E is for...

My 'to-do' list is getting a bit ridiculous. I've managed to knock off 'get car insurance' and 'pay gas bill' and now here's 'the letter E'. Unfortunately everything else seems to get neglected in favour of 'spend untold hours looking at random crap online'. Must start prioritising...sigh.

Engagement and observation

Back in the good old days (i.e. about six months ago), we had obs. These are not to be confused with physical obs, such as proper nurses might carry out to determine BP/heart rate/respiration etc. Obs in mental health consist of (a) ascertaining that the patient is breathing and (b) determining that the patient is not doing anything they shouldn’t be engaged in meaningful activity. Basically, whichever member of staff was failing to look sufficiently busy would get handed the obs board, which had charts for each patient detailing how often you had to check on them and a little space to sign to say they were breathing when you did. Sometimes you would write a little description of what they were doing to enable you to write up your notes later without having to think too hard, e.g. 5pm; sleeping, 5.30pm; sleeping, 6pm; etc. Patients were checked on a minimum of half-hourly, with many of them being on 5 or 10 minute obs. If you have a 20 bed ward, with 5 patients on 5 mins, another 5 on 10 mins and the rest on half hourly’s, you are basically spending your entire time looking for patients. Once found, the patient will sometimes helpfully say something like ‘what?’ at which you grunt ‘obs’ and then they grunt back. Repeat x 288 times per 24 hours.

If you are doing the obs on a night shift, you must take a torch and shine it directly into the patients’ eyes until they start swearing at you, hence proving they are alive.

One of the absolute best ways to get yourself fired is to say you’ve done the obs when you haven’t; if the obs are signed for and your patient turns out to have been (a) dead for several hours or (b) absconded then you are going to get found out. This in no way stops people from leaving the obs all night then signing 12 hours worth after having a quick check about at 7am.

Also much fun are constant or special obs, which basically do what they say on the tin; the patient gets the pleasure of a staff members’ company constantly. Generally a pain in the arse for the patient, who would otherwise be able to cut up/ligature/break things in peace. Although sometimes they still can, when the observer falls asleep/gets engrossed in their magazine.

Anyway; now we don’t have observation. We have engagement. No more ticky board, no more peering at patients through their bedroom window (that is, observation window, not actual window. That would be creepy (er)). Now, we – shock, horror - have to talk to them. Or engage. Therapeutically, ideally. Constant obs still exist, but there is more emphasis on using them…therapeutically.

Of course, it’s still handy to check that your patients are still there and still alive. So now you have fire checks (as in "crap, fire! Where are the patients?! Consult the fire check board!") that are carried out once an hour, and involve peering at the patient through the obs window…and ticking it off on a fire board.

It’s a completely different system, though. Honest.

Escort

No, not a hooker. It’s something a detained patient usually has to have when they leave the building. Escort level is decided by the MDT and documented on a form called a section 17. Some patients eventually get unescorted leave, but most need one or two staff escorts. Sometimes, they need even more; one patient who wouldn’t have any leave otherwise needs to attend another hospital for appointments, and he is escorted by three male staff due to his very unsettled mental state and scary scary strength. Escort levels are also often increased when patients are taken to court for trial or sentencing, in case they decide to make a last ditch break for freedom/notoriety. It’s not unknown for them to go with a four-man response team and a driver; the court personnel are not impressed if you can’t handle your own patient.

There is a kind of progression with escorts and leaves. Patients who are a risk (either of violence, absconscion or just a risk to women in general) are usually sent everywhere with two males, possibly progressing to a male and female if they behave themselves. This is important; the chances of there being three males (two to go out, leaving one as required on the ward) on a ward at any time are incredibly slim, so you are scuppered for leave if that’s your escort level. However, male/female leaves are much easier to facilitate. After this, you might progress to one male, then one staff of any gender. Sometimes, they throw in a requirement for one of the staff to be qualified, particularly if the patient has physical health needs, e.g. a patient who has epilepsy might be escorted by a qualified nurse so diazepam can be administered if they have a seizure whilst out.

Electronic records

Basically, all patients’ notes should now be on computer in our trust. This has good and bad points. Staff can now get instant access to any patients notes as soon as they’re admitted, without waiting for them to be couriered over, which is good. However, it now takes twice as long to do your notes because (a) this is the NHS and there aren’t enough computers and (b) there’s always someone hogging them who thinks a mouse is a small furry creature that eats cheese and takes an age to type anything. Good points for patients are that staff have access to their history; they should enable better care provision and patients shouldn’t have to repeat themselves too much. Bad points are that staff have access to their history and so they can’t make shit up (e.g. “at my last hospital I had unescorted leave and used to get temazepam every night.” Oh yeah? Computer says no.)

The ‘paperless office’ idea is just bollocks, though, frankly. The Mental Health Act has so much paperwork that needs an actual hard copy keeping that we still need folders for it all. Add to this letters, scan/test results, signed copies of care plans and s17 forms, etc and patients files aren’t actually much thinner than they used to be. Still, it’s handy for sharing information between professionals, which is always something that benefits from improvement.

Mr Door is still on nights, but so far my hormones remain in check...must be saving it up for our first day off together...