length of stay and duration of delirium were not significantly reduced, it was shown to be feasible and may possibly be most beneficial for the acutely admitted elderly population. More recently, successful sitter use was shown in the role of a ‘rehabilitation patient companion’ on an acute brain injury unit in an attempt to reduce costs and improve patient and nurse satisfaction.(17)
An absence of national guidelines or regulations governing sitter use has inevitably led to a lack of specific criteria (including indications) for hiring sitters, resulting in decisions being made at the local level. This lack of standardized criteria regulating the use of sitters and the absence of formal guidelines (provincial and federally) has highlighted an important deficit in the system that requires addressing.
One study based in the UK looked at sitters currently employed in the palliative care setting and identified the reasons why sitters got involved and showed (indirectly) that higher sitter turnover was linked with inadequate or insufficient training, which supports the need for adequate training for the role.(14)
A quality improvement project was done to assess the effectiveness of a one-hour educational program aimed at sitters (and nurses) which addressed key issues including policy and procedure, risk assessment, and symptom recognition, combined with self-learning.(18) In addition to showing improvement through the comparisons of pre- and post-test results, it was also shown to be cost-effective, which supports the use of similar interventions in the provision of sufficient training for sitters.
The use of sitters is dependent on the ability of nurses or health-care staff effectively recognizing patients requiring constant observation. However, one study, which addressed the recognition by nursing staff of patients with features of delirium by assessing nursing documentation, showed poor documentation of delirium features.(19) Thus, a failure to recognize such patients will inevitably affect the efficiency surrounding the use of sitters.
To help with identification of patients who would benefit from sitter use, and aid and improve sitter requests, an assessment tool, the ‘patient attendant assessment tool (PAAT) (20) was created. Using the PAAT, an improvement was seen in completion of the requisition forms, hiring of sitters, and in actual sitter usage, which was accompanied by reduction in restraint use.(20)
The use of sitters as part of the multi-interventional approach for delirium has been well established in the Hospital Elderly Life Program (HELP),(21) initially described by Inouye et al. This model used rigorously trained volunteers as part of an interdisciplinary approach to reduce the incidence and rates of delirium. The success of the program was based, in part, on the use of well-trained volunteers for delirium management.
Additional support for the use of sitters is provided from the results of the REVIVE study,(22) aimed at the prevention and reduction of delirium using a multi-interventional approach through the use of trained volunteers to provide patient interaction and re-orientation. The results revealed a reduction in the incidence and duration of delirium, together with a reduced frequency of falls, thus supporting the importance of this approach. In addition, it was associated with a reduced length of stay in hospital, providing indirectly evidence for the use of sitters for cost-saving purposes.
Another similar concept is the Specialized Adult-Focused Environment (S.A.F.E.) units.(23) This model is based on placing all patients who require constant or very close observation in close proximity to one another, either in a single room or unit in the presence of nursing staff, which provides for continuous or close monitoring for these patients. With the implementation of these SAFE units, the use of sitters was decreased significantly, in addition to a reduction in restraint use. A significant cost saving benefit was seen for the health region.
The specific costs pertaining to sitter use are not clear. One study that specifically focused on sitter costs stated median sitter costs as being $772 compared to $2397 for high sitter use.(24) The interpretation of this information, however, is difficult due to the terminology used for average and high sitter usage for which there is a paucity of data. Certain factors have been associated with higher rates of sitter usage and thus higher sitter costs, which include understaffing of units with registered nurses and certain patient characteristics. This same study proposed that increasing the number of hours worked by skilled nurses or by patient care assistants may reduce use of sitters and thus lead to lower sitter use and lower sitter costs.(24)
The cost-effectiveness of a Patient Sitter program was addressed using outcomes which included the frequency of patient falls and patient satisfaction.(25) The results from this study showed only a marginal benefit was gained for both patient satisfaction and fall rates. In this study, the cost for a typical sitter shift was $160, which, when adjusted for the (slight) benefit seen in fall rates and patient satisfaction, revealed a net cost expense of $156.24.
The HELP program, aimed at reducing the incidence and duration of delirium in hospitalized elderly patients, reduced hospital costs substantially,(26) and has the potential to be replicated in alternative settings from that in which it was first described, possibly making it the most cost-effective way for employing sitters.(26) However, a Cochrane Review looking at the cost-effectiveness of the implementation of similar programs has suggested that whilst this may reduce both incidence of delirium along with costs for ‘intermediate’ risk patients, there was no significant benefit seen in ‘high’ risk patients, either in incidence of delirium or cost saving.(27)
The potential benefit offered by sitters is tremendous, especially considering the provision of constant observation on a busy acute medical ward. The one-to-one monitoring that can be given is invaluable, and provides a safety net for the nursing staff for high risk patients. This is supported by one study which showed the presence of sitters acted as a significant motivator and improved nurses’ confidence in ensuring the provision of adequate patient care.(28)
The results from the REVIVE study(22) provided evidence of the potential benefit that trained volunteers could offer with patient interaction, whilst providing additional benefits in terms of reduced numbers of nursing assistants required, as well as hospital cost savings.
Whilst the role of sitters for use with certain patient population has previously been established, evidence for the cost-effectiveness of sitter usage for patients with delirium compared to traditional management is conflicting. Although the use of sitters may reduce restraint use, their impact on patient fall rates (a major patient safety outcome measure) is marginal at best,(25) and not clinically significant.
One study assessed the use of sitters for patients deemed at high risk of falling and patients in a psychiatric crisis.(8) By identification of patient volume, current sitter usage, and an assessment of demand, the study authors concluded that the use of constant observation with sitters was an ineffective and costly way of attempting to improve patient care. The study further noted that it was more beneficial to identify high-risk patients on admission (using assessment tools), and to train and employ the hospital’s own health-care staff as sitters (using a good quality sitter education program) rather than use an external agency.(8)
From this review, it is evident that sitters are being employed in a variety of settings. Although there has been no standardized definition created for a ‘sitter’, a common underlying theme is apparent regarding their role as an observer or companion for the patient — thus providing a potential definition for the sitter role as a person hired ‘to provide constant observation or companionship’.
The question of which type of person would provide the most benefit in the sitter role is still not clear. Studies have reported using a variety of people ranging from RN nurses and special care aides to (untrained) volunteers and patient relatives and family members. However, due to growing demands exerted on nursing duties, there has been an increasing trend towards using external ‘hired agency staff’ as sitters, with a resulting rise in costs.(2,7)
Family members have the potential to be effective sitters; their familiarity with the patient, close relationship, and motivation to stay with the patient can provide essential patient interaction important for delirious patients. In addition, a family member’s presence at the bedside can provide close observation, as well as familiarity, and thus enhance patient safety.(13) Their relationship with the patient, however, has the potential to negatively impact patient care if their goals are not the same as the health-care staff.
Volunteers may have the most potential in the capacity of the sitter, provided that they are adequately trained for the role and are freely available, which is evident from success of established program such as HELP model. This is supported by several studies that have justified the use of trained volunteers by showing them to be cost-effective.(22,26) Indeed, the use of sitters relieves the workload of overworked, stressed nursing staff who are often more than happy to have an additional pair of hands in the form of a volunteer sitter.(12)
As discussed earlier, sitters are currently employed across the country in several different settings with one of the most common being for delirious patients. Precise details relating to the frequency of the use of sitters at any individual locations are difficult to establish due to a lack of documentation at the local, provincial, and federal levels. This highlights a potential role for the development of a national reporting scheme for recording their use. The absence of a standardized job description for the sitter role and lack of regulations regarding their use have led to the development of a certain degree of unease concerning their use, and accounts for the significant amount of variation and inconsistencies seen in the use of sitters. Without a specific job description for the role of a sitter, health-care institutions are significantly restricted in this capacity, and hindered in benefiting from the use of sitters (i.e., provision of daily social interaction, cognitive stimulation, frequent reorientation therapy, etc.). This is important due to the significant clinical impact that can result following the implementation such interventions would have on delirium outcomes. However, without further clarification (in the form of national guidance) about their position, then these potential benefits offered by sitters cannot be utilized.
Currently there are no formal criteria regulating sitter usage. Sitters are mostly employed as part of the management of delirious patients. Use of sitters for the provision of constant observation for high-risk psychiatric patients is well established.(9) More creative and alternative roles for sitters have been successful, including their use as a ‘patient companion’ in the palliative care setting(14) and for patients with traumatic brain injury.(17) Although additional roles have used sitters in an attempt to reduce rates of wandering for high-risk patients and patient fall rates, these are theoretical advantages which are not supported by the current evidence available, and conflicts with the general consensus that sitters do not improve frequency of falling and may even increase fall rates; however, the reasons for this are not clear.
The process for identifying those patients who would benefit from the use of sitters has not been well established. The provision of pre-specified criteria or assessment tools to aid nursing staff in recognizing patients who would benefit from these costly resources is important for both reducing costs associated with using sitters and reducing rates of pharmacological therapy with its associated side effects. The importance of appropriate sitter usage is supported by evidence showing that whilst higher sitter usage was associated with decreased rates of soft restraint use, it was accompanied by an alarming increased rate of falls.(20)
If nursing staff are efficient in recognizing the presence of delirium, then this should naturally improve sitter use and cost-effectiveness. However, whether this happens is debatable. One prospective study looking at the accuracy of nursing documentation relating to their recognition of the signs and symptoms of delirium suggested possible poor recognition, with a possible exception being for severely ill patients.(10) Thus, the poor recognition of delirious patients will affect sitter usage within the hospital setting. Although there are no currently no formal established assessments tools available to aid with this process, there is great potential in the form of a specified assessment tool — the PAAT — as discussed previously,(20) which was created to help assist and thus improve the hiring and requisition of the use of sitters for high-risk patients.
Adequate training for sitters is crucial for clinical, ethical, and financial reasons. Common sense states that the use of untrained sitters in potentially risky situations may have negative consequences. A lack of orientation to either the patient and/or to their role is distracting and problematic for both the patient and sitter and this, combined with the lack of familiarity between them, could create a potentially disastrous situation, as well as being an inefficient use of resources and a hindrance to patient care. In addition, inadequate training for the management of aggressive or agitated patients could put sitters, the patient, and staff at danger and has legal consequences. This is important, as many situations in which sitters are employed (e.g., delirious patients and palliative care) are highly sensitive and emotionally charged settings in which the presence of a sitter can have a big impact on both the patient and relative. This further highlights the extreme importance of sitters receiving adequate training for this role.
As a consequence of the lack of formal/recognized training or assessment, the competence of these sitters has been questioned several times, especially since it is often untrained volunteers that are commonly used in this capacity.(18) The importance of this is evident from the dire consequences that can ensue due to the nature of settings in which these sitters are commonly employed. However, with adequate training, the effectiveness of fully trained volunteers in the sitter role is non-debatable, reconfirming the need for sufficient training for the position.
The employment of sitters in the management of delirious patients may benefit the patient both in terms of delirium control (through the application of consistent, frequent re-orientation therapy), as well as (possibly) reducing or preventing the use of pharmacological agents and/or restrictive devices. The HELP program has been shown to be successful in both reducing the rate and length of delirium episodes whilst reducing negative clinical outcomes associated with delirium.(21) Similar, smaller programs based on this concept have been set up,(29) the findings of which have shown similar results. Thus, the use of a well-established delirium program model for employing trained sitters (i.e., volunteers) may offer the most cost-effective method. However, the translation of a large established program to implementation of smaller similar programs at the local level can be one of the hardest barriers to cross due to restrictions exerted in terms of costs, resistant attitudes from staff, and insufficient staffing levels (to name a few). One article addressed this,(29) and looked at the degree of implementation of similar HELP programs across the country and their success rates. This study showed that only 25% of those who initially expressed interest in developing the program actually succeeded in establishing an active, functioning HELP program in their local institution.
The variation in sitter usage across the country is considerable. Certainly, in our local region, the use of sitters has been reduced substantially in the last couple of years due to financial restraints. This is hardly surprising considering the severe deficiency of good quality evidence for their use and lack of information supporting their role or even an accurate definition of their position. One study did produce a sitter guidance sheet, stating hints and tips which could offer useful information for current sitters.(30) The impact of this on sitter activity and possible future training would be very interesting to assess. The same review suggested that management of patients who require sitters should avoid placing delirious patients in one single area due to a possible negative influence that may be exerted on one another. However, other studies do not support this concept, which conflicts with evidence from the aforementioned SAFE study.(23)
From the 37 articles included in the review, nine studies directly addressed the role for sitters in delirium, with sample sizes ranging from 24–4763. Addressed outcomes included markers of delirium (incidence, severity, duration, number of episodes, and recurrence), patient outcomes (cognitive change, functional change, sleep quality), nursing assistant use, and financial cost. The use of mostly trained volunteers in the sitter role provided the main limitations to these studies. One article addressed training for sitter role in delirium (sample size: 1507) and six articles (sample size: 37–5346) addressed cost-effectiveness for role of sitters in delirium.
Current evidence supports a role for the sitter as part of the management of patients with delirium. Since the majority (and strongest evidence) is seen with the use of trained volunteers in the sitter role as part of an established delirium model (such as HELP), then this may likely be the most cost-effective way for advocating their use, possibly in conjunction with use a recognized sitter assessment tool such as the PAAT. The specific type of training required for the sitter role is not clear and requires further research. Certainly, when considering using a sitter, the health-care provider should carefully document the indications for sitter use, and monitor and reassess these indications alongside the frequency and use of the sitter in order to maximize cost-effectiveness. Long term, the creation of a national set of regulations or guidelines would provide safeguards in the industry to ensure safe and effective patient care, in addition to the creation of a national reporting scheme for sitter usage.
The author declares that no conflicts of interest exist.
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Canadian Geriatrics Journal , Vol. 16 , No. 1 , March 2013