Model for Minimum Staffing Patterns for Hospitals Providing Acute Inpatient Treatment for Children and Adolescents with Psychiatric Illnesses

Approved by Council, December 1990
To be reviewed

The AACAP makes the following statement to help physicians, patients, families, treatment institutions, planners and fiscal intermediaries, understand the therapeutic role of different disciplines and complementary relations among the staff in acute psychiatric hospital treatment programs.

Acute psychiatric treatment for children and adolescents requires the use of intensive and complex resources. We have the responsibility to our patients to ensure the quality and effectiveness of this treatment. The standards are designed to be a minimum in terms of both staffing structure and numbers of staff.

Various factors of patient selection and program objectives require increased staffing. Training ad research programs are examples. It should be noted that the requirements for psychiatrists are for diagnostic and psychiatric management only. Individual and family psychiatrists are for diagnostic and psychiatric management only. Individual and family psychotherapy, done by the attending psychiatrists, are considered to require additional time commitment.

The availability of a sufficient number of high quality staff is an absolute necessity to qualify a program to provide acute psychiatric hospital treatment. While there are many appropriate variations in programs and staffing, it is important that a model be established for minimum patterns of staffing.

Principles of Staffing

Team and Authority

• Staffing for an inpatient program depends on the mission of the program, severity of the illness, the degree of impairment, and the complexity of the situation. Program focus and physical design interact with program staffing. The responsibility for balancing these interactive factors rests with the program administrative team.
• At a minimum, the program administrative team with the responsibility for the entire treatment program must include a qualified child and adolescent psychiatrist, and a qualified psychiatric nurse.
• The program must be consistent with a hospital administration as conveyed by an appropriate representative of the administration.
• The program is developed by the administrative team and approved by the medical staff and hospital administration.
• Staffing and program organization and other ancillary services such as psychology, education, social work, pediatric medicine and occupational therapy, need to be professionals in those disciplines.
• It is the responsibility of the child and adolescent psychiatrists to maintain the integrity of professional judgements and behaviors independent of influence of the source of compensation (Principles of Practice of the American Academy of Child and Adolescent Psychiatry).
• The staff of various disciplines must meet the facility's specific written criteria for credentials and clinical privileges.
• The administrative team has the responsibility for a program of continuous quality improvement.

Model Staffing Patterns

Attending Psychiatrist

Credentials:

• A licensed physician who has completed an approved program in child and adolescent psychiatry. For patients 14 years of age and older, a general psychiatrist with documented specialized training, supervised experience and demonstrated competence in work with adolescents and their families, may be considered a qualified attending psychiatrist. Continuing medical education is essential.

Ratio:

• There will be a sufficient number of qualified attending psychiatrists to prove the basic functions of evaluations, admissions, diagnoses, prescribing of treatment, and discharging patients, and to supervise the clinical treatment team.

Basic Functions:

• At a minimum, functions must be performed as outlined at the frequency prescribed in the Documentation of Medical Necessity of Child and Adolescent Psychiatric Treatment: Guidelines for Use in Managed Care, Third-Party Coverage and Peer Review (AACAP, October 1990).
• At a minimum, the attending psychiatrists must document psychiatric management with progress notes every three days.
• At a minimum and not including individual, group or family psychotherapy, the attending psychiatrist must spend sufficient hours per week in the patient's psychiatric management and treatment to properly provide for admission, discharge, treatment team, family and staff conferences, ordering and supervising treatment, communication with parents, ongoing psychiatric assessment, and documentation. Week-by-week the time will increase or decrease according to the number of admissions, initial evaluations, basic evaluations or comprehensive examinations. Ordinarily it would be expected that these responsibilities would require no less than 2.5 hours per week.
• This minimum number of hours will need to be increased to account for additional medical factors, training and research.

Social Worker or Other Professional Responsible for Family Contacts

Credentials:

• Mental health professional who has a master's degree in social work or related field. A mental health professional with a bachelor's degree supervised by a master's-level social worker is also considered qualified. Continuing education and in-service training is essential.
• The staff must include at least one social worker who has experience in child and adolescent inpatient treatment.

Ratio:

• The number of social workers, or another discipline charged with family assessment and family contacts per week, should be at least one-full time equivalent to 10 patients. The number of staff may need to increase if extensive supplementary functions are included.

Basic Functions:

• A basic family assessment within three days of admission.
• A comprehensive social assessment within 14 days.
• A weekly family and/or agency contact and progress note documenting the staff's active involvement in the implementation of treatment plan goals.
• Coordination of discharge planning.
• Participation in at least one treatment team meeting a week.

Supplemental Functions:

• Family therapy and group therapy.
• Family, parent and patient education.

Psychiatric Nurses

Credentials:

• Registered nurse with appropriate state license supervised by a qualified psychiatric nurse, i.e., a bachelor's - or - master's - level nurse with experience in child and adolescent psychiatric inpatient nursing. Continuing education and in-service training is essential.

Ratio:

• A program requires one psychiatric nurse per shift for each 12 patients. An additional group of 10 patients. This number also needs to be adjusted according to the acuity, medical treatment, medication and extensive functions.

Basic Functions:

• Initial assessment of patient's nursing needs and documentation of nursing needs and documentation of nursing components of an initial treatment plan.
• A daily assessment and documentation of the patient, the patient's treatment and response to treatment.
• Supervision of assessments done by psychiatric technicians and countersigning of their documentation.
• Provision and documentation of medical treatment and medication as needed.
• Development of the appropriate psychiatric nursing components of the treatment plan.
• Implementation of the interventions in the treatment plan that are designated for psychiatric nurses.
• Implement milieu management.
• Health teaching.

Supplemental Functions:

• Primary nursing.
• Individual milieu interventions (individualized behavioral management).
• Group therapy.
• Specialized treatment for high-acuity patients, e.g., suicidal, assaultive, severely disorganized, elopement risk, acute medical distress (unstable diabetes or asthma).

Child and Adolescent Psychiatric Technician

Also known as a child care worker, mental health specialist, child care specialist, mental health associate.

Credentials:

• Educational credentials vary. Extensive pre-service and ongoing in service training is essential. The assignment of clinical responsibilities must consider careful evaluation of the combination of training, experience and personal characteristics such as maturity, empathy and objectivity.

Ratio:

• This is determined by considering general/generic supervision in the treatment milieu. (See final section on generic staffing).

Basic Functions:

• Establish and maintain behavioral supervision of children.
• Maintain implementation of safe, therapeutic milieu.
• Implement specific assigned aspects of the treatment plan.
• Observe, assess, and document the patient's status.
• Assist in planning and supervision of leisure activities.
• Participate in the observation and documentation of the patient's treatment.

Functions Shared By Nurse and Psychiatric Technician:

Certain functions are done by the nurse and/or psychiatric technician.

• Observation, assessment and documentation of the patient's condition on each shift. Where the observation and documentation is done by the psychiatric technician, the note is countersigned by the nurse responsible for the patient on that shift.
• Supervision of the patients and maintaining the safety and therapeutic quality of the milieu. (Both have responsibility for this).
• Assisting, as necessary, the children in their daily activities, including leisure activities, transportation, activities related to personal hygiene.

Shared Supplemental Functions:

• Individual patient discussions.
• Assisting in group therapy.
• Leading various therapeutic activities.
• Mental health education with parents and patients.
• Behavioral management classes.

Ratio for General Staffing/Generic Supervision

In these parameters, units are considered to be from 9 to 24 child or adolescent patients.

When the children are occupied primarily in the program unit during the day and evening, the minimum number is three staff to nine patients, proceedings in a three-to-one ratio.

With this staffing pattern staff can accomplish their basic responsibilities. Supplemental complex or intensive interventions will require additional staffing.

When 18 or fewer patients located on one program unit are asleep, the minimum number of staff is two. With over 18 patients asleep, the minimum level is three staff. In either case, there must be an additional person available to help with sudden change in acuity. This should not reduce the basic staffing on another unit.

At night, when the patients are asleep there should be one nurse to 50 patients per shift with an on-call nurse who can come on site.

Ratios are dependent on such variables as the number of children in the living unit, the physical configuration of the facilities, the acuity including developmental levels, the frequency of turnover and length of stay, and the availability of off-unit activities, e.g., specialized recreational activities.

Other Staffing Requirements:

Children and adolescents treated in acute psychiatric hospital programs require additional special staff. Due to the variability in program structure and patient characteristics, the number of staff is not specified. Staff must be available to meet the following program and supervisory functions:

Psychological Services:

Sufficient licensed psychologist to provide relevant and appropriate psychological testing. Cognitive evaluation is particularly important. In some programs, psychologists may be involved in treatment plan development, individual, group and family psychotherapy and other types of therapeutic intervention.

Educational Services:

Educators to assess academic achievement and needs, maintain educational progress and accomplish transfer into an appropriate post-hospital educational program. Patients need an educational program 5 days per week under the direction of a special educator.

Therapeutic Recreation Services:

A therapeutic recreation program provided 7 days per week under the direction of a certified recreation therapist.

Relevant and Appropriate Consultation in the Following Areas:

• Medical specialties
• Speech and hearing evaluation
• Occupational therapy

The Council of the American Academy of Child and Adolescent Psychiatry accepted these Guidelines for Minimum Staffing in 1990. The Academy has led in the development of policies, position statements and review standards. These labor-intensive efforts are fueled by the Academy's pledge to assure our patients and their families an adequate quality of medically necessary psychiatric treatment.