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______________________________________________________________________________ Policy Name: Patient Observation Interventions Policy Policy Number: GA-191 Category: ! Clinical " Non-Clinical Review Responsibility: Nursing Approved By: Administrative Director of Nursing Operations

Vice President, Clinical Services/CNO Effective Date: 9/1/2017 Reviewed/Revised Dates: 10/17, 10/18 Associated Documents/Policies: NS-057, GA-190, Patient Observation Initiation / Discontinuation Checklist and Patient Observation Record The policies set forth do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their clinical judgment in determining what is in the best interests of the patient, based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare policies for each. Accordingly, these policies should be considered to be guidelines to be consulted for guidance with the understanding that departures from them may be required at times.

I. PURPOSE:

To describe interventions available at CalvertHealth (CH) for providing observation services to patients at risk of harm to self or others or patients who pose a safety risk.

II. SCOPE:

This policy applies to all staff involved in care of patients.

III. DEFINITIONS:

Telesitter Technician: Staff who have completed continuous visual monitoring (CVM) training, including a competency checklist.

Patient Observer: Staff who have completed the Patient Observer Training and maintain current CPR. All Patient Care Technicians (PCT, GCT, OBT, ERT) receive Patient Observer Training in orientation. Health system staff in other roles in the organization that have completed Patient Observation Training and CPR may perform patient observer duties. CH provides different types of observation services depending on patient needs and equipment availability:

Continuous Visual Monitoring (CVM): Centrally located, specially trained staff (telesitter technician) continuously observes patients via remote technology. The telesitter technician provides continuous visualization of all patients being monitored via CVM technology. The telesitter technician can communicate verbally with the patients

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via remote technology. The continuous visual monitoring technology is utilized for patients who are at risk for harm due to: • Delirium/restlessness • Confusion, acute or chronic • Elopement risk • General safety concerns (inappropriate behaviors, impulsive behavior) • History of falls • High risk for fall • Alcohol withdrawal with CIWA score less than 9 • Medium or high risk for suicide on Columbia Suicide Scale unless patients fails CVM

criteria or nursing judgment indicates a need for a patient observer

Exclusion Criteria for Continuous Visual Monitoring (CVM) • Patient is four point restraints • Patient is in alcohol withdrawal with CIWA greater than or equal to 9 • Patient meets failure criteria - CVM has failed as evidenced by:

o Numerous re-directions in a short amount of time that interferes with safe monitoring of other remote observation patients

o Activation of STAT Alert alarm more than three times in 30 minutes o Escalating behavior resulting from use of CVM

Constant Observation is utilized for patients at risk for harm and would normally be monitored via CVM but for whom the technology is not available due to lack of devices or downtime of the CVM system. Constant observation is provided by trained personnel. Constant observation requires the observer to have visual contact with the patient at all times with the exception of toileting and showering. During toileting and showering, the patient observer must remain in audible contact with the patient.

One to One Observation is utilized for patients at risk for harm due to: • Medium or high risk for suicide on Columbia Suicide Scale who have failed CVM or

nursing judgment indicates a need for a patient observer • Four point restraints • Alcohol withdrawal with a CIWA score greater than or equal to 9

Patient observers must maintain continuous visual contact and proximity with the patient at all times. For patients in four point restraints, patient observers must be at the doorway or within the room of the patient at all times. For other patients receiving one to one patient observation the patient observer must be in the direct line of sight of the patient (even when toileting/showering) at all times. One to one patient observers should position themselves in a manner to maximize their own safety (near door). One to one patient observers must document the status of the patient every 15 minutes on the Patient Observation Record (see Attachment A).

IV. POLICY:

It is the policy of CH to utilize skilled personnel to observe patients that are at risk for harm, falls, violence or self-destructive behavior in an effort to keep patients safe using the least restrictive methods possible.

V. PROCEDURE:

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1. Clinical staff assesses a patient to potentially meet criteria for observation services. 2. Clinical staff completes the Patient Observation Initiation/Discontinuation Checklist

(see Attachment B). 3. Patient Observation Initiation/Discontinuation Checklist provides interventions to

consider prior to requesting observation services. 4. Patient Observation Initiation/Discontinuation Checklist assists in ascertaining which

type of observation service is required. 5. When a patient is scored as medium or high risk for suicide on the Columbia Suicide

Risk Scale, the patient is immediately placed on CVM. 6. If the patient meets CVM failure criteria, a one to on patient observer is requested.

CVM will remain in place until one to one patient observer arrives. 7. Patient Observation Initiation/Discontinuation Checklist is given to Charge Nurse. 8. Charge Nurse communicates indicated patient observer need to the Clinical

Coordinator. 9. Patient Observation Initiation/Discontinuation Checklist is delivered or faxed to

Clinical Coordinator. 10. Clinical Coordinator assesses the need and resources available and deploys

appropriate personnel or resource to observe patient. 11. Clinical Coordinator communicates to charge nurse who will observe the patient and

the estimated time frame observation will begin. 12. Each shift, the need for continued observation will be evaluated on every observed

patient regardless of the type of observation. 13. CVM and direct patient observation is discontinued by appropriate staff when patient

no longer meets criteria. 14. Suicidal patient observation (one-to-one or CVM) is discontinued by physician order

only. 15. Four-point restraint observation (one-to-one) is discontinued when the four-point

restraint is discontinued. 16. Alcohol withdrawal observation (one-to-one observation for patients with a CIWA

greater than or equal to 9) will be converted to CVM when the CIWA score drops below 9.

Determination: • The charge nurse, Registered Nurse (RN), unit director or clinical coordinator prior to

the assignment of an observer must evaluate the initial need for an observer using the Patient Observation Initiation/Discontinuation Checklist.

• The charge nurse, RN, unit director or clinical coordinator prior to the assignment of a direct or one-to-one patient observer will evaluate the relevant history of the patient, and to every extent possible, assign the same gender observer when deemed appropriate.

• The charge nurse, RN, unit director or clinical coordinator will re-evaluate the continued need for an observer every 12 hours or as needed.

• Based on clinical assessment, observation and judgment, or the addition of collateral information from family, friends or associates, the level of monitoring may be elevated higher than the risk score dictates. Indication for escalation of monitoring interventions will be documented in the patient’s EHR.

ATTACHMENT A PATIENT OBSERVATION RECORD

ATTACHMENT B

PATIENT OBSERVATION INITIATION/DISCONTINUATION CHECKLIST

Criteria for initiation: Select observation method and criteria

" Continuous Visual Monitoring (telesitter) " Patient Observer (1:1)

" Confusion/disorientation resulting in interference with medical care (pulling off O2, pulling out lines) " Safety restraints for medical device protection " Elopement risk " History of falls, actively trying to get out of bed □ High risk for falls " General safety concerns (inappropriate behavior, impulsive behavior) " Drug/alcohol withdrawal, CIWA score less than 9 " Patient scored medium or high risk on Columbia Suicide Scale Criteria for discontinuation of CVM: " Patient converted to constant or one-to-one patient observer " Patient no longer meets initiation criteria above " Remote monitoring unit reassigned to higher risk patient " Family/patient refused " Patient transferred to another facility " Patient discharged

" Patient scored medium or high risk on Columbia Suicide Scale and failed CVM " Patient is in four point restraints " Drug/alcohol withdrawal, CIWA score greater than or equal to 9 " Unattended children under the age of 12 " Any patient under 18 at risk for injury Criteria for discontinuation of 1:1 observer: " Patient converted to CVM " 1:1 observer discontinued by Provider " Patient no longer meets initiation criteria listed above " Patient transferred to another facility " Patient discharged

Process for requesting Telesitter or Patient Observer (1:1) RN name ____________________

1. Inform Charge Nurse of need RN phone ____________________ 2. Give completed form to Charge Nurse (place one copy in chart) 3. Charge Nurse communicates need to Clinical Coordinator Tech name __________________ 4. Request form is faxed or delivered to Clinical Coordinator Tech phone __________________ 5. Clinical Coordinator to communicate next steps to Charge RN

Process for discontinuing Telesitter or Patient Observer (1:1)

1. Complete discontinuation criteria above 2. Give completed form to Charge Nurse (place one copy in chart) 3. Charge Nurse communicates discontinuation to Clinical Coordinator and faxes/delivers form

______________________________________________ __________ ________ RN Signature Date Time

CVM# _______________________________________