Virtual sitters at Lee Health guard against danger to patients, help trim costs

Historically, Lee Memorial Health System, based in Fort Myers, Florida, has had a program to help observe patients who were potentially at risk of hurting themselves while in its facilities.


This could have been a patient who was confused, either chronically or acutely, or who had other medical or psychiatric concerns.

“We would then hire and assign an individual to sit at the bedside with the patient and provide visual and verbal cues to promote safety,” said Dr. William Carracino, vice president and chief digital health executive. “The problem was that this workforce had struggles maintaining itself.

“This was generally used for retired clinical nurses or others who had the time and desire to sit next to a patient,” he continued. “As a result, we had difficulty at times staffing the required situation. When that happened, we would generally have to re-assign an even more critical individual, such as a nurse or a patient care technician, to help protect that patient.”

This was a one-to-one direct observation role, so each patient who could benefit from this sitting needed an individual in the room with them.

“The funding for this program was also not considered medical inpatient care, so it was a revenue drain,” Carracino noted. “It had to be performed, but it took away from the value of reimbursement.”


When Lee Health embarked upon a technological proposal, it wanted to do a small pilot to prove the concept worked.

“The idea was to be able to monitor the patient remotely and more than one person at a time,” Carracino explained. “We started with one outside the room. We expanded quickly to two, but the technology was rudimentary.

“We built an order inside our Epic electronic health record to allow nursing criteria to request a virtual sitter assignment.”

Dr. William Carracino, Lee Health

“We began a new pilot that allowed for centralized staff and a six-to-one ratio, and plan to increase to an eight-to-one ratio,” he continued. “Fairly shortly, we envisioned the value in our leadership and saw the vision to provide funding to expand the program significantly to essentially all qualified patients who required this service.”

The idea was to improve safety by having a more highly trained individual watching that patient and building an escalation pattern so that this observer did not leave their desk when in-person attention was required.


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Lee Health started off with two to three virtual attendants at each facility. They monitored up to six patients each at a time. Staff chose patients who had a medical diagnosis, such as confusion or dementia. The health system is exploring expansion of the program to psychiatric cases.

“We built an order inside our Epic electronic health record to allow nursing criteria to request a virtual sitter assignment,” Carracino explained. “This means we were more able to expeditiously get those patients enrolled without requiring or waiting for a physician approval.

“We also needed to devise a new job role with a job description and requirements, because watching six or eight individuals on a video monitor and documenting inside the record was different than sitting at the bedside and controlling the situation in-person,” he continued. “We worked with human resources to create a new job code, description and rate of pay.”


Lee Health has seen significant cost savings, Carracino reported.

“We have avoided potentially dangerous situations, such as smoking,” he noted. “We have also even further decreased falls of these observed patients.”


“This is a project that needs to be run appropriately,” Carracino advised. “You need to include medical staff, nursing staff, compliance and potentially legal services. Change management is important, and visionary nursing leadership is critical.

“Good technology that has back-up downtime protection, as well as an escalation process, is important,” he concluded. “The technician cannot leave the virtual monitoring station, so he or she needs to be very well organized and have the ability to call either a runner, the primary care physician, a nurse or a floor supervisor.”

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