Attached is the final project paper, Wishing you luck in your submission. I am confident you will make it. The statistician did an amazing job! The paper is perfect, it will steer you forward.

Assessing the Effectiveness of Telesitter Systems in Reducing Patient Falls
Submitted by
Njideka Laura Akubuilo

DPI Project Committee
Shiela A. Leander, R.N, PH.D., C.C.C
Susan. Revero, R.N, MSN

Direct Practice Improvement Project Proposal
Doctor of Nursing Practice

Grand Canyon University
Phoenix, Arizona
June 25, 2019

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© by
Njideka Laura Akubuilo
2019
All rights reserved.

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GRAND CANYON UNIVERSITY

Assessing the Effectiveness of Telesitter Systems in Reducing Patient Falls

by
Njideka Laura Akubuilo

APPROVED:
Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Chairperson
Full Legal Name, Ed.D., DBA, or Ph.D., Committee Member
Full Legal Name, Ed.D., DBA, or Ph.D., Committee Member

ACCEPTED AND SIGNED:
________________________________________
Lisa Smith, PhD, RN, CNE
Dean and Professor, College of Nursing and Health Care Professions
_________________________________________
Date

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Abstract
Patient falls remains as one of the major challenges to the healthcare sector. Patient falls
have many negative consequences on the patient as well as the health institution. Patients endure
extended hospital stays, head injuries, broken limbs, increased pain and suffering, and many other
problems. This necessitates that new and better interventions be coined to help in reducing the
rate of patient falls. This project focusses on understanding the effectiveness of Telesitter systems,
identifying the challenges associated with the Telesitter monitoring systems, as well as identifying
the solutions to the identified problems. This project uses the Nightingale environmental theory of
nursing and Newman’s theory of health as expanding consciousness. The findings from this project
indicate that combining the use of Telesitter systems and Fallarm tactile sensor wearable device
can help to enhance the effectiveness of Telesitter systems as a falls-reduction intervention. The
Fallarm device helps by sounding an alert whenever the fall risk of the patient is escalated. This
intervention will ensure that patients with high fall-risk probability are closely monitored through
the Telesitter monitoring system as well as the tactile sensor device, ensuring that their probability
of falls is greatly reduced. This recommendation is also in line with Johnson (2014), whose
research found out that the best approach to solving patient falls is using a multi-interventional
approach. Implementing the two technological interventions in the healthcare system is deemed to
have invaluable benefits in reducing fall rate as well as boosting quality of care.

Keywords: Patient falls, Fallarm, Telesitter monitoring systems, fall prevention, acute care, and
fall risk.

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Dedication
I dedicate this project to all patients receiving care in the critical care unit, progressive
care unit, and the oncology unit. They are more prone to falls, and I am confident that the
findings from this project might in finding solutions to help to reduce fall risk. I am sure that
successful implementation of the proposals in this project will help in catering for the needs of
the targeted patient population, thus possibly reducing falls significantly.

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Acknowledgments
I take this precious opportunity to thank God Almighty for his infinite mercy and strength
He gave me throughout this project. I also seize this opportunity to thank my chairperson and the
committee team for their dedication and support, and immense contribution academically in
approving this project. They have helped me shape this project into a professional scholarly
project and I am confident that it will help to transform healthcare delivery in the acute care
environment. I also thank my mother for helping me run my home as I achieve this goal, also for
her contributions spiritually and morally. I also thank children, my siblings and the love of my
life, for their spiritual and moral support during the entire time of the project; I appreciate all of
you. God Bless you all.

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Table of Contents
List of Tables .....................................................................................................................13
List of Figures ....................................................................................................................14
Chapter 1: Introduction to the Project ................................................................................15
Introduction ..................................................................................................................15
Background of the Project ...........................................................................................17
Problem Statement .......................................................................................................19
Purpose of the Project ..................................................................................................20
Clinical Question .........................................................................................................21
Advancing Scientific Knowledge ................................................................................23
Significance of the Project ...........................................................................................24
Rationale for Methodology ..........................................................................................26
Nature of the Project Design ........................................................................................27
Definition of Terms......................................................................................................28
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Telesitter ...............................................................................................28

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Patient-fall ............................................................................................28

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Caregiver ..............................................................................................28

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Impromptu patient calls ........................................................................28

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Impromptu caregiver calls ....................................................................28

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Elderly patients .....................................................................................28

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Panic .....................................................................................................28

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Anxiety .................................................................................................29

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Fear .......................................................................................................29

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Fall rate .................................................................................................29

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Fallarm device ......................................................................................29

Assumptions, Limitations, Delimitations ....................................................................29
Summary and Organization of the Remainder of the Project ......................................30
Chapter 2: Literature Review .............................................................................................32
Introduction to the Chapter and Background to the Problem ......................................32
Theoretical Foundations and/or Conceptual Framework .............................................36
Review of the Literature ..............................................................................................38
Falls and their effects on patients and hospitals.............................................38
Falls associated with poor service quality and low patient satisfaction................ 38
Falls lead to longer hospital stays, more pain, and suffering to the patients. ....... 39
Falls lead to high unreimbursed falls-related costs. .............................................. 40
Factors related to falls. ...................................................................................42
Falls are caused by bone weakness, lack of exercising, and poor vision.............. 42
Mental conditions could increase the risk of falls. ............................................... 44
Falls are associated with low nurse to patient ratio, high nurse burnout, and lack
of stakeholder collaboration. ............................................................................................. 45
Fall prevention interventions including Telesitter systems, Fallarm wearable devices,
and fall risk assessments. ...........................................................................................47
The Telesitter systems offers the best remote monitoring of patients .................. 47

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The use of Fallarm wearable devices .................................................................... 49
Effective fall risk assessment is vital in fall prevention strategies. ...................... 49
Literature findings on the variables. ..............................................................51
Patient falls............................................................................................................ 51
Use of the Telesitter systems. ............................................................................... 52
Use of the Fallarm sensor monitoring systems ..................................................... 54
Summary ......................................................................................................................54
Chapter 3: Methodology ....................................................................................................58
Introduction ..................................................................................................................58
Statement of the Problem .............................................................................................60
Clinical Question .........................................................................................................61
Project Methodology....................................................................................................62
Project Design ..............................................................................................................63
Population and Sample Selection.................................................................................64
Instrumentation of Data ...............................................................................................67
Validity ........................................................................................................................67
Reliability.....................................................................................................................68
Data Collection Procedures..........................................................................................69
Data Analysis Procedures ............................................................................................70
Ethical Considerations .................................................................................................71
Limitations ...................................................................................................................72
Summary ......................................................................................................................73

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Chapter 4: Data Analysis and Results ................................................................................74
Introduction ..................................................................................................................74
Descriptive Data...........................................................................................................76
Results ..........................................................................................................................91
Summary ......................................................................................................................92
Chapter 5: Summary, Conclusions, and Recommendations ..............................................93
Introduction ..................................................................................................................93
Summary of the Project ...............................................................................................94
Summary of Findings and Conclusion .........................................................................95
Implications..................................................................................................................97
Theoretical implications.................................................................................99
Practical implications. ..................................................................................100
Future implications. .....................................................................................101
Recommendations ......................................................................................................101
Recommendations for future projects. .........................................................103
Recommendations for practice. ...................................................................103
Appendix A ......................................................................................................................112

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List of Tables
Table 1. Showing Numbers of Patient Falls Per Week in the Surgical/Oncology and the
Progressive Care Units .................................................................................................................. 77
Table 2. Descriptive Information of the causes of Falls and the Possible Solutions to Falls in the
Progressive and the Surgical/Oncology Units. ............................................................................. 78
Table 3a. Demographics of Nurses ............................................................................................... 81
Table 3b. Dependent Variables of Interest (Challenges) .............................................................. 82
Table 3c. Dependent Variables of Interest (Solutions) ................................................................. 83
Table 4a. Independent Samples t-Test and Analysis of Variance Results of Challenge Scores
amongst Demographic Subgroups ................................................................................................ 86
Table 4b. Independent Samples t-Test and Analysis of Variance Results of Solution Scores
amongst Demographic Subgroups ................................................................................................ 89

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List of Figures
Figure 1. Comparison of Patient Falls in the Surgical/Oncology and the Progressive Care Units78

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Chapter 1: Introduction to the Project
Introduction
Patient falls in hospitals remain as one of the biggest issues facing the healthcare sector.
It leads to the patient incurring injuries, death, extended hospital stays, and equally high
medication costs (Chan, 2015). Although there are many interventions put in place to help
prevent patient falls, it remains one of the most challenging issues in the healthcare sector,
especially in the acute care environment. As such, finding the most reliable and effective patientfalls prevention method is the key in enhancing the quality of patient care and patient
satisfaction.
This project focusses on identifying the challenges associated with the Telesitter
monitoring technology in preventing patient falls, as well as the possible solutions to these
challenges. The working mechanism of the Telesitter systems is closely related with that of bed
alarms and sensors, and the resultant effect of using the two systems is expected to be the same,
especially concerning their effectiveness (Shorr et al., 2013). This exposes the Telesitter systems
to the same challenges posed by the bed alarms. One such instance is when the video observer in
the Telesitter systems abruptly starts conversation with a specific patient, which can cause panic
and disturbance among patients. This scenario can cause the Telesitter system to be associated
with many challenges that can enhance the rate of patient falls rather than help in preventing
patient falls (El-Khoury, Cassou, Charles, & Dargent-Molina, 2013). This project used six
categories to identify the possible causative agents of the falls. The main categories of factors
include the physical factors, environmental factors, psychological factors (Delahoz & Labrador,
2014), video operator factors, Telesitter system factors, and the caregiver factors.

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In order to enhance the effectiveness of the Telesitter system in reducing patient falls, this
project found possible solutions to the identified challenges facing the Telesitter. Apart from
that, the use of the Fallarm equipment alongside the Telesitter system is encouraged for the highfall-risk patients (Davis, Kutash, & Whyte, 2017). Delahoz and Labrador (2014) present the
Fallarm equipment as a reliable tool that can help in reducing falls. The tool has capability to
detect the position of the patient and consequently warn them whenever their position indicates
that they have high fall risk. The system issues a warning sound as well as warning lights to
indicate whether a patient is in good position or is faced with high fall risk.
The Fallarm device is beneficial because it will help in detecting high-fall-risk situations
and alerts the patient as well as the caregivers. Fallarm is a small wearable wrist device that can
detect patient movements and positions and warn the patient whenever the fall risk rises
(Delahoz & Labrador, 2014). The device has mini speakers where the patient can communicate
with a caregiver; it also has a visual feedback component and tactile feedback component (Davis,
Kutash, & Whyte, 2017). The device uses inertial sensor to detect the position and movements of
the patient. The device warns the patient of high fall risk by flaring a light alert. The lighting
system gives red, amber, and green to indicate high fall risk, medium fall risk, and low fall risk
respectively. The device also has a tactile system that uses pager motor to tap the user
consistently whenever their fall risk levels rise (Davis, Kutash, & Whyte, 2017). The system also
notifies the caregiver whenever a patient’s movements or position translates to high fall risk.
This enables the caregivers to attend to patients that need immediate attention, thus helping to
reduce falls.
Although studies have in the past focused on the benefits of the Telesitter technology in
preventing patient falls, no research study has yet ventured in finding out the disadvantages of

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using this technology in the acute care environment (McCurley & Pittman, 2014). In light of this,
this project is unique and beneficial in the healthcare sector because it helps to solve the
problems facing with the Telesitter monitoring systems, helping this phenomenal tool to further
reduce the rate of falls when used as a falls reduction intervention. According to Davis, Kutash
and Whyte (2017), the use of Telesitter monitoring systems as opposed to in-room sitters helped
to reduce fall rate by 6%. Considering the technological advantage of Telesitters, this reduction
rate is small, and there is need to address the possible challenges associated with the tool to
ensure that it has higher capability of reducing falls significantly. Addressing these challenges, as
well as combining with the use of Fallarm devices among the high-fall- risk patients, is deemed
to offer a better solution to the challenge of patient falls in the healthcare sector (Delahoz &
Labrador, 2014).
This project used the surgical/oncology and the progressive care units at the Southern
California hospital as the main source of participants. Although the Telesitter systems are
currently being used in these units to monitor patients, there is still high rate of falls. This project
is set to find out the challenges leading to the falls and the solutions as outlined in the various
falls incident reports.
Background of the Project
Patient falls, especially in the acute care environment, have been a long time problem in
the healthcare sector. Although many solutions have been adopted to prevent patient falls, the
incidence of patient falls across the United States has remained alarmingly high. Currently, at
least 700,000 to 1 million patients exhibit falls in the healthcare environment each year (AvaSys,
2014). Among those who experience falls, 30% and above exhibit serious injuries that result in
extended hospital stay or even death due to head injuries (Pearson & Coburn, 2011). On average,

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each single patient fall costs the healthcare system and the patients an extra $14,000 (AvaSys,
2014). In 2008, the Centers for Medicare & Medicaid Services classified patient falls as a
hospital-acquired condition and withdrew compensation for the complications that ensued
(AvaSys, 2014). Considering that the costs associated with patient falls are not payable by
Medicaid and other third party payers, it is important that better patient-fall prevention strategies
be implemented to help in reducing the additional falls-related cost burden on healthcare
institutions.
A new milestone in the healthcare sector occurred in 2008 when the AvaSure
Corporation developed the AvaSys Telesitter systems as a technological solution to the problem
of patient falls (AvaSure Holdings, 2015). Although this system is effective, it does not offer the
best solution to the issue of patient falls. The main challenge of this technological tool is its
impromptu mode of operation where the video controller or a patient abruptly initiates
communication through the device. This is mainly associated with disturbances to the other
patients in the ward, who require calm environments to enhance their rest. The impromptu
blaring of sound from the video operator through the system or from a patient to the video
operator can cause disturbance to resting patients, which can then induce panic, anxiety, and fear
among patients, leading to more falls. To the nurses, the impromptu mode of operation of the
Telesitter systems can cause panic, anxiety, and nervousness among nurses, which can lead to
more accidents and errors. The reliance on calls from the video operator can also lead to nonobservance of the other patients. This is because the nurses rely more on the video operator,
which can derail their attention from the other patients who do not show physical signs of
suffering and pain. Reliance on the video operators is also not an effective approach because the
mode of operation of the Telesitter systems would fail when the video operator falls asleep or is

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not attentive in monitoring the patients. This challenge gives chance to the idea of combining
Telesitter systems with Fallarm devices (Delahoz & Labrador, 2014). This project also set out to
find possible solutions to all other challenges associated with using the Telesitter systems as a
falls reduction tool.
Problem Statement
The main problem of focus for this project is the continued incidence of patient falls even
after the implementation of the Telesitter monitoring systems as a fall reduction strategy. This
project set out to find the factors leading to falls despite the use of the Telesitter systems in
wards. The project also ventured into finding the possible solutions to the challenges associated
with using Telesitter systems as a fall reduction strategy. Telesitter systems are a technological
tool, one that offers better prospects to the clinical sector when focusing on patient monitoring
and surveillance. The system was specifically designed as a fall prevention system, but has fallen
below expectations in the recent years since patient falls are still on the rise (CDC, n.d.). Finding
and addressing the challenges associated with the Telesitter systems is vital in enhancing the
fight against patient falls.
The population affected by the problem of falls is predominantly elderly individuals aged
65 and over, but even younger individuals can develop healthcare complications that need
surgery and chemotherapy and can be equally be affected by falls. This project targets the factors
leading to falls in the surgical/oncology unit and the progressive care unit at a Southern
California hospital. The categorization and prioritization of these factors in regard to their
manifestation guided the DNP student to select the best solutions. Implementing these solutions

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is deemed the best possible intervention in ensuring that the Telesitter is an effective tool in
reducing the rate of patient falls.
This project contributes to the literature by outlining the challenges associated with the
Telesitter systems, equally offering possible lasting solutions to these challenges. It is not known
whether the use of the Telesitter system could be causing panic, anxiety, and fear among patients
and caregivers, which could lead to more falls, accidents, and errors in the healthcare
environment. This is because the system works using observation which has the assumption that
patients that appear to be still and relaxed during observation are doing fine, but this assumption
might be wrong in most cases. There is need to find out if the use of the Telesitter system
decreases caregivers’ vigilance and alertness in providing care to patients. Identifying the
challenges associated with the Telesitter system when used as a fall reduction tool helped to
suggest corrective measures. It is important to investigate if the Telesitter systems are a
contributory factor to some of the falls. These factors were measured through evaluation of
participants’ perception about the challenges associated with the Telesitter. The Telesitter system
is particularly of focus because it is technological, but its mode of operation is similar to that of
bed alarms and sensors, which in the past have been associated with many challenges to both the
patients, as well as the caregiver. As such, the project helped in identifying the most effective
solutions to the challenges, associated with Telesitter systems, and thus improve its effectiveness
in preventing patient falls.
Purpose of the Project
The purpose of this quantitative exploratory-descriptive project is to identify the
challenges associated with using the Telesitter monitoring systems in the clinical environment, as
well as finding lasting solutions to these challenges to ensure that the Telesitter system is a

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reliable tool in the reduction of patient falls. This project assessed and evaluated the causes of
patient falls in the two wards – surgical/oncology and the progressive care units, at a Southern
California hospital. Using the two units helped to identify the most recurrent fall risk factors in
these wards. This offered a more comprehensive list of the factors leading to falls despite the use
of the Telesitter systems. Identifying the factors causing falls in the two units helped to identify
the most-recurring factors, which pointed out the best possible solutions to these challenges.
This project hopes to determine the effectiveness of the Telesitter systems in preventing
patient falls, as well as the possible challenges facing this falls-prevention intervention. The
findings from this project guided in understanding the challenges associated with the Telesitter
systems and how best these challenges can be addressed to ensure that it is a more effective tool
in reducing patient falls. The Telesitter system is a phenomenal intervention in the fight against
patient falls; ironing out its associated challenges will present a more reliable and effective tool
in reducing patient falls.
Clinical Question
The major clinical questions that guided this project include the following:
Question 1: What are the challenges associated with using the Telesitter monitoring system as a
falls reduction intervention?
Question 2: What possible solutions can be implemented to solve these challenges and make the
Telesitter systems more reliable and effective as a fall-reduction tool?
The first clinical question helped in understanding the challenges associated with the
Telesitter monitoring systems, whereas the second question helped in understanding how these
challenges can be avoided. Evaluating the rate of patient falls in the two units helped in
identifying the most pertinent risk factors in reducing falls. Assessing both units also shed light

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on how best the patients in the two units can be safeguarded to reduce falls. This is considering
the patients in the two units have different patient characteristics but are both highly affected by
falls.
The clinical PICOT elements that guided this project include the following:
● Population – Nurses giving care to patients in the surgical/oncology unit and progressive care
unit at a Southern California hospital.
● Intervention – Using the Telesitter monitoring systems as a fall-reduction intervention.
● Comparison – the factors influencing falls in the two units. The identified solutions to the fall
factors in the two units.
● Outcome – reduced falls
● Timeline – Over a period of one month
The DNP student was interested in finding out how the causes of falls in the two units
compare. The main difference between the surgical/oncology unit and the progressive care unit is
that the surgical unit is mainly associated with patients that have undergone surgery, who usually
have high fall risk. On the other hand, patients with acute illnesses that require long-term
observation and monitoring characterize the progressive care unit. These patients too are at high
risk of falling while in the clinical environment.
Comparing the fall rate in the two units helped in understanding which factors among
patients and the clinical environment are mo...