Mental health patient

As part of an overall strategy to promote personal and environmental safety for patients admitted to psychiatric settings in Fraser Health, best practice guidelines and a regional policy for levels of observation are in place across Fraser Health Mental Health and Substance Use.

Levels of observation (LOO) refer to the intensity and frequency of nurse monitoring, and are based on a patient’s mental health status and risk to self or others. The original Fraser Health policy was released in 2009 to address the discrepancies and lack of consistency that were identified across eight psychiatric units in twelve Fraser Health hospitals.

“Patients who suffer from depression, suicidality, psychosis, disorganized behaviour, confusion, anxiety, or inability to cope or function on their own, are observed and monitored based on LOO assessments,” says Denyse Houde, Director, Mental Health and Substance Use. “Before we implemented the regional policy and guidelines, each hospital in Fraser Health had a slightly different system of levels and different descriptions of what they meant – it was very confusing for staff, patients, and families. We could also see when we looked at our BC PSLS data that this was a high-priority that we needed to address to enhance patient safety.”

In 2014, under Denyse’s leadership, a diverse group of stakeholders participated in broad consultation with Clinical Nurse Educators, Patient Care Coordinators, managers, directors, and physicians in Mental Health, Maternal Infant Child Youth, and Emergency Departments to develop a revised policy that would apply to acute, tertiary and adolescent units, and cover five risk areas: cognition, mental status and vulnerability, self-harm, eloping, and harm to others.

“How much freedom someone has while they’re in hospital should be based on individual risk factors and recovery goals. Today, there’s more emphasis on helping people transition back to the community so they can become fully functioning citizens in their community. Having standard guidelines for levels of observation is really important for staff in mental health settings.”

So, what do the levels mean…really?

  • Constant monitoring: The most restrictive – a staff person must be sitting with the patient constantly (e.g. patients who are extremely suicidal or high-risk to harm themselves or others).
  • Level 1: Patient must be observed every 15 minutes; patient must be in hospital pajamas and can wander on his own, but cannot leave the unit.
  • Level 2: Patient must be observed every 30 minutes; patient can wear his own clothes and leave the unit with a responsible adult.
  • Level 3: The least restrictive – patient can wear his own clothes, leave the unit, and account for his whereabouts, but the nurse needs to know where the patient is every hour for those admitted to an acute care unit, or per the resident’s care plan for those in a tertiary mental health facility.

Denyse explains that the decision of what level of observation a patient needs is a joint decision between the nurse and physician – a decrease in monitoring frequency is based on the progress of the patient, their mental state, and recovery from their illness.

“It takes a considerable amount of teamwork to care for patients in need of mental health support, but it’s part of the services we provide. Patients are with us in acute care an average of 14 days – they arrive quite sick, stabilize, and recover well enough to be cared for in the community.”

Adopting a common policy and best practice guidelines for levels of observation provide a significant opportunity to enhance mental health services in BC.

Denyse Houde would like to acknowledge the Mental Health and Substance Use team from across Fraser Health for contributing their time and expertise to this important patient safety initiative.

Denyse Houde is Director, Mental Health and Substance Use for Burnaby, New Westminster, Tri-Cities, Maple Ridge, Developmental Disabilities Mental Health Services, and Older Adults Community Mental Health Services. She’s worked in the mental health sector for over 40 years. You can reach Denyse by email at

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