What worked: Gained buy-in from staff at all levels from the beginning and kept the team informed of progress.

Root cause analysis: Some patients try to get out of bed because they're bored and restless—so staff members have made it a priority to talk with the patient and family to learn about the patient's interests and hobbies and offer specific activities for patients to do during their stay. "Using the activity boxes (which contain games, crafts, videos and more) with patients has been a great way to help patients stay busy, and it makes them feel better," according to UBT labor co-chair Glenda Vosberg.

On changing assumptions: "Often staff is concerned about patient safety when we talk about alternatives to assigning PSAs and may be reluctant to try other options. However, literature (and our local experience) shows that having a PSA in the room does not guarantee the patient won't fall or pull out their IV lines," said Susan Woods, RN, a clinical nurse consultant who worked with the team. "We've found that reduction of PSA usage has not negatively impacted patient safety, just as the literature suggests."

Background: When UBT co-leads took a close look at their PSA usage, they quickly agreed that reducing the number of patient safety assistant hours was a top priority. From January to May, the unit already had spent more than $60,000 in staffing and used 1,550 hours to fill PSA requests. The goal was to reduce the use of PSAs by 10% by the end of September.

Knowing this was going to take effort from all unit staff, a mandatory in-service was scheduled and the co-leads explained the situation to the rest of the team.

"Staff were given the data and information to help them understand the impact of the situation and get their feedback on alternative options to using a PSA," according to Imelda Zapata, department manager.

The team enlisted the assistance of the clinical nurse consultant in the hospital, Susan Woods RN. One of Woods' responsibilities is to provide consultations with patients who are assigned PSAs. In this role she works with the patient, family and the nurse to develop a plan that best fits the needs of the patient. .

Woods explained that patients often have a reason when they try to get out of bed on their own. They might need to use the bathroom, or they may be bored or restless. Understanding issues like this can help lead to the creation of a plan that will help ensure patient safety. Patients who are restless often need a change of scenery, which might mean moving the patient to the nurses' station or to a public area; or there might be a need to reduce noise by closing doors at shift change and keeping it quiet at night. Hourly rounding and toileting schedules have been used successfully on several units to meet patients' needs.

Kaiser Permanente has also invested in several different equipment options, including low beds, which can be put all the way down to the floor, and bed and chair alarms that let nurses know if a patient tries to get up. The combination of equipment, changes to the environment and activities for patients has allowed the team to keep their patients safe and improve their morale while decreasing the usage of PSAs.