Psychosomatics 41:289-293, August 2000
© 2000 The Academy of Psychosomatic Medicine
Constant Observation in the General Hospital
Michael Blumenfield, M.D.,
Jane Milazzo, M.S., R.N., C.S., and
Barbara Orlowski, Ph.D.
Received April 15, 1999; revised August 29, 1999; accepted November 19, 1999. From the Division of Consultation-Liaison Psychiatry, Westchester Medical Center; and the Department of Psychiatry, New York Medical College. Address reprint requests to Dr. Blumenfield, Department of Psychiatry, Behavioral Health Center, New York Medical College, Valhalla, New York 10595; email: ronellan{at}aol.com
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ABSTRACT
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Constant observation (CO) is a technique in which continuous one-to-one monitoring is used to assure the safety and well-being of an individual patient or others. This study reviewed 115 patient charts in a tertiary-care hospital to determine the correlates and predictors of the financial cost of CO. The mean duration for CO was 13.9 days with a median of 7.5 days. The cost average was $3,415 per incident with a range of $144–$68,500. The median cost was $1,872. The most common diagnosis was organic mental syndrome. Significant predictors of CO were disorientation, psychiatric medication used, and absence of alcohol use.
Key Words: Constant Observation
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INTRODUCTION
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The use of constant observation (CO) in the general hospital is of great concern to both clinicians and hospital administrators. An appropriate working definition for CO is "an increased level of observation and supervision in which continuous, one-to-one monitoring techniques are utilized to assure the safety and well-being of an individual patient or others in the patient-care environment."1
Several hospital surveys have shown a range of 1–480 CO cases a year.2–6 A mean of 107 cases per hospital was demonstrated in one study.2 The mean length of time for CO sited in various studies was between 3.7 and 9.2 days,4–7 and the length of time for CO ranged from 1 to 63 days.3–4,6–8
The process of having a CO program can be labor intensive and expensive for the hospital. Furthermore, the costs are usually not covered by Blue Cross, Medicare, and other 3rd-party insurance companies, as they regard CO as a component of routine care.7 Estimates of costs range from $1,000 to $240,000 per hospital per year with a mean of $51,800 in a survey of 118 hospitals.2 Another study showed a range of $232,999 to $581,000 per year of CO costs in three general hospitals,1 and this finding was confirmed in a later study.6 An additional study had similar but slightly lower costs.5 Frequently, the actual costs of CO are not available and are buried in personnel and overtime budgets.1,7
The cost-containment policies of managed care companies is another factor that impacts a hospital. No direct citation was found in the literature that reflects a managed care policy on CO costs. The behaviors that have been reported to warrant the institution of CO include suicidal behavior, self-mutilation, delirium, agitation, physical aggression, hallucinations, and the need to monitor patients in mechanical restraints.1,3–4,7,9–12
Our present study focuses on determining the correlates and predictors of CO as well as the length of CO per admission and the financial cost to the general medical hospital.
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METHODS
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Westchester Medical Center is a 620-bed, tertiary-care hospital located in a suburban area 30 miles north of New York City. A chart review was conducted on all patients at the medical center who were put on CO during a 9-month period between October 1, 1993, and June 30, 1994. The patients on CO were identified by the nursing department, which had the responsibility of supplying all the COs for the hospital. The hospital chart of each patient on CO was reviewed by a registered nurse on light-duty assignment from the nursing department. The reviewing nurse completed a 127-item data collection form that included demographic information, medical history, presenting medical problems, the reason for the CO, and clinical findings that occurred during the time that the CO was in place. Data were recorded based on chart notations that reflected patients' behavior and conduct during the CO and at the termination of it. The use of medication and of physical restraints was also documented. The cost data were calculated based on an hourly rate paid to various people performing CO. The study was reviewed and approved by the hospital's institutional research review board.
Statistical analysis was performed using a multiple-regression analysis for predictors and a two-tailed analysis of variance for correlations. Statistically significant correlations were then entered into the regression analysis as possible predictors of duration and, therefore, cost.
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RESULTS
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During the time period of the study, 119 patients were placed on CO. Chart documentation on four patients was not complete and therefore 115 were used for the study, which included one outlier. However, in specific categories, variables were missing for some subjects, and therefore the number of subjects changed depending on which variable was being examined. In the regression analysis, 105 patients were used. The patients' ages ranged from 7 years to 85 years of age (mean age of 44 years and a median age of 41 years). The other demographic characteristics of the patients in this study are presented in Table 1.
The most common diagnostic categories of mental conditions (Table 2) of the patients on CO were organic mental syndrome (42.1%), no mental illness (21.1%), and mood disorder (15.8%). Incidence of the other diagnostic categories ranged from 3.5% to 7.9%.
Outlier
One patient that was 9 standard deviations above the mean spent 240 days on CO at a cost of $68,500. The patient was a 27-year-old male with a history of substance abuse who was also HIV positive. The patient also had multidrug-resistant tuberculosis. He had psychotic manifestations that were believed to be related to an HIV dementia. He was uncooperative in taking medication and was mandated to the hospital by the county health department. The degree to which this patient affected the findings of this study is demonstrated in the comparative analysis in Table 2.
The mean duration of CO for all patients was 13.9 days with a median of 7.5 days. The range for all patients was between 0.5 and 240 days. The duration drops to a mean of 11.9 days and the upper limit of the range drops to 69 days when the outlier is excluded. The mean cost of a CO incident was $3,415 per patient, with a range of $144 to $68,500. The median cost for all patients was $1,872 (Table 2). When the outlier was dropped, the cost of a CO incident averaged $2,844 per patient, with a range of $144 to $19,872. Table 2 shows the duration and cost of CO for each diagnostic group and also includes the duration and cost with the outlier.
Correlations
Table 3 presents an analysis of the continuous and dichotomous variables in the database that correlated (two-tailed) with cost but that were not necessarily predictors of cost. Table 3 also presents the analysis excluding the outlier.
Predictors
A step-wise multiple-regression analysis was used to determine which variables were the significant predictors of the cost of CO (Table 4). We determined that three variables contributed to 17% (adjusted R2) of the variance in cost (F [3,104]=8.161, P< 0.0005). These variables were were disorientation (9.4%, P= 0.001), psychiatric medication used (4.1%, P= 0.017), and absence of alcohol use (4%, P= 0.021).
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TABLE 4. Predictions of the cost of constant observation as predicted by multiple-regression analysis using study variables
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DISCUSSION
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It is not surprising that patients with organic mental syndrome comprise the largest category of patients on CO. These are usually patients with a diagnosis of dementia and delirium. However, since the diagnosis was determined from chart review, which included consultations and observation by various levels and disciplines, we do not believe we had sufficient validity to make the distinction between these two diagnostic entities in this study.
Many of the patients included in the second-largest diagnostic category, "No Mental Illness," did not have a psychiatric diagnosis at the time of the chart review. Also included in this category would be uncooperative patients for which a psychiatric diagnosis could not be made.
The third-largest diagnostic category, "mood disorders," usually included suicidal patients who always require CO. External circumstances, changes in family support systems, changes in the patients' own psychodynamics, and a resolution of the patients' mood state could yield future findings, which would indicate that CO could be eliminated.
We were unable to determine the annual cost of COs for our hospital because of overlapping budgets for overtime and agency personnel. However, if we extrapolate from our 9-month study using the average cost of $3,415 per patient, an annual cost estimate for CO would be $500,000. Our estimate is within the upper range of cost found among similar hospitals by Moore et al.1
Efforts to diminish the manpower and therefore the total cost required for CO should address psychiatric factors that correlate and predict the need for CO. Disorientation, psychiatric medication used, and absence of alcohol use were found to be the significant predictors of the need for CO. It is not surprising that disorientation and the use of psychiatric medication predicted the need for CO; special attention paid to disorientation, early and throughout the admission, may result in a decreased amount of time on CO. Nurses often use techniques to help reorient patients (e.g., a night-light, a clock, a calendar, personal objects, or pictures). The absence of alcohol as a predictor of CO was an unexpected finding. We were uncertain if this reflected an inaccurate alcohol or drug history that sometimes is characteristic of patients needing CO. It is also possible that a hospital is already effectively treating alcohol-use problems when they are identified and therefore CO is not being used excessively for this purpose.
In addition to rapid, effective use of psychotropic medication, there may be other techniques that can be used to eliminate or shorten the need for CO. These techniques include intensive psychotherapeutic intervention and psychosocial interaction with the patient's family. It may also be possible to alter CO by using one observer for multiple patients or by designating a special unit where there could be a more effective use of well-trained staff. Such units could use special construction in order to assure safety (e.g., unbreakable glass). Guidelines are needed for the training of CO staff and institutional policy for the implementation of CO. The use of closed circuit video for CO can also be considered. Still another approach would be the use of a med-psych unit where clinical care of the patient is shared by both psychiatry and medical/surgical departments to achieve cost savings. Prescreening patients who are likely to develop the need for CO may allow for prevention and early intervention techniques, which may also be helpful in reducing the need for CO.
We expect that with increasing cost concerns in health care today, all these possibilities will be explored in the near future.
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ACKNOWLEDGMENTS
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This study was presented in part at Poster Session, American Psychiatric Association, New York, May 8, 1996.
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REFERENCES
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Moore P, Berman K, Knight M, et al: Constant observation: implications for nursing practice. Journal of Psychosocial Nursing 1995; 33:46–50
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Goldberg RJ: Use of constant observation with potentially suicidal patients in general hospitals. Hospital and Community Psychiatry 1987; 38:303–305[Free Full Text]
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Lamdan RM, Ramchandani D, Schindler BA: Use of constant observation in an urban teaching hospital: implications for improved care. Psychosomatics 1995; 36:189–190
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Lamdan RM, Ramchandani D, O'Dowd MA, et al: A comparison study of constant observation in three urban centers. Psychosomatics 1995; 36:188–189
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O'Dowd MA, Freedman JB, Bernstein G, et al: Reduction in use of constant observation in the general hospital and cost savings as a result of quality improvement monitoring. Psychosomatics 1995; 36:189-190
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Goldberg RJ: The use of constant observation in general hospitals. Intl J Psychiatry Med 1989; 19:193–201[Medline]
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Talley S, Davis DS, Goicoechea N, et al: Effect of psychiatric liaison nurse specialist consultation on the care of medical-surgical patients with sitters. Archives of Psychiatric Nursing 1990; IV:114–123
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Cohen MAA, Alfonso CA, Duffy DL, et al: For their own good: bioethical issues in mechanical restraint use in general care. Psychosomatics 1995; 36:190
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ABSTRACT
INTRODUCTION
