dhulwa mental health unit (dmhu) - consumer …€¦ · web viewprocedure and the clinical risk...

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Canberra Hospital and Health ServicesClinical ProcedureDhulwa Mental Health Unit (DMHU): Consumer ObservationContents

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Alerts.........................................................................................................................................2

Section 1 – Introduction............................................................................................................3

1.1 Clinical Risk Assessment and Management................................................................3

1.2 Clinical Handover........................................................................................................4

Section 2 – Increasing and decreasing observation levels........................................................4

2.1 Increasing the level of observation.............................................................................4

2.2. Decreasing the level of observation...........................................................................4

Section 3 – Observation levels..................................................................................................5

3.1 General observation...................................................................................................5

3.2 Increased observations...............................................................................................5

3.3 Continual observation................................................................................................6

3.4 Special observations 1:1 or at arm’s length................................................................6

3.5 Seclusion Continuous Observations............................................................................7

Section 4 – Review of Observation levels..................................................................................7

Section 5 – Documentation.......................................................................................................8

Section 6 – Visits....................................................................................................................... 8

Section 7 – Leave...................................................................................................................... 9

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

Definition of Terms................................................................................................................. 10

Search Terms.......................................................................................................................... 11

Doc Number Version Issued Review Date Area Responsible PageCHHS16/250 1 20/12/2016 01/05/2018 MHJHADS – JHS 1 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

The purpose of this procedure is to provide DMHU clinical staff with: information regarding processes for observations of consumers, guidance in setting an appropriate level of observation that is based upon an assessment

of the risk of the consumer and sound clinical judgement, and direction regarding their role in undertaking general, increased, continual and special

observation.

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Scope

This document applies to all clinical staff working at DMHU.

Assistant in Nursing (AIN) staff are not responsible for visual observations or head counts of consumers.


Alerts

Staff should always refer to the Mental Health Act 2015, the Mental Health (Secure Facilities) Act 2016, the Crimes Act 1900 and the Corrections Management Act 2007 for understanding, interpretation and explanation of the applicable legislation, particularly when making any decisions under these Acts.

The Clinical Nurse Consultant (CNC) or Nurse in Charge (NIC) is responsible for ensuring that consumers requiring an increased level of observation are allocated to staff skilled to undertake this duty.

Regular attention to the needs of the nurse/nurses allocated to conduct Increased, Continual or Special Observations should be provided. Nurses conducting increased, continual or special observations should be: supported by frequent verbal contact with another clinician; and relieved hourly for a short comfort break (except for meal breaks, which will be longer)

for all observations.




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Section 1 – Introduction

General principles of Consumer Observation in DMHU are as follows:

All consumers within the DMHU must have a document level of observation in their Treatment, Placement, Restrictions, Monitoring Plan (TPRIM), as outlined below, at all times, consistent with their current mental state and level of assessed risk.

Observation is a process that ensures monitoring of and engagement with all consumers, and should be purposeful and therapeutic.

There may be times when a consumer requires more intensive observation to ensure their safe management e.g. when there is an increased risk of harm to self or harm to others, or during times of increased distress.

If a consumer’s observation level is increased, the reasons for the observation level, a clear understanding of the actions required by nursing staff during observation and reviews of the observation level must be documented in the consumer’s clinical record.

Observation times should always be staggered, i.e. five minutes before or after the hour, to prevent consumers predicting them.

Consumer observation can be intrusive and impinge on the rights and dignity of the consumer. Observation should be set at the least restrictive level, for the least amount of time within the least restrictive setting.

The consumer’s privacy, rights, dignity and autonomy should be maintained to the fullest extent possible consistent with safe and effective care and an understanding of the actions required when there is an escalation of risk. This should include:o ensuring gender and cultural sensitivity is maintained, along with sensitivity to

previous traumatic experiences, ando making provisions for any special needs the consumer may have, wherever possible,

e.g. any physical limitations or disability. The consumer and their Primary Carer/Nominated Person should be provided with a

clear explanation of the rationale for the level of observation assigned to them and indications of what would reduce their level of observation, e.g. reduction in distress, reduced risk of harm to self or others, increased safety.

1.1 Clinical Risk Assessment and ManagementA Multi-Disciplinary Team (MDT) approach should be taken when developing Treatment, Placement, Restrictions, Monitoring plans, including the level of observation of the consumer.

Risk management plans should be thoughtful and considerate of the consumer as an individual and will be determined by the consumer’s mental state. The risk should be well documented in the consumer’s clinical record.

Whenever possible the consumer should be included in the decision to alter their level of observations. Risk assessment will inform development of the TPRIM and must be conducted in line with the DMHU Assessment and Management of the Risk of Violence Procedure and the Clinical Risk Assessment and Management (CRAM): A Practical Manual for Mental Health Clinicians (NSW Health) used to develop a plan to manage the risk. Doc Number Version Issued Review Date Area Responsible PageCHHS16/250 1 20/12/2016 01/05/2018 MHJHADS – JHS 3 of 11


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Observation of consumers in seclusion must be in accordance with the MHJHADS Seclusion of Persons with Mental Illness or Mental Disorder Detained under the Mental Health Act 2015 Procedure.

1.2 Clinical HandoverClinical handover should be carried out before and after every period of observation to ensure staff are briefed regarding the consumer’s current presentation, the reason and the purpose for the prescribed level of observation.


Section 2 – Increasing and decreasing observation levels

2.1 Increasing the level of observationThe Nurse in Charge (NIC) (and the MDT when available) can approve an increase in a consumer’s observation level in response to deterioration in the consumer’s mental state or increase in risk. Staff should not hesitate to discuss an increase in a consumer’s observation level with the NIC, if they believe that this is required. For example, the consumer appears to be becoming increasingly distressed, confused or agitated or the risk of harm to self or others may be increasing.

Once the NIC or member(s) of the MDT have approved an increase in observations they will notify the Assistant Director of Nursing (ADON)/ Clinical Nurse Consultant (CNC)/NIC (business hours) or Consultant Psychiatrist or the on-call Psychiatry Registrar (after hours) as soon as practical to determine the ongoing frequency of observation and level of risk to the consumer and others.

All changes within the level of observation must be reflected in the consumer’s TPRIM Plan and communicated to the consumer. Ongoing efforts should be made to engage the consumer’s cooperation with their prescribed care and treatment.

2.2. Decreasing the level of observationA decision to reduce the level of observation should only be made by the Consultant Psychiatrist in consultation with the MDT (business hours) or the on-call Psychiatry Registrar or on-call DMHU Consultant Psychiatrist (after hours) in consultation with the allocated nurse or the NIC. Risk factors must be identified and alternative management strategies must be implemented prior to any change in observations consistent with the DMHU Clinical Risk Assessment and Management Procedure and the Clinical Risk Assessment and Management (CRAM) Manual: A Practical Manual for Mental Health Clinicians (NSW Health).

For any level of observation above general observation, the MDT may prescribe that observations be reduced while the consumer is sleeping. For example, a consumer of 15 minute observations may be increased to 60 minute observations while they are sleeping. This needs to clearly be documented in the consumer’s TPRIM.



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To ensure consumers are not left on an inappropriately high level of observation, it is recommended that forward planning occurs, particularly to plan for weekends. The MDT, where possible, should specify the circumstances that would permit a reduction in a consumer’s observation level. This planning must be documented contemporaneously in the consumer’s clinical record.


Section 3 – Observation levels

3.1 General observationAll consumers in DMHU require general observation (see definition of terms), unless a different observation level as been assigned by the MDT. Hourly observations are the minimum acceptable level of observation for a consumer admitted to the DMHU. The consumer’s allocated nurse must know the location of the consumer at all times. General observation should be established as part of unit routine and followed rigorously and regularly by the consumer’s allocated nurse as part of their everyday practice to maintain the safety of consumers.

3.1.1 Consumer CountsClinical staff are required to conduct consumer counts every two hours to ensure that staff are aware of the whereabouts of all consumers in their care at all times and to ensure a timely response if a consumer cannot be located.

Any problems in locating consumers during a shift must be reported in the Shift Handover Report. See Dhulwa Escape and Abscond Procedure.

3.2 Increased observationsIncreased observations (see definition of terms) are considered suitable for those consumers, who following a risk assessment, are considered to be requiring a degree of supervision higher than general observations.

The MDT must determine the appropriate restrictions in conjunction with the consumer, wherever possible, and document those restrictions in the consumer’s TPRIM. These may include: the frequency of observations, i.e. generally 60, 30, 15 minute intervals. any limitations to the environment(s) the consumer can occupy, including restrictions to

ground leave, visits and supervision of visits.

Observations of consumers during normal sleeping hours may require the nurse to enter the consumer’s bedroom to ensure safety.

3.3 Continual observationContinual observation (see definition of terms) should be used for consumers considered to pose a significant and imminent risk to self and/or others. Continual observations require a minimum 1:1 nursing allocation.



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A nurse must visually observe the consumer all times. Respect for privacy should be an important consideration but safety is priority in all matters such as escorting to the toilet or bathroom, for example.

The nurse must not leave the consumer under any circumstances or for any period of time, no matter how short, unless another staff member has taken over the observation role.

The consumer must be managed in a highly visible area of the unit.

When a consumer is on continual observations during normal sleeping hours, two nursing staff will sit outside of the consumer’s bedroom, with the bedroom door open. Generally, two staff are required for such observations to prevent staff isolation. The MDT may prescribe that this can be reduced to one nurse, depending on the risk, i.e. self harm or risk of violence, etc.

3.4 Special observations 1:1 or at arm’s length Special Observations (see definition of terms) are implemented when the consumer is

considered to be at very high immediate risk and cannot be safely managed on Continuous Observations. The consumer should be within arm’s reach of a member of staff at all times and in all circumstances. Special Observations require a minimum 1:1 nursing allocation.

The allocated member of nursing staff must not leave the consumer under any circumstances or for any period of time, no matter how short, unless another staff member has taken over the observation role.

Special Observation is intrusive, and should only be used when judged necessary by the MDT and should not be done by an AIN.

The consumer must have been clinically assessed as requiring intensive and skilled intervention as a consequence of their very serious elevated level of risk.

Respect for privacy should be an important consideration but safety is priority in all matters such as escorting to the toilet or bathroom, for example.

Where a consumer requires nursing in their bedroom, e.g. overnight or if they are sedated due to medication, careful consideration should be given concerning gender, culture and associated risks.

The consumer will not have access to leave, unless during an emergency situation. In such situations a minimum of two staff must be in attendance to facilitate escort.

Leave is restricted to external medical leave. The MDT must review and determine the number of staff required to facilitate the

escort. The MDT must give careful consideration during Continual Observations and Special

Observations as to whether consumer visits should occur. If visits are to occur, they must be supervised during the period the consumer is on Continual Observations. These and other restrictions determined on an individual basis must be communicated with the consumer and visitors where appropriate, and documented in the consumer’s clinical record.



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It is acknowledged that gaining the consumer’s cooperation during one on one supervision may be extremely difficult due to their presenting mental state. However every effort must still be made to inform the consumer of the reasons for any increased level of observation and actively involve them in this process whenever possible. It is expected that this level of observation should wherever possible be treated as an opportunity for therapeutic interaction rather than a form of custodial care.

When a consumer is on special observations during normal sleeping hours, two nursing staff will sit beside the consumer’s bed, with the bedroom door open. Generally, two staff are required for such observations to prevent staff isolation. The MDT may prescribe that this level of observation be reduced while the consumer is sleeping. This must be clearly documented in the consumer’s TPRIM.

3.5 Seclusion Continuous ObservationsIf a consumer is secluded (see definition of terms), Continuous Observations are to be performed by a registered nurse.The clinical record will contain a detailed entry in respect to the commencement of Continuous Observations. This entry will include: a full mental health risk assessment and risk management plan review of medication, this will include monitoring of side-effects and the effectiveness of

any PRN medications consumer reaction/feelings to being on observations an individualised MDT plan of care and treatment an indication as to whether this plan has the consumers agreement/cooperation, and an exit plan to cease seclusion.

3.5.1 Review Prior to seclusion being ceased, the NIC and the available MDT or the on-call Psychiatry

Registrar or Consultant Psychiatrist (after hours) must complete and document a clinical assessment of the consumer’s mental state and level of risk.


Section 4 – Review of Observation levels

The MDT, in consultation with the on-call Psychiatry Registrar or Consultant Psychiatrist (after hours) must review and document the review of the consumer’s level of observation for consumers on increased, continual or special observation at least every 24 hours. This review must outline the continued need for this level of observation or alternative management strategies.

Any change to the consumer’s observation level must be implemented immediately.


Section 5 – Documentation



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A consumer‘s observation level must be documented in their clinical record and their TPRIM.

A Record of Observation Form must be used to document consumer’s observations throughout the day.

Both the relieved nurse and the nurse commencing observations must sign the Record of Observation Form at the time of handing over responsibility for observation of the consumer.

For consumers on general observations, observations must be documented in the consumer’s clinical record once per shift at a minimum and more frequently if there are significant changes in the consumer’s presentation.

Alterations to the consumer’s mental state, activities and any interactions must be documented in the consumer’s clinical record.

For consumers on increased, continual or special observations, observations must be documented in the consumer’s clinical record every two hours.

Significant aspects of the consumer’s mental state, activities and any interactions must be documented in the consumer’s clinical record.

An increase in a consumer’ observation level, including the reason for and duration of increased levels of observation must be documented in the consumer’s clinical record.

A decision to reduce a consumer’s level of observation, including the rationale for this decision, must be fully documented by the Consultant Psychiatrist or the on-call Psychiatry Registrar or on-call DMHU Consultant Psychiatrist (after hours) in the consumer’s clinical record.


Section 6 – Visits

The MDT must give careful consideration during increased, continual or special observations as to whether the consumer is well enough to have visitors (see DMHU Visitors Procedure).

If visits are to occur, the MDT will prescribe the level of supervision required, i.e. the number of staff. These and other restrictions are determined on an individual basis, by the MDT, must be communicated with the consumer, primary carer and visitors where appropriate, and documented in the consumer’s clinical record.




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Section 7 – Leave

Any consumer on an observation level higher than general observation will not be granted external leave from DMHU leave for any purpose other than emergency leave (See DMHU Leave Procedure).

The MDT must review and determine the number of staff required to facilitate the escort.


Implementation

The contents of this procedure will be communicated through the following means to DMHU staff: Education Orientation documentation and sessions Leadership and governance expectations regarding adherence to policy, procedure and

legislation Structured Case review and MDT Ward Rounds that reflect the procedure Performance Agreement plans


Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Work Health and Safety PolicyACT Health Work Health and Safety Management SystemACT Health Incident Management PolicyACT Health Consumer and Carer Participation PolicyACT Health Restraint of a Person PolicyCHHS Medications Handling PolicyDMHU Leave Policy

ProceduresACT Health Incident Management ProcedureACT Health Significant Incident ProcedureCHHS Clinical Handover ProcedureMHJHADS Director on Call Roles and Responsibilities ProcedureMHJHADS Unauthorised Leave of Admitted People from MHJHADS Inpatient UnitsMHJHADS Clinical Handover ProcedureMHJHADS Significant Incidents Reporting ProcedureMHJHADS Assessment and Intervention for People Vulnerable to Suicide ProcedureMHJHADS Seclusion of Persons with Mental Illness or Mental Disorder Detained under the Mental Health Act 2015DMHU Assessment and Management of the Risk of Violence Procedure



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DMHU Clinical Risk Assessment and Management (CRAM) Manual – PlaceholderDMHU Leave ProcedureDMHU Search ProcedureDhulwa Escape and Abscond Procedure Dhulwa Escape and Abscond Procedure

FrameworksMHJHADS Divisional Framework for the Management of Aggression and ViolenceDMHU Security Procedural Framework

Standards Australian Charter of Healthcare RightsNational Standards for Mental Health Services 2010National Safety and Quality Health Service Standards 2012

LegislationMental Health Act 2015Mental Health (Secure Facilities) Act 2016Children and Young People Act 2008 Public Advocate Act 2005Human Rights Act 2004Carers Recognition Act 2010Health Records (Privacy & Access) Act 1997Guardianship and Management of Property Act 1991Crimes Act 1900 Privacy Act 1988Discrimination Act 1991Work Health and Safety Act 2011Official Visitor Act 2012Territory Records Act 2002Working with Vulnerable People (Background Checking) Act 2011


Definition of Terms

General Observation – means the consumer’s allocated nurse having knowledge of the consumer’s general whereabouts at all times, whether in or out of the unit. General observations should be an established part of unit routine and followed rigorously and regularly by nurses as part of their everyday practice to maintain the safety of consumers.

Increased Observation – means the consumer’s allocated will observe the consumer nurse more frequently than general observations. The interval frequency of observation will be prescribed by the MDT and will generally be at 60, 30, or 15 minute intervals.

Continual Observation – means one on one observation, i.e. with the nurse visually observing a consumer at all times.



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Special Observation – means one on one observation, i.e. with a nurse being within arm’s reach of the consumer at all times and in all circumstances.

Seclusion - involuntarily placing a consumer alone in a locked room from which free exit is prevented.


Search Terms

DMHU, Observation, Clinical Risk Assessment and Management, CRAM, special observation, continual observation, increased observations, general observation

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



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