Summer 2014 St. Luke’s University Hospital PRACTICE ALERT: Understanding Continual Observation in non-Behavioral Health Units Summer 2014 St. Luke’s University Hospital

Directions Review the information in the following slides; open in “SlideShow”. Follow link on slide #5 and review the Continual Observation Policy. Close PowerPoint program. Take Test to acknowledge your understanding of the material. Complete this review of Continual Observation on or before August 15, 2014.

Why is a Practice Alert needed? A recent review of patient records completed as part of a DOH investigation demonstrated inconsistent practice with ordering, implementing, and documenting Continual Observation. Inconsistencies included Physician/Advance Practitioner orders for 1:1, Behavioral Observation, and q 15 minute checks were incorrectly accepted and implemented on acute care/critical care units (non-Behavioral Health Units) where the appropriate order should have been Continual Observation (Suicidal or Non-Suicidal).

Policy Highlights Continual Observation: visual contact with the patient at all times. Registered Nurse: the RN/primary nurse assesses the need for Continual Observation, initiates Continual Observation after obtaining LIP/other qualified healthcare personnel order, and reassesses the continued need for observation. Assigned staff member: (i.e. RN, LPN, PCA, MHT, security staff, Patient Observation Attendant, etc.) who provides continual observation and maintains visual contact with the patient at all times. Licensed Independent Practitioner (LIP): an individual permitted by law and by the organization to provide care, treatment and services without direct supervision. Note: Physician Assistants (PAs) and Certified Registered Nurse Practitioners (CRNPs) who function in the role of nocturnist/house officer and are credentialed/privileged by the Network are referred to as “other qualified healthcare personnel” within the text of this policy and are permitted to order Continual Observation.

Continual Observation Policy Make sure you are viewing in “SlideShow”, then click the link below to review the policy: Continual Observation Policy

When to Use Continual Observation… Continual Observation may be initiated in the following situations: 1. Non-Suicidal: Patient behavior and/or judgment is impaired to a degree that renders him/her unable to provide for his/her own safety. 2. Suicidal: Patient has expressed suicidal ideation and/or has attempted suicide. Practices & interventions in Behavioral Health Units may differ!

Required Components of a Continual Observation Order 1. There is a written/electronic, time-limited, order for all Continual Observation. 2. The time-limited order includes: - Start date and time and reason for use. - Continual Observation is reordered once each calendar day based on the continuing need. - A face-to-face assessment of the patient must be conducted by the LIP/other qualified healthcare personnel within 24 hours of the initial order. 3. Standing orders or PRN orders for Continual Observation are prohibited. 4. Continual Observation may be initiated by an RN on an emergent basis. An LIP/ other qualified healthcare personnel is notified to obtain an order during the emergent initiation of or immediately after the continual observation is started. 5. The attending physician is notified as soon as possible and within 24 hours if he or she did not order the Continual Observation. 6. An order from an LIP/other qualified healthcare personnel is required to discontinue the Continual Observation.

HEO – CPOE – Physician Orders for CONTINUAL OBSERVATION REASON

Continual Observation Orders The previous screen shot outlines the only acceptable order for “watches” or Continual Observation in all inpatient areas EXCEPT in Behavioral Health Units. SLUHN eliminated the use of all previously used language (i.e. 1:1, close watch, etc.) to describe Continual Observation when the policy was changed in 2011. Physicians/LIP orders for “1:1 watch”, “q 15 minute checks”, “Behavioral Watch”, “Security watch”, etc. and/or those completed on the Behavioral Health iForms, should all be clarified with the ordering individual and entered/written correctly to order Continual Observation (Suicidal or Non-suicidal) on non-Behavioral Health Units.

Documentation The RN documents completed assessments and reassessments to validate the need for Continual Observation. Reassessments for Continual Observation occur at frequent intervals, normally not to exceed four hours. The appropriate staff documents the following in the patient’s medical record: 1) Any alternatives attempted 2) A description of the patient’s behavior; staff concerns regarding safety risks to the patient, staff, or others 3) Notification to the attending physician of Continual Observation 4) Room/environmental readiness: - date and time of search result of the search patient response and actions taken 5) The patient’s response to the intervention(s) used 6) FULL Name of staff member performing the Continual Observation 7) Patient care interventions provided/offered (documentation occurs throughout the shift) 8) Patient and family education regarding Continual Observation 9) Consultations (i.e. Psychiatry or Occupational Therapy), if warranted

Are you responsible for patients who may require Continual Observation? A separate educational program for clinical and non-clinical staff can be found on MyNET. MyNET > Learning tab > Staff Ed. tab > Continual Observation Education link (follow directions for the correct program based on your role).

Thank You! Exit program. “Take Test” to complete requirements of this Practice Alert.