UM Guidelines
Behavioral and/or Medical Observation Level of Care

Inpatient and Surgical Care (ISC)

BCBST modification effective June 18, 2014*


Observation Care Admission Criteria

  • Admission is indicated for 1 or more of the following: [A][B][C][D][E][F][G][H][I]
    • Recent significant or substantial increase in signs or symptoms of substance abuse, dependence, or withdrawal
    • Recent significant problem with or substantial deterioration of self-care or role functioning due to substance abuse, dependence, or withdrawal
    • Thoughts (but no plan) of suicide or serious self-harm
    • Thoughts (but no plan) of homicide or seriously harming another

Observation Care Discharge Criteria

  • Discharge to non-acute-care follow-up is appropriate for a patient with ALL of the following: [I]
    • Preparation of patient and supports for transition to maintenance outpatient care, including ALL of the following:
      • Assure sufficient knowledge of ALL of the following:
        • Patient's illness
        • Medication
        • Risk factors for relapse
        • Warning signs of relapse
      • Review crisis plan with patient and supports
      • Plan for periodic urine drug screening if appropriate
    • Appointments for maintenance outpatient care


  1. Academy of Psychosomatic Medicine. (1998, August). The academy of psychosomatic medicine practice guidelines for psychiatric consultation in the general medical setting. Retrieved January 24, 2012 from
  2. American Academy of Pediatrics. (2011). Technical report – pediatric and adolescent mental health emergencies in the emergency medical servicessystem. Retrieved January 24, 2012 from
  3. American Academy of Pediatrics. (2000, April). Suicide and suicide attempts in adolescents. Retrieved January 24, 2012 from;105/4/871.
  4. American College of Emergency Physicians. (2006, January). Clinical Policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Retrieved January 24, 2012 from
  5. BlueCross BlueShield of Tennessee network physicians April - June 2014.
  6. U.S. Preventative Services Task Force. (2004, May) Screening for suicide risk: a systematic evidence. Retrieved January 24, 2012 from
  7. Department of Veterans Affairs. Department of Defense. (2013, June). Assessment and management of risk for suicide working group: VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Retrieved April 2, 2014 from


[A] Medical and psychiatric reasons for agitation (e.g., psychosis, intoxication, withdrawal, dementia, delirium) should be evaluated and should delineate possible etiologies (e.g., toxic metabolic disturbances cardiopulmonary, endocrine, neurologic disorders (1)
[B] Suicide risk factors for all age groups are similar but particular clinical risk factors are notable for younger populations. The strongest risk factors for suicide attempts in adults are mood disorders and co-morbid substance use disorders. The strongest risk factors for attempted suicide in youth include mood disorders and co-morbid substance use disorders, but they also involve aggressive or disruptive behaviors and history of physical and sexual abuse. (5)
[C] Adolescents at higher risk commonly have a history of depression, a previous suicide attempt, a family history of psychiatric disorders (especially depression and suicidal behavior), family disruption and certain chronic or debilitating physical disorders or psychiatric illness. Living out of the home and psychosocial problems and stresses (e.g., conflicts with parents, breakup of a relationship) are commonly reported or observed in young people who attempt suicide. (3)
[D] Alcohol use and alcoholism indicate high risk for suicide. Alcohol use has been associated with 50% of suicides (3)
[E] Suicidal thoughts or comments should never be dismissed as unimportant. Serious depression in adolescents may manifest in several ways. For some adolescents, symptoms may be similar to those in adults, with signs such as depressed mood almost every day, crying spells or inability to cry, discouragement, irritability, a sense of emptiness and meaninglessness, negative expectations of self and the environment, low self-esteem, isolation, a feeling of helplessness, markedly diminished interest or pleasure in most activities, significant weight loss or weight gain, insomnia or hypersomnia, fatigue or loss of energy and inability to think or concentrate.
[F] It is more common for an adolescent with serious depression to exhibit psychosomatic symptoms or behavioral problems. They may seek care for recurrent or persistent complaints, such as as abdominal pain, chest pain, headache, lethargy, weight loss, dizziness, syncope or other nonspecific symptoms
[G] Adolescents may manifest behavioral problems such as truancy, deterioration in academic performance, running away from home, defiance of authorities, self-destructive behavior, vandalism, alcohol and other drug abuse, sexual acting out and delinquency.
[H] Suicidal or homicidal ideation related to any patient should be evaluated. Traditionally, clinicians view severity of suicide risk along a continuum, ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with a plan (high severity), the latter of which is significant risk factor for suicide attempt. (5)
[I] Specific outpatient plans are needed because compliance with outpatient therapy is often poor. Most adolescents examined in emergency rooms and referred to outpatient facilities fail to keep their appointments. This is especially true when the appointment is made with someone other than the family pediatrician or the person who performed the initial assessment. Continuity of care is of paramount importance. Pediatricians can enhance continuity and compliance by maintaining contact with suicidal adolescents even after referrals are made. All firearms should be removed from the home because adolescents may still find access to locked guns stored in the home.