Observations
This care bundle describes seven actions to ensure the best clinical outcome for patients who have been subject to observations. Care must be delivered in a safe and positive manner to ensure safe decision making and environmental controls for behaviourally disturbed wards. Each described intervention will be required to be delivered, however these do not need to be completely sequentially.
Aim:
Support the Patient in understanding the system of observations implementation.
What to do:
- Inform all admissions of observation policy before admission to allow for informed consent.
- Pre-plan care using supporting documentation such as person centred care guides, Safety plans, Positive Behavioural Support plans, risk assessments and SAFEWARDS etc.
Consider influence/impact of:
- Length of time on observations
- Restrictions imposed by observations
- Privacy and Dignity
- Physical Health conditions
Consider actions that can be proactively taken to reduce observation levels, taking into account safety, Human Rights, patient choice, capacity and dignity.
Aim:
Ensure timely and accurate record keeping. Develop robust systems for the management of observations.
What to do:
Ensure all staff who are involved in delivering observations have completed local training.
Ensure all staff involved in delivering observations have access to supervision and any learning needs are addressed.
Clear documentation on PARIS of rationale for the use of observations and actions, following its commencement.
Explain with rationale each change, to patient, and document.
Update and review the clinical documentation regularly including the care plan and risk assessment.
All reviews of observation level and decisions reached (including not to change observation levels) must be fully documented with a clear clinical rationale.
Review and update risk assessment.
Aim:
Safe management of observation levels which is trauma informed and prioritises the patient experience.
What to do:
Consider least restrictive practice principles of the observation levels, taking into account safety, Human Rights, patient choice, capacity and dignity.
Inform patient (and where indicated carers/visitors) of how this level of observations may restrict them.
Complete care plan for patient including behaviours that indicate which level of observations they are on.
- Why this level manages the risk.
- Why this level is least restrictive option.
- Strategies aimed at preventing behaviour escalating.
- Active strategies to reduce level of observations.
- The indicators that risk has reduced to allow observations to reduce.
Ensure observing staff are aware of risks and rationale for level of observations, and any specific interventions required.
When allocating a member of staff to observe, the nurse in charge should be sensitive to patient’s personal preferences and issues surrounding gender, privacy and dignity.
Inform Day area/HUB/OT of observation status to allow for access to OT.
Review and update risk assessment.
Aim:
Foster a multi-disciplinary approach to care planning for observations to manage challenging behaviour.
What to do:
Team to review level of observations decision continuously using criteria in care plan.
Clinical review:
Level 3 - Every 24 hours
Level 4 - Every 7 days
Clinical Review including Nursing staff and medical team to review care plan, current management plan.
Feedback from clinical review to be included in care plan and risk assessment.
Formal discussion each handover to be documented using criteria in care plan.
Formulation of risks to assess the continued need for observations and explore possible alternatives.
Inform patient (and where indicated carers/visitors) of the review of level of observations and what this means.
Assess effectiveness of current care plan – consider onward referral.
Ongoing review of management and routine treatment and any possible interactions.
Aim:
Where a serious risk has indicated high level of observations, foster a multi-disciplinary approach to care planning for reducing observations after managing challenging behaviour.
What to do:
Team to review level of observations decision continuously using criteria in care plan and future plans to manage risk including alternatives to high level observations.
Clinical review
Level 1 & 2 - every 24 hours.
(every 72 hours to include Heads of Nursing/Nurse Consultants/Matrons).
Feedback from clinical review to be included in care plan and risk assessment.
Formal discussion each handover to be documented using criteria in care plan including formulation of active plans to reduce observations.
Discuss the use of high levels of observations in next MDT ward round/Clinical team review for the patient.
Assess effectiveness of current care plan – consider diagnosis.
Ongoing review of current care plan and routine treatment and any possible onward referral.
Aim:
Develop a robust system that ensures that the patient’s psychological and emotion wellbeing is monitored.
What to do:
MD Team to include in next (and subsequent) MDT reviews, active measures to assess and promote
- Psychological and emotional impact of observation level
- Protection of Family and private life (article 8)
Liaise with Hub/OT Day area to ensure therapeutic and occupational activity.
Consider level of support required by staff/patient following any period of observations for psychological impact.
Any staff member who delivers more than 2 hours continual observations (level 1, 2 or 3) should report this on a DATIX incident form, so that this can be reviewed.
Ensure patients are given the opportunity to reflect on their experience of the observations.
Review the positive behavioural support plan, advanced directives and other clinical documentation.