Supervision Levels on the PBMU

When kids are in crisis, they often engage in behaviors that are unsafe. We supervise patients closely on the PBMU for this reason. Your child will be assessed by their clinical team and assigned supervision levels that will keep them safe during their stay on the PBMU. Supervision levels include:

• Suicide Level (1 to 3)
• Run Level (1 to 3)
• Aggression Level (0 to 3)
• Problematic Sexualized Behavior (PSB) Level (0 to 3)

Based on their supervision level, a staff member will frequently check on your child or constantly supervise them. Patients are never allowed to be alone together without staff supervision. This is true for all patients.

Suicide Level (SL) is a classification system used to assess and monitor a patient’s risk of self-harm or suicide. The level is assigned based on our assessment of your child’s risk of danger, and may be classified as low, moderate, or high risk.

SL1 is considered high risk and is the most restrictive level. The patient, their room, and belongings will be regularly searched, and they will be supervised by a staff member (1:1 sitter) always, including in the bathroom. Their head and neck must always be visible to staff.

SL2 is considered moderate risk. The patient, their room and belongings will be regularly searched, and they will be within line of sight of staff while awake. Patients will be checked on every 15 minutes while asleep and their door will remain at least partially open, with their head and neck visible to staff. A staff will stand outside of their door while they use the bathroom and do a verbal check-in every 2 minutes. If the patient has a medical device (such as a nasogastric tube or IV), a staff will monitor their bathroom use with the door slightly open.

SL3 is considered low risk. Patients assigned this level will be checked on every 15 minutes if left alone in their room. A staff will stand outside of the door while they use the bathroom and do a verbal check-in every 5 minutes.

Run level (RL) is assigned to patients who are at risk of trying to run away from the hospital.

RL1 is considered high risk and is the most restrictive level. RL1 is assigned to patients that are attempting to run away from the unit or have run in the last 24 hours. The patient will always be within line of sight of a staff member (1:1 sitter) while awake. The patient’s shoes will be stored elsewhere, and they will not be allowed to leave the unit.

RL2 is considered moderate risk and is assigned to patients who are having thoughts of running away. They are required to be within line of sight of staff while awake and will be checked on every 15 minutes at night.

RL3 is considered low risk. Patients will be checked on every 15 minutes if left alone in their room.

Aggression level (AL) is assigned to patients with a history of aggression or property destruction in the community or in the hospital. Every patient is assigned an AL when they are admitted to the PBMU. If your child does not have a history of aggressive behavior, they will be assigned an AL “no-level.”

AL1 is assigned when a patient has been aggressive in the last 24 hours. This level communicates to staff that they need to maintain a minimum of 10 feet of body space from the patient to prevent harm and to help recognize when they become escalated.

AL2 is assigned when a patient has been aggressive in the hospital in the past. They will remain at this level for the entire stay on the PBMU unless they display aggressive behavior during their stay.

AL3 is assigned when a patient has a history of physical aggression in the community but has not exhibited these behaviors in the hospital or on the PBMU.

A PSB level is assigned to patients with a history of developmentally inappropriate sexualized behaviors that involve sexual body parts and can be potentially harmful to the youth or other individuals impacted by the behavior. If the child or youth does not have a history of problematic sexualized behaviors, they will be assigned a PSB “no-level.”

• If patients have the developmental and cognitive abilities to suggest ability to understand the impact of their behavior on others, a level 1 is described as a patient with recent history of inappropriate sexual acts with another person this admission and/or within the past 12 months, or patient has engaged in sexual touching of oneself in public or visible space within the past 24 hours.
• If patients do not have the cognitive abilities to suggest ability to understand the impact of their behavior, a level 1 is described as frequent inappropriate touching of others' private areas that is difficult to redirect and appears to be combined with intent to target specific areas of others, or frequent masturbation that is difficult to redirect and the patient is actively positioning themselves in close proximity or in view of others after attempts to redirect patient to private area.

Supervision for this level entails continuous, unobstructed visual and auditory supervision at all times. Staff will stay 5 feet away from patient if PSB has been directed at staff, and staff to supervise all interactions between the patient and peers.

The patient is expected to maintain a "personal space bubble" of at least one arm's length between themselves and others. The staff must position themselves in such a way that they can visually ensure the patient does not have physical contact with other patients or staff. During morning and evening routines and other self-care activities, staff will supervise closely to ensure the patient maintains privacy.

More intensive therapeutic interventions are provided as well and additional precautions may be enacted to ensure safety.

• If patients have the developmental and cognitive abilities to suggest ability to understand the impact of their behavior on others, moderate PSBs or a PSB Level 2 is described as sexual acts in public or visible spaces and/or intentional displays or demonstrations of sexual acts, or intentional touching of others' private parts, or patient has not had a PSB event in the last 24 hours but was previously on Level 1.
• If patients do not have the cognitive abilities to suggest ability to understand the impact of their behavior, a level 2 is described as occasional sexualized behaviors that can be redirected most of the time, often don't appear targeted to specific gendered staff or to specific areas of body of all staff when upset without discrimination or targeting an area, occasional inappropriate touching that does appear targeted but is intermixed with random grabbing, or public masturbation appears mostly self-stimulatory rather than active attempt to get attention and often can be redirected to private space.

Supervision for this level requires constant visual and auditory supervision at all times. Staff will stay 5 feet away from patient if PSB has been directed at staff, and staff to supervise all interactions between the patient and peers.

The patient is expected to maintain a "personal space bubble" of at least one arm's length between themselves and others. The staff must position themselves in such a way that they can visually ensure the patient does not have physical contact with other patients or staff. During morning and evening routines and other self-care activities, staff will supervise closely to ensure the patient maintains privacy.

• If patients have the developmental and cognitive abilities to suggest ability to understand the impact of their behavior on others, at-risk or PSB level 3 is described as repeated discussion or simulating sexual behaviors or verbal sexual harassment of others or unwanted sexual comments towards others that are difficult to redirect, despite staff coaching and limit-setting at Children's.
• If patients do not have the cognitive abilities to suggest ability to understand the impact of their behavior, a level 3 is described as infrequent behavior that is typically redirectable and/or appears to be random grabbing of others when upset, infrequent targeting of specific gendered staff or to specific areas of body, public masturbation appears self-stimulatory in function and is redirectable to private spaces.

Supervision for this level requires constant visual and auditory supervision at all times, staff to stay 5 feet away from patient if PSB has been directed at staff,

Sometimes we may need to search your child, their room, and their belongings to ensure that they have no items that could hurt themselves or others. Any belongings not allowed on the PBMU are stored off unit in the lockers in family reception and we encourage you to take them home.

This varies from patient to patient, and it depends on your child’s willingness and actions to be safe towards themselves and others. Suicide and Run Levels are assessed by clinicians every day. Aggression Level can be changed by the nurse or the coach anytime following an episode of aggressive behaviors.

While at the hospital, PBMU staff members are solely responsible for supervising patients.

We will check on your child every 15 minutes with a flashlight. This is a safety precaution for all patients, to ensure that they do not harm themselves at night. If your child is on SL1, then a 1:1 sitter will be by their door at night. If your child is on SL1 or SL2, their head and neck will need to be visible to staff. Their door will be opened at night as well, to enhance supervision. If a parent or guardian stays the night, then the door may be closed, and we will do checks through the window.

For information about what items are allowed on the PBMU, see our handout “Patient and Visitor Information for the PBMU” at seattlechildrens.org/pdf/PE2018.pdf.