Observations in behavioral health hospitals: a comparison of US and UK clinical practices
Around the world, observations have long been a routine part of behavioral health inpatient care. These are checks carried out by clinical staff at regular intervals - or continuously for high-risk patients - throughout the day and night.
Observations can serve multiple purposes; for example, they can be used to monitor patients for signs of distress, self-harm or aggression. They can also be used to assess the effectiveness of treatment, evaluate changes in a patient's condition and ensure compliance with medication protocols.
Ultimately, they help staff manage risk, make clinical decisions, and promote patient safety and wellbeing.
Although observations are universally undertaken in behavioral health hospitals, specific practices vary from country to country and even between different regions in the same country. Here, we explore how observations compare and contrast in the US and UK.
How frequently are observations carried out?
In the US, standard practice is for staff to check on patients no less than every 15 minutes. Providers in the UK take a slightly different approach: the frequency of observations is determined by a patient’s assessed level of risk and can be four times, two times or one time per hour. The level of risk is established by clinical staff on the unit and will be adjusted if the patient’s care needs are considered to have changed (there is no specific time frame defined for reassessment). In both countries, the intervals between intermittent observations are expected to be unequal, so that patients can’t predict when a staff member will be checking on them and adjust their behavior accordingly.
In the US and the UK, a patient who is judged to be at an immediate risk of harm to themselves or others, that cannot be managed safely with intermittent checks, will be placed on continuous 1:1 observations. In the US, the patient will remain in the observer’s ‘line of sight’ and in the UK they will either be within ‘eyesight’ or ‘arm’s length’.
As well as being burdensome for staff and costly for providers, continuous observations can be intrusive for patients. They should therefore only be used for the least amount of time considered clinically necessary.
It is important to bear in mind that the average length of stay for patients in behavioral health hospitals in the US is just ~10 days, versus ~28 days in the UK. Since patients in US hospitals tend to be in an acute phase of stay - when the risk of harm is very high - they often can’t be left alone and may therefore require a more intensive level of observation than patients in UK hospitals.
What happens during the night?
Observations need to be carried out 24/7. Night-time checks are particularly important to ensure the safety and wellbeing of patients who may be at an increased risk of self-harm, agitation or other behavioral disturbances during the night. They can, however, disrupt patients’ sleep and be difficult for staff to carry out.
In US hospitals, staff typically enter a patient’s room and count three rise and fall movements of the chest to confirm the patient is breathing. In UK hospitals, staff also look for chest movements, and they may also listen for the sound of regular breathing. However, some doors are fitted with hatches and/or observation panels so they don’t always have to enter a patient’s room at night to check they are safe. Staff in both countries often make use of flashlights to allow them to see in the dark.
Half of NHS England’s behavioral health providers now use Oxevision to support patient care. The system helps staff around the clock but is especially useful at night because it enables them to check on patients remotely instead of disturbing them while they are trying to sleep.
Who carries out the observations?
Mental health technicians in the US are generally responsible for conducting observations. However, in many hospitals a registered nurse may also carry out what’s known as a purposeful round using a standardized protocol. This normally takes place 1-2 times per shift and involves completing an actual or mental checklist of tasks to improve the overall quality of care for the patient.
In the UK, observations are usually done by healthcare assistants, who work under the supervision of nurses and whose role it is to make sure the patient experience is as good as possible. Sometimes, nurses will carry out the checks instead. This is dependent on the availability of staff on the shift.
What is recorded and how?
The recording of observations - in terms of the insights collected and the method of documentation used - varies across facilities.
Some common types of information noted down during observations in both the US and UK are:
- Mood and behaviors, including any associated with violence and aggression
- Speech and level of engagement/interactions with staff and other patients
- Mental status including cognitive functioning
- Physical health data such as pulse and breathing rate
- Medication administration and other interventions
Currently, paper-based observation methods are widely used. These tend to be inefficient and are prone to errors and inaccuracies that can compromise patient safety. They are also difficult to audit. Some providers have therefore turned to digital rounding tools. In the UK, these tools are often hand-me-downs from general medicine and not fit for purpose. By contrast, Oxehealth’s new digital rounding solution - Oxevision Observations - is designed specifically for behavioral health.
What are the regulations?
Interestingly, observations in behavioral health hospitals are not mandated by US national guidelines. The Joint Commission (in National Patient Safety Goal 15.01.01) and the Centers for Medicare & Medicaid Services (CMS; in Tag A-0144) both only explicitly recommend using 1:1 monitoring with continuous visual observation for suicide prevention when psychiatric patients who are at high risk require medical care in non-psychiatric settings which do not have ligature-resistant environments.
The Joint Commission notes, “in inpatient psychiatric units/designated psychiatric areas that are ligature resistant and free from other safety risks, it is up to the organization to determine monitoring requirements for patients determined to be at high-risk for suicide and define such in their policy”. Regarding the right to personal privacy, the CMS specifies (in Tag A-0143) that “a patient’s right to privacy may…be limited in situations where a person must be continuously observed to ensure his or her safety, such as…when the patient is under suicide precautions”.
The UK’s Mental Health Act: Code of Practice recommends being “caringly vigilant and inquisitive” and having “a clear plan in relation to monitoring and supervision” for patients at risk of serious self-harm or suicide. It goes on to state, “there may be times when enhanced levels of observation are required [on an intermittent or continuous basis] for the short-term management of behavioural disturbance or during periods of distress to prevent suicide or serious self-harm”.
The National Institute for Clinical Excellence in the UK has no published guidelines on self-harm and/or suicide prevention in behavioral health inpatient services, but recommends using observation for the short-term management of violence and aggression in these settings, “only after positive engagement with the service user has failed to dissipate the risk of violence and aggression”.
Like in the US, each UK provider establishes their own observation protocol - see examples from South London and Maudsley NHS Foundation Trust and Solent NHS Trust.
