15 minute checks...worth using??

[Meraki]

I am currently in the middle of a discussion with my management team as to whether or not to keep close obs (15 minute checks) in our obs policy. On one hand they are useful for transitioning a patient off 1:1, and also for other patients that require more support (med problem, or non risk related psych problems ie OCD, isolating etc).

The problem with them...1) they are useless for patients at high risk to self harm as 15 minutes is more than long enough to seriously self harm 2) they are overused without clinical justification in order for docs to cover themselves liability wise and 3) they are VERY hard to efficiently operationalize on the floor...ie if a nurse has 3-4 patients then to check on someone and document it every 15 minutes while also providing care to the other patients is almost impossible.

So do you use them in your facility....If yes:

1) do you actually document every 15 minutes or do you document retroactively when you get a chance?

2) how often in actual fact are the checks missed due to the nurse being busy...ie with admissions, discharges, taking pts off the floor, running programming, dealing with pt in crisis, talktime, family session etc...

3) do you put any special procedures in place to make 15 minute checks more manageable....ie one staff does all checks, or nurse with pts on close obs have only a 2 pt assignment, or pts do self check in...????

Clinically, the docs in our area want them included, operationally and without addtional resources...it is really hard to realistically expect staff to do them.

Now, we have them and they are done but not efficiently. Staff will fill in the sheets a couple hours later and some checks get missed...so having them but not implementing them as per the policy leaves us open to negligence/liability in the case of an incident.

Any ideas??? Any of your facilities found a solution???

Thanks

Jenn

By the way I work on a locked adolescent inpatient unit

[suzanne4, RN]

There are documented checks every 15 minutes, at least the first hour for any type or restraint. Even drug and soft restraint..............per JCAHO policies. And this is just for regular types of units, med/surg or critical care, etc. Even infants.............

[elkpark]

Hi -- I am a child psych CS with lots of experience on inpatient adol psych units, both as a staff nurse and CS, so I understand all your very legitimate concerns.

I am enough of an old-timer that I remember back when everyone in psych understood that "15 minute checks" is a short "nickname" for RANDOM CHECKS NO MORE THAN 15 MINUTES APART. You are right that 15" is certainly more than enough time to kill oneself, let alone just hurt oneself. 15" checks are useless if all they do is allow a potentially dangerous patient to figure out (quickly, usually) that he or she can count on 15 minutes of uninterrupted peace and quiet once staff has checked on him or her ...

"15" checks" used to mean that you checked on the person at random intervals but no more than 15 minutes apart. That way, the patient never knows, if you just checked on him or her, whether it will be quite a while before you check again or whether you'll be popping in any second now ... THAT is how "15" checks" help keep a person safe, not the "every quarter hour on the quarter hour" approach that most places now use.

I worked for several years as a mental health investigator/inspector/regulator for my state, and I can't tell you how many deaths on psych units I investigated, all patients who were on 15" checks when they killed themselves. The staff were always quite confident that they had done all they could have done to keep the patient safe, because, by golly, they had checked on the patient EVERY 15 MINUTES, regular as clockwork, come heck or high water. I'm not condemning or criticizing any specific staff members; they were following hospital policy and doing what their bosses had told them to. But, as I said at the beginning of my rant, I remember when when we all understood what "15" checks" was supposed to mean ...

I hate to sound like an old battleaxe/old fogey (which I now am, I guess), but this issue has become one of my pet peeves, esp. since I've had first-hand experience with all the deaths I mentioned above. Not only are the patients dead in those situations, but family members are bereaved, unit staff are traumatized by the experience, and (not to put too fine a point on it,) it makes the hospital/unit look bad to the public. Plus, in my experience, the investigations triggered by the deaths often ended up with the hospital in significant trouble with the state or the Feds, which is always unpleasant and unfortunate for everyone.

As for documentation, if you're doing the randomized interval checks you check on the person more frequently than q 15" and that is easy to do in the normal course of coming and going on the unit. I am accustomed to not necessarily documenting right when I did every check, but I certainly wouldn't go more than a few checks before catching up the paperwork.

Many facilities assign a single staff person (typically, a tech rather than a nurse) to be responsible for doing all the safety checks, but some leave it to the staff person assigned to each patient (who is on checks) -- and how many patients are on checks may determine which approach makes more sense. Yes, if the individual staff are doing the checks on their assigned patients, that is considered a heavier patient care load and the assignments are adjusted to reflect that ... I'm accustomed to the charge nurse being responsible for assigning the checks and following up to be sure they have been done and documented. If one person is going to be doing all the checks, often that is broken up during the shift, so that (e.g.,) Tech A does the checks for the first two hours of the shift, then Tech B does them for two hours, etc. Of course, the charge nurse also has to figure in coverage for staff meal breaks, etc.

I've been saying for years (and some colleagues have been grinding their teeth and rolling their eyes when I say it), for what it costs to be on a psych unit, THE LEAST we can do for people is keep them safe ... It's really not that much more effort than all the stuff that is done on psych units in the name of safety that really DOESN'T do anything to help keep people safe ...

I apologize for the lengthy rant :chuckle -- hang in there ...

[Meraki]

suzanne...we do have a pretty intense obs policy for restraints...it's all the other times!

elkpark...thanks for the great reply...i guess this problem has been around for awhile, your knowledge and experience is appreciated

I also agree that 15 minute checks must be done randomly...i have managed to get them to allow me to leave the time slots blank on the documentation tool I am developing so that staff will write in the actual time they checked.

The guideline they want instead is "a minimum of 3 checks per hour, at 10-20 minute intervals". They have also agreed that intermittent obs will not be used for pts with high suicide risk. Admin is not prepared to pay for a tech to do checks so it will have to be assigned staff...which on an acute, crisis unit is hard to get done.

Overall despite my numerous frustrations with management and admin, I think in my facility I have good support and resources compared to many other facilities...our current staff-patient ratio is 1:3, and in 26 years no one has ever committed suicide on the unit...although there have been many close calls...some saved only due to what can only be 'nurse intuition' or a 'gut feeling' that something is wrong.

[maureeno]

we assigned times for each staff to cover

checking on all patients while staying out

in the hall most of that 1.5-2 hour period.

documentation was done realtime at the site

walking the hallway on a night shift I could

sometimes feel the friendly 'ghosts' of nurses past

many times problems were obviated because

someone was watching and checking

[Bjo]

I, too, remember the days when death occured in psychiatric hospitals. We use the 15 minute, random, checks for all patients on precautions. If the patient is on one to one it is a given, you are never away from them. We also do hourly checks on every patient on the ward. We, as I'm sure you all do as well, use numbers and letters to indicate where the patient is. If a person on 15 minute checks has been sleeping, in their room and isolative, or otherwise non-productive, for three consecutive checks, we make certain that we arouse the person, or engage them in some type of conversation and then we document it. It's more of a safety issue than a pain in the butt. If the patients on the ward are under my care, I want to know that when I leave at the end of the day that they are all well and safe.

I'm not going to say that we have never missed a check when we were swamped with admissions, or at other times of crisis. But that is more the exception than the rule. The checks at our facility are a top priority!

We don't assign a particular person to do the checks. Everyone is responsible and many times when one staff member checks, they have already been done by someone else.

[TitaniaSidhe]

We do not use Q15 min checks for patients at behavior risk. We use either COS-A (arms length) or COS-V (within eyesight). The ratio is 1 staff- 1 patient. This is why management complains b/c of the cost & demands that we as nurses "encourage" the docs to remove patients from status.

One thing we do use however for added safety on our unit is Q30 min health & safety rounds. This is basically done 24/7 every 30 minutes & it is a face to face check of each & every patient on the unit. This assignment is usually divided up among 1-3 NA's per shift, has a flow sheet with times & codes to enter for behaviors observed. I know a lot can & does happen in 30 minutes but it does help to some extent. During the night shift when I am working my NA's stagger the times as was mentioned earlier. I agree that predictability will only lead to someone doing something unpleasant.

[elkpark]

I, too, remember the days when death occured in psychiatric hospitals.

What's with "the days when ..."?? People are dying on psych units every day (somewhere ...) When I say that I investigated deaths, I'm talking about within the last few months, not the dark ages.

[TitaniaSidhe]

True deaths still can & do occur. Had a completed suicide on our unit just 4 years ago...

[CharlieRN]

Yes.

[medpsychRN]

We have q 15 minute checks. I would hope that this has prevented something from happening but as we have been incident free it's hard to say that this is true solely because of the checks.

Actually, I like doing them. I get out of the nurses station for an hour (we rotate every hour) and walk the unit. Good exercise and it gives me an opportunity to observe patients other than my own, interact with patients and I get a good feel for what's going on.

[CharlieRN]

Our routine checks are q 30mins. We uses 15's as the next step. For example I admitted a suicidal pt last night who contracted for safety while in the hospital. She went on 15's. If she had not contracted she would have been on constant observations or one to one's. We have used 15's while asleep and CO's while awake. Any pt who is on an increased level of observation is restricted to the unit.