Spotlight

1. Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering

2. Source and Credits • This presentation is based on the June 2014AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthcare Security Consultants, Inc. • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Define patient wandering • Relate common risks associated with patient wandering • Identify measures for reducing risks related to patient wandering • Describe an off unit policy and "hall pass" system used for patients allowed to leave their unit

4. Case: Wandering Off the Floors A 74-year-old man with a history of congestive heart failure (CHF) secondary to alcoholic dilated cardiomyopathy was admitted for management of alcohol withdrawal. After several days of aggressive treatment, he was improving and being managed on the medical-surgical floor. Initially the patient had been confused in the setting of alcohol withdrawal, but by hospital day 6 his mental status was clear and he was nearing discharge. On the morning of hospital day 6, the patient was feeling ʺcooped upʺ and ʺneeded a change of sceneryʺ and a cigarette. He wandered off the floor without informing his bedside nurse or any other health care provider, and he left the hospital grounds.

5. Case: Wandering Off the Floors (2) When the patient returned to his room an hour later, he complained of new right arm pain. He was examined and the physician found evidence of diffuse bruising of his right arm. A subsequent radiograph revealed a fractured humerus (bone of the upper arm). After the radiography results were revealed to the patient, he acknowledged that he had fallen while he was off the floor. He was treated for his fracture, and the institution began to consider a policy regarding patients leaving the floor while hospitalized.

6. Background • Patient wandering, patient elopement, and patients leaving health care facilities (HCFs) against medical advice are closely related and challenging incidents • According to the Veterans Health Administration (VHA) Directive 2010-052, a wandering patient is: • "An at-risk patient who has shown a propensity to stray beyond the view or control of employees, thereby requiring a high degree of monitoring and protection to ensure the patient's safety"

7. Background (2) Others have defined wandering as referring to a patient who ʺstrays beyond the view or control of staff without the intent of leavingʺ Elopement, on the other hand, is defined as ʺa patient that is aware that he/she is not permitted to leave, but does so with intentʺ The patient in this case appears to have been wandering with the intention of returning

8. Frequency & Motivation There are few data on the prevalence of patient wandering in health care facilities Discharges against medical advice comprise up to 6% of discharges of general medicine patients in acute care—it seems likely that wandering is at least as common

9. Frequency & Motivation (2) • From the literature, it is unclear what motivates patients to wander while in an acute care hospital • From experience, common reasons patients wander include: • Claustrophobia; need to ʺget some fresh airʺ • To smoke a cigarette • To use other illicit substances • To manage important life events (e.g., pay rent, attend important meetings, etc.)

10. Harm Related to Wandering • Patient wandering can be extremely dangerous • Patients who wander beyond their assigned ward or unit without assistance place themselves at risk for complications that include: • Slips and falls (as in this case) • Deterioration of a medical condition • Dislodgement of medical devices, intravenous catheters, or oxygen • Acquisition or spread of infection • Death (in extreme cases)

11. Harm Related to Wandering (2) Fatalities associated with wandering are rare but occasionally in the news Death often results from exposure to the elements (too hot or too cold) or issues related to the illness that brought the patient to the HCF

12. Legal Liability Versus Patients' Rights • Hospitals may be legally responsible if patients are harmed while wandering • Legal precedents state that health care professionals and institutions have a duty to adequately supervise patients and to maintain reasonably safe conditions in the hospital • If a patient is competent to make decisions and wanders with the intent to return, ascertaining the hospital's responsibility is more complicated

13. Legal Liability Versus Patients' Rights (2) • Patients who are not on legal or medical holds generally have the right to leave the unit • Hospitals are not prisons and should not be viewed as such • Therefore, health care facilities may implement reasonable rules to allow patients to safely leave units, balancing patient safety and legal risk with patient rights and autonomy

14. Reducing the Risk • Options for reducing the risk of patient wandering include: • Patient assessments • Physical security • Policies pertaining to patients who are off unit • Response plans for recovering wandering patients

15. Patient Assessments • Assessments are critical in determining the risk of wandering incidents • Assessments should be conducted on a regular basis to evaluate and monitor patient cognitive status • According to the VHA Directive, patients are at risk if they: • Are legally committed • Have a court-appointed legal guardian • Are considered dangerous • Are disabled due to a mental disorder • Lack cognitive ability to make appropriate decisions • Have physical limitations that raise their risk

16. Physical Security HCFs may choose to implement physical security measures that reduce the potential for elopement and reduce risk to patients These might include locked units, radio frequency identification alarms (similar to infant tagging alarms systems), motion sensor alarms, and cameras A more complete discussion of patient assessments and physical security measures can be found in a previous AHRQ WebM&M commentary on elopement

17. Safe and Reasonable Rules There are a number of creative and rigorous steps that have been taken by HCFs to balance safety and patient autonomy HCFs may require patients to inform staff when they are leaving the unit Some HCFs issue a specially colored ʺPatient Off Unitʺ hall pass to patients authorized to leave the unit

18. ʺPatient Off Unitʺ Hall Pass A unit log is maintained with time the patient obtained pass and time of return to the unit These ʺPatient Off Unitʺ passes have the patient's floor and time to return on the pass The passes can be easily identified by other staff members of the HCF

19. Safe and Reasonable Rules (2) • Other institutions establish clear policies that limit the time a patient may be off a unit without observation • One hospital allows patients to be missing from their room or hospital ward for one hour • After one hour, they are officially discharged from the hospital • Policy is clearly communicated to patients at time of admission and strictly enforced

20. Challenges of Restrictive Policies • There are some practical challenges to a restrictive policy including: • Who will issue the pass? Many nursing units do not have adequate staffing all day/night • How long should patients be allowed to leave the floor? • What happens if patients do not comply with the policies? HCFs should consider discharging patients who do not comply

21. Response Procedures Even if preventive measures are implemented, patients may still wander from hospital units HCFs should create specific procedures for responding to patient wandering The VHA Directive provides an excellent procedure for searching patients, if necessary

22. This Case It does not seem that the hospital in this case had a clear policy to handle this patient's needs or desires to leave Apolicy utilizing a ʺhall passʺ structure may have prevented the harm

23. Take-Home Points Patient wandering refers to a patient who goes beyond the view or control of staff without intent of leaving the facility Patients may choose to wander for many reasons, ranging from a sense of claustrophobia to a desire to smoke or use illegal drugs Patients who wander may experience harm (including death) due to a weakened condition or underlying disease Hospitals may be legally responsible for wandering patients who are harmed Specific policies and procedures, such as establishing a ʺPatient Off Unitʺ hall pass system, may be effective at ensuring patient safety while respecting patients' rights