Direct observation nursing: adverse patient behaviors and functional outcomes

The authors describe a study at a rehabilitation facility that was designed to enhance understanding of which patient behaviors and cognitive problems were predictive of the need for 1:1 or 1:2 full-time staff direct observation (DO). The costs associated with such 1:1 monitoring are substantial, having been estimated at $6,000 for a typical 3 week LOS, or $78,000 per year for each patient so monitored. Traumatic brain injury, stroke, and poor mental status had previously been associated with impulsivity, patient falls, and other adverse events, and thus such patients were frequently subjected to medical immobilization (restraints). Such immobilization has serious negative consequences for rehabilitation patients, so nursing assistants would frequently be assigned to stay with, observe, and redirect such patients around the clock. This study, which was designed to ascertain the significant differences between the patients who were placed on physician-ordered direct observation status when compared with those not needing DO, encompassed all patients admitted to a 36-bed rehabilitation unit between October 1995 and April 1996.