When the Hospital Staff Isn't Enough
By Abigail Trafford, Washington Post, Sunday, January 7, 2001; Page A01

Jaromir Ledecky sits in Room 427 in the Renaissance Wing of Sibley Memorial Hospital. With him is Alexia James, who bathes him, helps him from the bed to the chair, takes his blood pressure. If anything goes wrong, she is there to alert the nurse. Ledecky, who is recovering from a leg operation, hired James, a certified nursing assistant, or "sitter," at his own expense. He did the same thing six months ago when he underwent a heart operation at Washington Hospital Center. And when he had surgery in Baltimore, he hired his own nurses.

"I feel to improve the quality of care, the only thing I can do is to have somebody here 24 hours a day," said Ledecky, 73, an economist. "I could not get the service I require from the hospital staff."

It has come to this: Bring your own nurse. Even in the best hospitals, patients and their families are turning to private nursing help to supplement care from staffs that are often short-handed and over-worked. As hospital nurses focus their efforts on patients in crisis, private "sitters" are there to tend to the more personal needs of patients, and provide some of the TLC services of yesteryear.

Hiring a private-duty nurse or nurse's aide brings peace of mind to patients and their families, say its proponents. It can also be a hedge against substandard care, adding an extra pair of eyes and ears to prevent errors and injuries.

But the security can add thousands of dollars to hospital bills -- and it's usually not covered by insurance. Prices range from about $100 a shift for an aide to about $350 a shift for a registered nurse. Despite the cost, an increasing number of families of middle income appear willing to pay for the extra care.

"I tell all my family and friends: If they are going to the hospital, they should consider a private-duty nurse, and if that level is not needed, I'd say, get a sitter," said nurse Diana Mason, editor in chief of the American Journal of Nursing.

"When patients go to the medical floor, I advise a private duty nurse," said New York neurosurgeon Jamshid Ghajar, who treats people with serious head injuries. "The biggest effect on the patient is the nurse. If you have good nursing care, you have significantly better outcomes."

Even Consumer Reports on Health, in an article headlined "Avoiding Hospital Blunders," has this advice: "If you can afford it, consider hiring a private-duty nurse."

There are no good statistics on the bring-your-own-nurse trend. But anecdotes from Alabama to Oregon suggest that more and more patients are hiring private nurses or nursing assistants when they go to the hospital. Private agencies that supply nurse's aides report a dramatic rise in requests from hospitalized patients in the past few years.

Sitters or certified nursing assistants do not give medications or insert IVs. They provide the personal touch. A sitter will help a patient to the bathroom, and deliver a meal. If a patient is frightened, a sitter holds his hand. At night, a sitter
watches that a patient doesn't fall out of bed or become wedged between the bed railings and the mattress, where the patient might suffocate.

The growing use of sitters reflects the turmoil in health care during the 1990s. Hospitals are in a squeeze to provide more intensive care at less cost. Lower reimbursement rates from managed-care plans and government programs have pressured hospitals to cut expenses and trim staffs. Patients tend to be sicker and older. That leaves fewer nurses to deal with more needy patients and more complex therapies. One consequence is that families are turning to sitters.

"What we're talking about should be part of basic nursing care," said Sue Karen Donaldson, dean of the Johns Hopkins School of Nursing. "The fact of the matter is that [patients] aren't getting it."

Nurses who are on staff at hospitals "want to relate to patients and their families," she continued. "When you pull nurses back from that, they lose a compassionate part of themselves. Nursing is so short-staffed, nurses can't practice their profession."

All this has led to an exodus of nurses from hospitals and the nursing field. Nurses under age 30 account for about 10 percent of the profession.

Some patients who hire a private nurse's aide just want an extra level of care, even if it's not medically necessary. One Washington woman, 50, who recently underwent a hysterectomy at Holy Cross Hospital, arranged to have a sitter the first night after surgery, at a cost of $112 for one shift.

"I wanted someone there all night who was awake and whose only concern was me," explained the woman, who didn't want her name used because she's employed by a medical group. The sitter tended to her every time she woke up. She kept her mouth and tongue moist. "She gave me psychological comfort. I
didn't have to press the call button," the woman said. The help allowed her husband to go home and get some sleep. And it gave her a watchdog against mishaps. "Because I work in the field, I'm more conscious than the average person that hospitals are not so safe," she said.

Sitters are especially recommended for certain kinds of patients—the elderly who are frail or disoriented, for example. Or in certain circumstances—when patients are just coming out of the intensive care unit, where the nurse-patient ratio is one-to-one, to the general medical floor, where there may be one nurse for four or even eight patients.

"Families want it," said Sue Henderson, a nursing director at Washington Hospital Center, where she estimates that 10 percent of patients have sitters. "They don't want to leave their moms and dads without someone."

Older patients require more nursing care and support.

"If we think a patient is at risk of falling, if a patient is unsteady or might be confused -- for all these safety reasons, we would encourage sitters to the family," said Joan Vincent, director of medical and surgical nursing education at Sibley Hospital.

Some hospitals discourage the use of outside sitters as unnecessary and potential interference with the staff. Sitters or not, the hospital is responsible -- and liable -- for the care and safety of the patient.

Others have taken steps to help families find private nursing assistants and nurses who are treated as extended staff. "That's very common," said Karen Amann Talerico, a nurse researcher at Oregon Health Sciences University,
who notes a marked increase in hospital sitters in the past several years. "Most hospitals are just coming up with training guidelines for these people."

Families usually go through the nursing office to find extra help. At Northwestern Memorial Hospital in Chicago, for example, general instructions posted on the Internet tell consumers: "If you would like a private duty nurse, please talk with your nurse, who can make arrangements for you. It is your responsibility to pay the private duty nurse or agency directly." This is generally the case unless a hospital deems the extra nursing help a "medical necessity."

Family & Nursing Care Inc., the Silver Spring agency that provided aides for Ledecky, is responding to increased demand with a new marketing campaign:
"We are providing one-on-one [sitter] personal care in the hospital. We will respond to your call within 20 minutes. . . . Rates $13-$14 per hour," states a flier.

Potomac Home Support Inc. has a partnership with Suburban and Sibley hospitals to supply sitters, though families can hire from other agencies. "We are getting more business," said clinical manager Jean Stocker. "It's definitely up." The agency sends sitters to Washington Hospital Center and Holy Cross as well as Sibley and Suburban. "They don't have enough staff in place to tend to these situations," she said.

When physician Elaine German, 73, of Princeton, N.J., went to the hospital in New York City for a hip replacement, she made sure she had a private nurse with her. "From personal experience, I know the floor nurse can't give me adequate attention," said the specialist in endocrinology.

The operation was successful and she encountered only one serious complication: bleeding into her joint. "I didn't feel well," she recalled. "I was light-headed and sleeping all the time. I knew something was wrong." Her private nurse made sure she got proper medical attention. Without prompt therapy with blood transfusions, her recovery would have been slower.

"I don't think a floor nurse would have the time to do what she was able to do," said German.

Nurses have traditionally been the "safety sentinels" for hospitals, points out Mary Foley, director of the American Nurses Association. But she advises consumers who go to the hospital: "Don't assume that everything is going to be taken care of."

The U.S. health care system boasts of miraculous technologies. "It will probably cure you but it can't protect you," said Foley.

According to an Institute of Medicine analysis, as many as 98,000 Americans may die each year of medical errors that occur in the hospital. Many are medication mistakes—the wrong drug, the wrong dosage.

"How do you not make errors?" asked Oregon's Talerico. "What's most important is the assessment—to look, touch, feel and see how the person is doing. If you don't have the time to do that, then everything that happens isn't going to be of high quality, particularly for the elderly."

To some leaders in the nursing field, the bring-your-own-nurse trend is a flashing yellow light that signals basic problems in the way hospitals operate. There is general consensus among medical leaders that when you go to the hospital, you need an advocate—a family member or friend who can follow your care and watch out for errors. The private nurse or nurse's aide can serve as a stand-in.

"You want your own advocate there all the time," said David Lawrence, the head of Kaiser Permanente health plans and member of the IOM committee on medical quality. "If there is no family member, you can hire a care management nurse to be there with you. Or a minister. You need an adult who is not going to be intimidated by the place.

"That will be necessary until we put in more systematic approaches that build in safety."

In the Renaissance Wing at Sibley Hospital, Jaromir Ledecky, the father of Jonathan Ledecky, co-owner of the Washington Capitals hockey team, built aa comfortable rapport with his sitter. An immigrant from Prague who has earned three degrees in the United States, Ledecky chatted easily with Alexia James, 31, who came from Guyana 11 years ago.

One afternoon, Ledecky felt dizzy and faint. James went immediately to the nurse, who called the doctor. Ledecky's blood pressure had plummeted. He was put to bed with a drip in his arm. In a few hours, his blood pressure had recovered. "That's the advantage when you have somebody," said Ledecky. "You don't have to worry. Alexia is my voice out there in the nursing station."

Ledecky and his family are very pleased with the nursing care at Sibley. They're also grateful to James. "It's the only way to go," Ledecky said. "I don't know what I would do if I couldn't afford it—if my children couldn't afford it."

"What do people do who don't have resources?" asked Berta Ledecky, his wife. "Where are we going with health care [if] you can't go into the hospital and count on the care?"

© 2001 The Washington Post Company