INTERDISCIPLINARY CLINICAL MANUAL
Policy & Procedure
TITLE:
Effective Date:
Close Patient Monitoring, and Constant
Observation on Mental Health Inpatient
units
May 2013
NUMBER:
CC 65-038
Page
1 of 10
Applies To:
Holders of Interdisciplinary Clinical Manual – Mental Health Program
POLICY
1. If a patient‟s behavior poses risk of harm to self or others; increased observation and
monitoring by Health Care Providers (HCPs) is required when clinically indicated. This
may involve temporarily limiting the liberty of the patient to provide supportive
interventions, monitor safety and decrease risk.
2. Monitoring/observation interventions are based on a risk assessment and critical
decision making and are provided in the least restrictive and intrusive manner used for
the least amount of time.
3. The decision to increase the level of monitoring is collaboratively determined with
members of the team and involves the patient and SDM when possible.
4. Restriction of a patient‟s liberty is never to be used for purposes of convenience or
punishment.
5. HCP‟s assigned to provide monitoring/observations are to have the appropriate skills
and competencies to observe for changes or improvements and report
monitoring/observation data.(see Handout: Guidelines for HCP‟s assigned Constant
Observation)
DEFINITIONS
Close Patient
Monitoring:
A clinical intervention to monitor and maintain safety of a
patient on an intermittent basis at a frequency of at least
every fifteen minutes.
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controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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Constant Observation:
An intensive clinical intervention where the patient at risk
requires direct, continuous, unobstructed visual observation
and monitoring by an assigned Health Care Provider.
Assigned Health Care
Providers (HCPs) who
may provide Close or
Constant observation:
Registered Nurses (RN), Licensed Practical Nurse (LPN),
Care Team Assistants (CTA),Developmental Workers (DW),
Recreation Therapists (Rec T), Recreation Therapy
Associate (RTA), Occupational Therapists ( OT or OTA)
Therapeutic Assistants (TA), Agency staff (Sitters)
Physician
Psychiatrist or Resident
GUIDING PRINCIPLES AND VALUES
1. Capital Health is committed to:
1.1. providing a safe and healthy environment for all Capital Health patients, visitors,
volunteers, employees, physicians and learners
1.2. a philosophy of least restraint consistent with respect for patient‟s dignity, rights,
values and preferences.
2. Consistent with Capital Health‟s vision, mission and values, the Mental Health program
supports strategies to provide for the safety and therapeutic milieu of the inpatient
environment through individualized care plans and increased level of assessment and
monitoring when required
3. Every patient has the right to liberty as long as this does not interfere with the safety of
self or others. When this occurs, HCPs are expected to make a reasonable and
proportionate response which both maintains safety, privacy and respects the human
rights and dignity of all persons.
4. Every patient has a right to make choices, decisions and have input into their care and
treatment. Throughout their hospital stay, HCPs engage the patient to discuss their
understanding of their situation, their needs and the planning of their care, including
periods of risk of physical harm to self or others.
5. The decision to use close /constant observation must consider the potential risk of
intrusion, invasion of privacy, and risk to exacerbate certain behaviours with patient‟s
clinical need for safety and therapeutic benefits. Promoting a therapeutic environment
and building a relationship is crucial to the care of “at risk” and suicidal individuals.
6. The patient‟s circle of support (family and/or SDM) is invited / encouraged to be involved
in care discussions in accordance to the patient‟s wishes. The SDM will be involved for
decision making when patients do not have capacity.
7. Each patient and his/her situation are to be considered on an individual basis with an
assessment and evaluation to guide understanding and direct management of their
care.
8. Every patient has the right to access advocacy services (e.g. Patient Representative) in
a timely manner throughout their stay in hospital, and in particular, at the time of
potential restrictions on their freedom/liberty. HCPs provide contact information for the
Patient Representative and/or Legal aid or lawyer referral services.
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controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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PROCEDURE
1. Assessment/Initiation/Daily Review/Discontinuation:
Assessment:
1.1. The RN and/or Physician assesses the need for Close/Constant patient monitoring:
Indications include:
1.1.1. Risk of suicide
1.1.2. Risk of self-harm or harm to others
1.1.3. Risk of aggression
1.1.4. Risk for elopement
1.1.5. Intrusive or inappropriate behavior
1.1.6. Risk associated with physical or medical conditions (risk of falls, wandering
behaviors, unstable physical condition such as delirium, adverse effects from
medication or treatment)
Initiation:
1.2. The Physician and/or Registered Nurse may initiate Close/ Constant Patient
Monitoring.
1.2.1. When an RN initiates Close/ Constant Patient Monitoring, the RN informs the
physician and determines, whether an immediate (within one hour) face to
face physician‟s assessment of the patient‟s condition and treatment needs
is required or whether this assessment can be conducted at the first
opportunity during regular daytime hours (including weekends and holidays).
1.3. The RN updates the care plan and communicates to all team members (ie. Kardex,
white boards, report sheets, pass monitor).
1.4. Constant Observation: During regular working hours the RN informs the Health
Services Manager (HSM).
Daily Review/Discontinuation:
1.5. Daily (within 24 hrs) or sooner as clinically indicated ( including weekends and
holidays) the physician and RN reassess the patient and the clinical need to
continue or discontinue Close/ Constant Patient Monitoring. Record assessment
and decision in the Progress notes.
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controlled and should be checked against the electronic file version prior to use.
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1.5.1. If a Physician orders Close/Constant Patient monitoring, obtain a Physician‟s
order to discontinue.
1.5.2. If a RN initiated the Close/Constant Patient monitoring, a RN collaborates with
nursing staff and other team members to decide whether to discontinue
Close/Constant Patient monitoring.
1.5.3. If a RN, in collaboration with other nurses and team members, discontinues
Constant observation, the RN informs Physician and the HSM of the clinical
decision.
2. Interventions:
2.1. The RN or Physician provides the patient with a clear explanation of the reason for
this level of monitoring, what to expect from the staff, where they can go on the unit,
and what behaviours/changes would support a reduction in observation level.
2.2. As appropriate, based on the patient‟s wishes, the RN or Physician discusses with
the SDM / Circle of support the reasons for this level of care and how they might be
involved in the plan of care.
2.3. HCPs maintain and support a safe environment by removing any potentially harmful
objects and minimize environmental stimuli.
2.3.1. Constant Observation: Where feasible, allocate a private room for the
patient to help ensure patient‟s privacy and safety requirements.
2.4. Each shift, the Charge Nurse /Assigned Nurse assign a HCP to provide
Close/Constant Patient Monitoring responsibilities for each hour of the shift.
2.4.1. Constant observation: The Charge Nurse / Assigned Nurse assess and
determine the skill level required of the HCP to provide Constant Observation
and adapts the assignment as appropriate to the patients changing clinical
needs. (See Appendix A: Key Considerations about Constant Observation).
2.5. The Assigned Nurse provides the HCP with a comprehensive report on:
2.5.1. reason for Close/Constant Patient Monitoring, and any specific care
requirements to support safety.
2.5.2. current mental and/or physical status
2.5.3. behaviours /symptoms to observe and report, level/type of interaction and
engagement.
2.5.4. activities/interventions that are helpful.
2.5.5. expected /anticipated outcomes of the nursing interventions
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controlled and should be checked against the electronic file version prior to use.
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2.5.6. when/how to contact the nurse and if there are specific concerns that require
immediate reporting
2.6. At a minimum of every 4 hours, the Assigned nurse checks with the HCP and
reviews the patient‟s progress.
2.7. The HCP providing Close /Constant Patient Monitoring reports all changes to the
Assigned Nurse in a timely manner.
2.8. Close Patient Monitoring:
2.8.1. Based on clinical assessment, the charge nurse may organize care such that
one HCP may oversee the Close Patient Monitoring of a group of patients.
2.8.2. The Charge Nurse/Assigned Nurse decide if a patient on Close Patient
Monitoring may leave the unit accompanied by an HCP, where clinically
beneficial and safe for the patients care and the HCP.
2.9. Constant Observation (See Appendix A: Key Considerations about Constant
Observation)
2.9.1. The HCP ensures a full view of the patient at all times and does not leave the
patient until responsibility is passed to next assigned HCP. (See Guidelines
for HCP’s Assigned Constant Observation).
2.9.2. Restrict „Off–unit‟ activities primarily to diagnostic and medical/psychiatric
procedures.
2.9.2.1. Assess (RN and/or Physician) the need for off-unit activities on an
individual basis.
2.9.2.2. Obtain a physician‟s order for the patient to participate in the off-unit
activity.
2.9.2.3. Unless otherwise ordered; ensure two HCPs accompany the patient.
2.9.3. If Constant Observation extends beyond 72 hrs, the physician notifies the
Clinical Director for a second opinion.
2.9.4. Once Constant Observation is discontinued, the RN debriefs with the patient
about the experience. (Seek out their understanding, what helped and what
was not helpful).
2.9.5. If Pinel physical restraints or the Emergency Restraint Chair are used, an RN
or LPN is assigned to provide the Constant Observation monitoring. (Refer to
CC 65-031 Use of Rapid Physical Restraints on Acute Care Mental Health
Inpatient units (Pinel System) or Emergency Restraint Chair for Patient
Transport interim policy)
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controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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2.9.6. If the Lawyer or Patient Rights Advisor or Patient Representative requests to
see the patient in private, the RN provides information regarding the specific
care requirements for safety, when and how to contact staff, and advises that
the patient must never be left alone.
Note: To grant privacy, the staff assigned to provide constant observation
may leave the patient with the designated person and resume constant
monitoring once the private consultation has concluded. The designated
person requesting the private consultation notifies the appropriate staff person
at the conclusion of the interview.
3. Special clinical situations:
3.1. When a patient requires extended use of Constant Observation (over 2 weeks), the
Physician and RN, in consultation with the Clinical Director, determine the time
frame (at minimum of weekly) for re-assessment, re-orders and documentation of
clinical presentation and clearly outline such in the plan of care.
3.2. When writing the order for Special Constant Observation, the physician specifies
any specific care requirements to support the patient‟s clinical needs. (E.g.
participation in „Off- unit‟ activities, monitoring required only while awake, or to stay
within arm‟s length of the patient).
4. Documentation:
4.1. The RN and/or Physician documents on the progress notes:
4.1.1. The reason for level of monitoring; including behaviors and mental status
changes leading to decision and any specific care requirements (e.g. at arms
length from patient, to remain in bedroom)
4.1.2. What behavioral changes are necessary to decrease/discontinue level of
monitoring.
4.1.3. The outcome of daily re-assessment and whether to continue or discontinue.
4.1.4. Outcome of discussion with patient, SDM and/or and Circle of support (where
appropriate)
4.2. The RN updates the plan of care.
4.3. The assigned nurse assesses and documents a summary note at a minimum of
each shift or more often as the clinical need dictates.
Note: Where the LPN is the Assigned Nurse, the RN and LPN collaborate/
communicate any changes to the patient‟s mental or physical status and the RN
revises the plan of care to meet expected outcomes.
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controlled and should be checked against the electronic file version prior to use.
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4.3.1. Include in the documentation:
4.3.1.1. assessment of risk,
4.3.1.2. mental and physical status,
4.3.1.3. response to interventions,
4.3.1.4. changes to plan of care and
4.3.1.5. decision to continue or discontinue Close/Constant Patient
Monitoring.
4.4. The HCP immediately reports any clinical changes to the Assigned Nurse and
records on the:
4.4.1. Close Patient Monitoring form (CD0077MR) every 15 minutes.
4.4.2. Constant Observation flow sheet (CD1353MR) at 1 hour intervals.
REFERENCES
Cleary, M., Jordon, R.,Horsfall, J.,Mazoudier, P., Delaney, J., (1999). Suicidal Patients and
Special Observation. Journal of Psychiatric and Mental Health Nursing. 6, 464-467.
Cox, A., Hayter, M., Ruane, J., (2010). Alternative Approaches to Enhanced Observation in
Acute Inpatient Mental Health Care: A Review of Literature. Journal of Psychiatric
and Mental Health Nursing 17, 162-171.
Cutcliffe, J. R., Barker, P., (2002) Considering the Care of the Suicidal Client and the Case
for Engagement and Inspiring hope or Observations. Journal of Psychiatric and
Mental Health Nursing, 9, 611 – 621
Fletcher, R., (1999) The process of constant observation: perspectives of staff and suicidal
patients. Journal of Psychiatric and Mental Health Nursing 6, 9-14.
Hamilton, B., Manias, E., (2007 Dec 20). The Power of Routine and Special Observations:
Producing Civility in a public Acute Psychiatric Unit. Nursing Inquiry 2008 15 (3), 178
– 188.
Janofsky, S. J., (2009). Reducing Inpatient Suicide Risk: Using human factors analysis to
improve observation practices. The Journal of the American Academy of Psychiatry
and the Law, 37 (1), 15-24.
Jayaram, G., Sporney, H., Perticone, P., (2010 Aug). The Utility and Effectiveness of 15minute Checks in Inpatient Settings. Psychiatry (Edgemont), 7 (8), 46-49.
MacKay, I., Paterson, B., Cassells, C., (2005). Constant or Special Observations of
Inpatients Presenting a Risk of Aggression or violence: Nurses perceptions of the
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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rules of Engagement. Journal of Psychiatric and Mental Health Nursing 12, 464471.
Neilson, P., Brennan, W., (2001). The use of Special Observations: an audit within a
psychiatric unit. Journal of Psychiatric and Mental Health Nursing, 6, 147 - 155.
Ray, R., Perkins, E., Meijer, B., (2010. The Evolution of Practice Changes in the use of
Special Observations. Archives of Psychiatric Nursing, 0(0), 1-11
Rooney, C., (2009) The Meaning of Mental Health Nurses Experience of Providing one to
one Observations: A Phenomenological Study. Journal of Psychiatric and Mental
Health Nursing, 16, 76-86.
Stewart, D., Bowers, L., & Warburton, F. (2009). Constant Special Observation and Self
Harm on Acute Psychiatric Wards: A Longitudinal Analysis. General Hospital
Psychiatry, 31, 523 – 530.
Vrale, G. B., Steen, E., (2005) The Dynamics between structure and Flexibility in constant
Observation of Psychiatric Inpatient with Suicidal Ideation. Journal of Psychiatric and
Mental Health Nursing, 12, 513 - 518.
Royal Ottawa Hospital Literature Review (2006) provided by Lisa Murata MN
RELATED DOCUMENTS
Policies
CC 65-030
CC 65-031
CC 65-xxx
Use of Seclusion on Mental Health Inpatient services
Use of Rapid Physical Restraints on Acute Care Mental Health Inpatient units
(Pinel System)
Interim policy „Use of Emergency Restraint Chair for Transportation in
Simpson Landing‟
Forms
CD1353MR Constant Observation Flow Sheet
CD0077MR Close Patient Monitoring
Appendices
Appendix A – Key Considerations about Constant Observation
Other
Handout: Guidelines for Health Care Providers Assigned Constant Observation
***
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controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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Appendix A
Key Considerations about Constant Observation
The decision must consider the potential risk of intrusion, invasion of privacy, and risk to
exacerbate certain behaviours with patient‟s clinical need for safety and therapeutic
benefits. Promoting a therapeutic environment and building a relationship is crucial to the
care of “at risk” and suicidal individuals.
RN and/or Physician may initiate Close or Constant Patient Monitoring.
If Close or Constant is ordered by a Physician, then a Physician’s Order is required
to discontinue.
The RN is accountable to update and maintain the plan of care.
At a minimum, each shift the assigned nurse is responsible to assess, evaluate and
document in the progress notes.
Note: Where the LPN is the Assigned Nurse, the RN and LPN will collaborate
/communicate any changes to the patient‟s mental or physical status and the RN
revises the plan of care to meet expected outcomes. Include the decision to continue
or discontinue Close/Constant Patient Monitoring.
A careful balance of activity, silence or privacy must be maintained. Consider the person‟s
strengths and coping skills. Activities can offer an effective method of observing an
individual‟s level of functioning and an opportunity to assess ones mental state.
The Assigned Nurse is accountable to ensure the patient has an appropriately trained staff
providing Constant Observation at all times. Consider the appropriate assignment if there is
a gender difference of patient and HCP.
Non-licensed care provider (eg. PSW, DW, CTA, Sitters) need to be aware of their
role and responsibilities and how / when to contact the nursing staff.
Skills competencies and accountabilities:
- Understands the duties and accountabilities
- Possesses skills in detection, de-escalation and management of aggression
- Provides supportive interventions, brief and practical distractions, as outlined
in the plan of care
- Acknowledges the individual and demonstrates an optimistic, positive attitude
- Knows how and when to contact nursing staff
- Documents patient behaviors/responses and interventions/ interactions on the
Constant Observation flow sheet CD1353MR_03_2013
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controlled and should be checked against the electronic file version prior to use.
Close and Constant Observation – Mental Health CC 65-038
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The Assigned Nurse provides a comprehensive report to the HCP. This includes:
- the reason of constant observation
- plan of care including the patients care needs, and ways to engage with the
patient (verbal contact and activities/ interventions),
- what to expect from the patient during constant observation,
- where to sit/be located to ensure best visual observation
- any specific care requirements or approaches that support patient care (ie. at arms
length from patient or to remain in room).
Ensure the staff knows the best way to contact the RN/LPN or other staff when providing
constant observation.
Assignment considerations:
- Assigned Nurse collaborates with the Charge nurse to schedule the staff
assignment
- Ensures relief for assigned breaks (lunch and contracted breaks). Consider the
fatigue factor for this level of monitoring. As needed, provide short relief break
from duties (5 minutes) periodically throughout the shift
Requests for private consultation:
If the Lawyer or Patient Rights Advisor or Patient Representative requests to see the
patient in private, the RN provides information regarding the specific care requirements for
safety, how and when to contact staff and advises that the patient must never be left alone.
Note: To grant privacy, the staff assigned to provide constant observation may leave the
patient with the designated person and resume constant monitoring once the private
consultation has concluded. The designated person requesting the private consultation
notifies the appropriate staff person at the conclusion of the interview.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.