Falls by hospitalized patients are common and can result in serious injuries and complications. About 700,000 to 1 million patients fall annually in hospitals, and about one-third of these falls are considered preventable, according to the Agency for Healthcare Research and Quality.

A commonly used strategy to prevent falls is the use of sitters-nurses or other hospital staff members or trained personnel hired from an outside agency-to provide constant observation of the patient. Sitters stay with patients at high risk for falls, particularly older adults with delirium or dementia who may try to get out of bed without assistance.

Sitters have long been considered effective in preventing falls, but there's little supportive evidence. Sitters are also expensive. They can cost an acute care hospital more than $1 million annually, leading researchers to explore the effectiveness of less expensive alternatives such as video monitoring.

A recent systematic review in the Annals of Internal Medicine used data from 20 previously published studies to determine the effectiveness of sitters and alternative strategies for fall prevention. Two of the included studies that examined the effect of adding sitters to existing care to prevent falls had mixed results. In one, the rate of falls was cut in half 18 months later, from 15.6 to 8.8 per 1,000 occupied bed-days, while in the other, falls increased from 14.5 to 15.5 per 1,000 occupied bed-days four months after the addition of sitters (the increase was not statistically significant).

The other 18 studies assessed interventions to reduce sitter use. Eight studies involving video monitoring of patients showed either unchanged or lower fall rates after the reduction of sitter use and implementation of video monitoring. Other studies focused on placing higher-risk patients together in close observation spaces or adding nurse assessment and decision tools to reduce sitter use. All of these resulted in decreased sitter use but had less consistent effects on fall rates.

Because of the small quantity of studies available for review, the authors concluded that it would be premature to stop using sitters altogether, despite "scant" evidence in support of their effectiveness. The "rationale for [their use] to prevent falls is compelling," the authors wrote. And, since the practice is so engrained, it's probably not feasible to conduct a randomized controlled trial comparing the use of a sitter with no sitter. Instead, the authors urged researchers to focus on trials of alternative fall prevention interventions, particularly video monitoring, which to date has the most evidence to support its use as a safe and cost-effective alternative to sitters.-Joan Zolot, PA