Engagement/Oservation Policy

1. Prior to and on Admission

A risk assessment should be made by whoever is admitting the patient and where possible, will be done jointly with a member of the nursing team from the ward. It will then be jointly negotiated with the nursing team as to the level of observation required and this will be recorded.

2. Following Admission

The duty doctor should psychiatrically assess emergency admissions. All patients will have a full care plan written indicating the level of observation required and the reasons for this indicated within 24 hours. This will enable  initial  safety  to  be  maintained.  A  full  nursing assessment will  be completed within 72 hours of admission, which will enable safety to be considered based on a multi-disciplinary assessment of the patient’s current mental state.

May be initiated by a registered nurse or a registered medical practitioner as far as possible this will be done jointly based on  the evidence available. However, the senior nurse in charge can initiate an increased level of observation BUT must NOT reduce this level without consultation with a doctor. This is because reducing the level of observation carries with it a degree of risk and the national standard requires the involvement of a doctor in this decision.

If an RMN initiates or increases the level of observation, then a mental state assessment which will include an assessment or risk by a doctor will be arranged within 24 hours.

If there is disagreement regarding the level of observation, the higher level is implemented until the issue is decided upon in the consultation with the patient’s RMO. This will enable the safety of the patient to take priority whilst issues are resolved.

Following consultation with the Royal College of Psychiatrists about procedures for the reduction of observation level, it has been agreed that out of hours, a named senior nurse can reduce the observation level in consultation with the junior on-call doctor, providing a written patient-specific plan is pre-agreed with the Responsible Medical Officer.

All staff who are involved in assessment of levels of engagement and observation whether this is focused on initiation or review are reminded of the requirement to ensure health and safety isses are considered.

Levels of Engagement/Observation - there are three types of observation/engagement

The General Level

i.    The general level of observation is intended to  meet  the needs of most patients for most of the It should be compatible with giving patients a sense of responsibility for their use of free time in a carefully planned and monitored way. The staff on duty should have knowledge of the patients’ general whereabouts at all times, whether in or out of the ward. This is achieved by establishing a patient allocation system whereby the nurse in charge is kept informed of each patient’s whereabouts. Service users and care staff can agree, after shared risk assessment, what measures need to be in place to ensure their safety. This can then be documented in the Safety Care Plan.

Constant Engagement/Observation

ii.  Observed by suitably skilled nursing staff at the discretion of the nurse in

iii.Any specific instruction negotiated in respect of privacy, leave or escort will be written in the form of a care plan, g. toileting and attending to personal hygiene. Any changes within this category can be negotiated between patient, key worker and/or the senior nurse in charge of the shift. This must be documented in the nursing notes and the care plan should be altered to reflect this change.

iv.A member of staff should engage with the patient throughout a 24-hour period, ensuring they are able to see or hear them throughout this The patient may leave the clinical area to facilitate appropriate therapies/physical interventions as long as they are accompanied by nursing staff/AHP/other professions/family/carer.

Special Observation

v.  Observed by an RMN and may require additional support from extra staff. The patient will be clinically assessed as requiring intensive and skilled intervention as a consequence of their very serious mental and/or physical state.

vi.The patient should be in sight and within arms reach of RMN at all times over a 24-hour period, commensurate with the patient’s mental state. This will include when the patient is asleep, attending to personal hygiene and toileting or receiving physical treatment in a general hospital setting.

All constant and special observations should be subject to freaquent review (every 24 hours) involving appropriate members of the multi-disciplinary team.

All patients will have a written care plan indicating the level of observation required and the reason for this.

Observations will be recorded as follows:-

General Observation

• Any specific instructions will be documented in care plan
• Nursing notes every shift by the allocated nurse and care plans kept up to date on a shift-to-shift basis
• Observation Instruction Form
• Nursing staff can initiate constant or special observation at any time

Constant Observation

• Any specific instructions regarding privacy must be written in the form of a care plan and must be kept up to date on a shift-to-shift  basis
• Documentation to be used are :
  • The alert form,
  • Nurse's notes
  • Observation Instruction  Form
• Observation status to be reviewed by nursing and medical staff every 24 hours (only with agreement of medical staff can it be discontinued)

Special Observation

• Every half hour/hour using alert form, the nurse observing for that period and/or the patient’s allocated nurse for that shift must keep care plans up to date on a shift-to-shift basis.
• The allocated nurse/s document/s in nursing notes for that shift
• Including the Observation Instruction Form
• Reviewed by nursing and medical staff every 24 hours (only with agreement of medical staff can the level of observation be discontinued).

The reduction in the level of observation should ideally be a team decision. To ensure patients are not left on an increased level inappropriately, it is recommended that teams plan ahead, particularly at weekends, clarifying the circumstances that would enable a reduction in observation level.

There must be a specific plan for each patient, which putlines the agreed changes in behaviour that would facilitate a reduction in observation level and the exact procedure for this decision to be actioned.  It must detail the role of duty medical staff or senior nurses in this process.

At the beginning of each shift, the Senior Nurse responsible for the ward should satisfy themselves that the ward environment is safe in terms of checking fire escapes, fire equipment and that nothing is blocking doorways or emergency exits.    This will enable observation to be conducted in a safe environment.

The current bed state will reflect the patients in the ward at the time and the nurse in charge will check that all patients are accounted for in order that a clinical summary at handover can be accomplished safely and effectively to the nurse in charge of the next shift.

i) Role of Nurse in Charge

The Nurse in Charge of the ward/unit is responsible for coordinating decisions regarding engagement/observation levels. They are also responsible for allocation of suitably skilled staff to engage/observe patients who require any of the three levels of engagement/observation.

ii) Role of Medical Staff

The consultant must ensure that it  is  clearly stated in  notes  any  pre-agreed written patient-specific plan to assist on-call junior doctors with decision to reduce engagement/observation level.

The on-call junior doctor should be involved in examining the patient’s mental state and discussing the risk with the senior nurse on duty before the decision to reduce observation is made. Where there is any doubt the decision should be  discussed  with  the  on-call consultant or postponed until the next opportunity when the full team, including the patient’s Responsible Medical Officer (RMO) is present. The RMO retains final responsibility.

There must be a record of decisions regarding observation kept within the patient’s notes including an explanation as to why an increased level is used. It is recommended that a simple record be kept to allow auditing of the frequency, level and duration of increased levels of observation as well as  the  clinical reason(s) behind the choice. The record must clearly show the perceived risks, which lead to the decision, who was involved in the decision and the patient’s opinion of the need for increased observation. This audit trail provided key information both in monitoring the frequency of the usage of raised levels of observation and in Critical Incident Reviews.

iii) Role of Professions/Carers

It must be acknowledged that it is primarily psychiatric nurses who provide 24-hour care and who will therefore carry the majority of the responsibility for the observation of the patients. However, with the emphasis on multi-disciplinary team working  and the  increasing  role of family and carers,  consideration  should be given to the role of these groups within this area of care.

It seems correct that in appropriate situations other professionals (apart from nurses) should be involved  and have responsibility for the observation of a patient.

For non-nursing staff to be involved in engagement/observation the following issues must be addressed:

• There must be a foolproof system of staff knowing who is responsible for the observation of a patient at all times
• There must be a simple way of communicating between staff members of all changes in the level of observation
• All staff must accept the responsibility for carrying out the observation to local standards
• All staff must receive appropriate training in this role especially staff for whom this role is new (NHS Borders includes this in Induction and Clinical Updates for all staff).
• There must always be RMN present with other professions/carers when patient is on special engagement/observation
• A risk assessment must be carried out for patients on constant engagement/observation to assess if they are safe to be with other professions/carers without nursing staff

iv) The use of Bank staff or Staff from other areas for observation will be at the discretion of the Nurse in charge of the Ward

• Clear, concise handover on commencement of shift
• Give details of reasons why patient is on increased engagement/observation level
• Be clear about what is expected from nurse on engagement/observation
• Ensure that local induction of ward area has taken place

Under no circumstances will staff accpet extra observation responsibility without being clear of the patient's background and the reasons for observation.

Patient allocation should be implemented in order that nurses who are  familiar  with  the patient will be working closely with the patient being observed.

As observation can be stressful, the longest a nurse should be observing a patient at any one time will be up to one hour followed by up to 15 minutes to hand over to the next nurse and to document their observations. This timescale remains discretionary. The nurse taking over the observation will hand over in the presence of the patient to discuss how the observation is going. If it is not felt appropriate to hand over in the presence of the patient, another suitably qualified nurse will be required to briefly observe the patient until the hand over is completed. The senior nurse in charge will facilitate this.

Periods of observation are recorded using time started, the time taken over and the time finished.

Informing Patients and Carers

It is nursing staff’s responsibility to  ensure written  information on  observation is  provided to  all patients and carers/relatives on admission. Ongoing discussion with patients and carers regarding their observation level will be integral part of the care planning procedure.

Potential Violence

No nurse should be left alone to conduct special observation of a patient who is thought to be at risk of violence to others.  Training in control and restraint is now provided by NHS Borders. The nurse in charge must assess the need for extra staff or transfer of patient to a more secure unit.

Resources

If, in the nurse’s view, resources do not cover the provision of the prescribed level of observation, the duty nurse in charge will be contacted in order to provide extra resources to the area or to initiate alternatives. If this consultation does not resolve the problem, senior managers will be called and provision for the observation will be made whilst consultation takes place, without placing the patient’s safety at risk. This may include referral to IPCU.