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Management Brief No. 162

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Management eBriefs
Issue 162 November 2019

The report is a product of the VA/HSR Evidence Synthesis Program.

One-to-One Observation: Systematic Review

Preventing adverse events in hospitalized patients is a priority goal of patient safety programs. In-facility falls and in-facility suicide are two priority conditions that are thought to be preventable. An estimated 700,000 to 1,000,000 hospitalized patients fall each year, and as much as one-third of these falls are considered preventable. The Centers for Disease Control and Prevention (CDC) reported medical costs for falls totaled more than $50 billion in 2015, with evidence suggesting the annual cost is rising, especially with an increasing elderly population. Nurses or other personnel have been used to monitor patient behavior in continuous or constant observation to prevent falls and reduce self-harm and suicide, but the practice is costly. US acute care hospitals can each spend more than $1 million annually on sitters.

One-to-one sitters – or constant observation – is an intervention that has long been used. Staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act. However, evidence that one-to-one sitters is effective is uncertain; hence, VA policymakers asked for an up-to-date review to inform policy and practice.

Investigators with VA’s Evidence Synthesis Program (ESP) in Los Angeles, CA conducted searches in PubMed from inception to 12/18/2018, Web of Science from inception to 11/29/2018, Cochrane Database of Systematic Reviews and Cochrane Trials and PsycINFO from 01/01/1970 to 12/04/2018, and CINAHL from inception to 11/30/2018. To be included in this review, a study had to include one-to-one sitters as an intervention in an acute hospital’s general medical/surgical or psychiatric hospital setting, and report an outcome of interest (i.e., falls, wandering, suicide/self-harm). The study also had to show that preventing such an outcome was the intervention’s primary goal. Investigators screened 1,845 articles; of these, 19 met study inclusion criteria and most were observational. Only two studies assessed the effect of adding sitters to usual care, but both examined only falls as an outcome. The remaining 17 studies assessed the effect of interventions aimed at reducing sitter use – and all examined falls as the outcome of interest. There were no studies with VA populations.

Summary of Findings

Despite a strong rationale for the use of one-to-one sitters, there is surprisingly little evidence of its effect, with only two studies assessing the effect on falls—and no studies assessing the effect on wandering or suicide/self-harm. Of the alternatives to sitters that have published results, the use of interventions with video monitoring is the most promising, although, like any information technology intervention, the success is likely to be highly context-dependent.

Implications for Current Practice and Policy

The fundamental value of one-to-one sitters remains a question in search of an answer. The effect of one-to-one sitters on reducing falls, wandering, or suicide/self-harm has yet to be established. The available data are most compatible with a hypothesis that sitters are, at best, only modestly effective for fall prevention.

Future Research

The use of one-to-one sitters may be so ingrained into usual care that a standard randomized control trial comparing sitter use to no sitter use is not feasible to conduct, in which case the “alternatives to sitters” research route should be pursued. This can be done as controlled before-and-after studies within a hospital, which will provide a much stronger basis for causal conclusions than a pre/post study, or as a time series study with incremental additions of intervention components.  

A Cyberseminar titled “One-to-One Sitters to Prevent Falls in Acute Hospitalized Patients” will be held on December 19,2019 from 2:00pm – 3:00pm ET. Register here.

Shekelle PG, Greeley AM, Tanner EP, Mak SS, Begashaw MM, Miake-Lye IM, and Beroes-Severin JM. One-to-One Observation: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2019.

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Read past HSR&D Management e-Briefs on the HSR&D website.

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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