When patients wander

Hospitals need detailed policies on patient elopement to avoid this sentinel event and protocols for responding when it does happen.

One very cold February morning in Iowa, a young man was admitted to the ED of a community hospital for a behavioral health evaluation. After an hour or so, he asked to leave, but before he could be discharged, he walked outside, breaking into a run and disappearing into the distance when a security guard tried to detain him. Seventeen days later, he was found dead from exposure.

Photo by Thinkstock
Photo by Thinkstock.

“It was a sentinel event that caused us to review our policies and procedures regarding elopement,” said James Lehman, MD, FACP, vice president of medical affairs at Wheaton Franciscan Healthcare, a nonprofit health care system with three acute care hospitals in Iowa. “Everyone on our staff is acutely aware of the need to prevent at-risk patients from leaving without supervision.”

Most hospitals have policies and procedures around patient elopement and wandering, which The Joint Commission considers sentinel events. However, it's easy for the issue to fall off the radar in a hectic acute care hospital where clinicians have many competing urgent priorities and patients are constantly coming and going.

“Many organizations underestimate how potentially devastating elopement can be,” said Dr. Lehman. “If you have a patient who elopes who isn't capable of self-preservation or sound decision making, it's a very serious issue which can result in significant harm to the patient.”

The definition of elopement includes patients who depart from a facility unnoticed, even if they don't make it off the grounds. To prevent such events, hospitals must do more than simply have a policy on the books, experts say. Assessment, prevention, and response strategies must be integrated into the daily workflow and prioritized by leadership.

“Hospitals need common procedures for identifying and supervising patients at risk and mounting an immediate response when someone goes missing,” said Meredeth Rowe, RN, PhD, a professor of nursing at the University of South Florida in Tampa who has written about preventing elopement in patients with dementia. “The first hours of a search are critically important—the longer someone remains missing, the less likely it is they will be found alive.”

Assessing risk

One of the most important steps in preventing elopement is conducting a thorough risk assessment at admission, said Jacqueline Bezaire, RN, JD, senior vice president of Arlington, Va.-based Willis Towers Watson's National Health Care Practice, which provides risk management services to hospitals and long-term care facilities. However, the intake forms hospitals use often don't go into enough detail about a patient's medical history and propensity for wandering.

It's not enough to simply check a box indicating whether or not a patient has a history of wandering, she said. In the case of elderly patients, for example, discussions with families should include detailed questions about any recent changes in medication, evidence of anxiety, or variations in mental status at different times of day.

Hospitalists can help by making sure to learn any relevant info gathered in the ED, but don't assume that the ED staff will flag all patients at risk for elopement, because important details can fall through the cracks in that hectic environment, advised Paul Meek, RN, a nurse based in Tampa, Fla., who offers consultancy services through the National Institute for Elopement Prevention and Resolution.

“Maintaining a flow of information between the ED and the units is key,” he said. “For example, a patient might be admitted to the ED for an injury related to an earlier elopement, but that information is not always communicated to the attending physician.”

Hospitals can borrow from the comprehensive risk assessment tools used by long-term care or skilled nursing facilities, said Paula Lester, MD, FACP, a specialist in geriatric medicine, palliative care, and hospital hospice care at NYU Winthrop Hospital in Mineola, N.Y. For example, the Algase wandering scale is a commonly used questionnaire that asks about patients' past walking and eloping behavior as well as their tendency to become disoriented or lost.

Be aware that some elderly patients may be at risk for wandering even if they haven't been previously diagnosed with dementia, said Dr. Rowe.

“The family may not know that their loved one has early dementia because they function just fine when they're at home in familiar surroundings,” she noted. “However, their symptoms can become more pronounced in the hospital.”

As a result, it's important to consider the results of a comprehensive cognitive assessment along with input from family members, she said. In addition, clinicians should be alert to certain behaviors after admission, such as patients having difficulty remembering simple instructions or seeming confused or disoriented.

“These patients will often do things like look for their clothes or frequently ask why they're here and when they will leave,” she said. “Those kinds of questions are clues that the patient isn't able to correctly process all of the cues from their environment and make sound decisions.”

Other patients at high risk for elopement include those with mental health and substance abuse issues, said Dr. Lehman, whose hospital has dedicated behavioral health and chemical dependency units. Anyone admitted with a court committal, for example, is probably in the hospital against his will and may try to leave. Patients who are suicidal or intoxicated should be considered incapable of making sound decisions, he added.

“Patients admitted due to overdoses or suicide attempts are initially placed on the medical units or in the ICU,” he said. “These patients must be closely monitored while they sober up or recover; we have to make sure they don't try to leave before we evaluate them to ensure they're stable and safe.”

Strategies for prevention

It's important to have a system in place for keeping a close eye on patients at high risk for elopement, said Dr. Rowe. Strategies include having patients wear distinctive wristbands or gowns and making notations in the patient's chart to alert clinicians taking over care on a new shift.

Electronic monitoring bracelets equipped with GPS are one way of increasing the odds that a patient who elopes will be found alive, she added. Hospitals and patients' families can ask local law enforcement agencies to attach the bracelets at admission and remove them at discharge.

Also critical is communicating with everyone involved in the person's care, for example, radiologists, respiratory technicians, and physical therapists. Employees at the front desk or main entrance should be able to easily recognize a patient considered at risk for elopement.

“If the patient is scheduled for an X-ray, make sure they are not left sitting in the waiting room unmonitored,” said Dr. Rowe. “There needs to be a common procedure across the hospital for identifying patients that need extra supervision.”

Simply taking the time to talk to a patient who seems confused can prevent an elopement, noted Mr. Meek.

“If you see a patient walking around alone, don't assume that someone knows about it and everything is under control,” he said. “Take a minute to ask the patient their name and offer to help them find their room if they're confused. If they're on the wrong floor in a gown with no escort, chances are they are trying to leave.”

It can be a challenge for hospitals to keep at-risk patients safe while still allowing other patients the freedom to move around, said Ms. Bezaire. While installing alarms on every door is common practice for mental health and nursing facilities, it isn't practical for hospitals with the constant flow of people coming and going.

However, some steps are relatively easy to implement, such as positioning an at-risk patient's room close to the nursing station and making sure nurses have a clear view of exits, she said. In addition, clinicians should make a habit of frequently looking in on at-risk patients.

At Wheaton Franciscan Healthcare's hospitals, a safety companion is assigned to sit in or outside the room of high-risk patients with dementia, said Dr. Lehman. Security guards are assigned to the ED, which is equipped with video cameras and controlled access (a staff member must open the door for someone to leave). Patients also wear burgundy-colored gowns so they are easily recognizable if they wander away unaccompanied.

“Hospitals are busy places with many people coming and going, so creating a safe environment requires awareness and communication among everyone,” said Dr. Lehman. “The safety and security of our staff, visitors, patients, and families is our top priority and we have taken measures to more easily identify and mitigate high elopement risks.”

The stakes are high, he noted: CMS considers it a violation of the Emergency Medical Treatment and Labor Act if a hospital allows a patient to leave when she is not capable of self-preservation, and fines can be $100,000 or more per occurrence.

Responding to elopement

Once a patient has gone missing, a comprehensive search involving all available staff should begin immediately, said Dr. Rowe. All possibilities—no matter how implausible—should be considered, because patients often do not behave in predictable ways. Individuals with dementia, for example, often seclude themselves in wooded areas or abandoned vehicles within the first hour of going missing.

“Once they make the decision to seclude themselves, it's very unusual to find them alive,” she said. “That makes the early part of the search extremely important.”

At Wheaton, a missing person page is ordered as soon as a patient can't be located, said Dr. Lehman. The page alerts all staff to check exit areas and stairwells, while security guards survey the grounds.

The best way to ensure an effective response is to have a detailed policy, said Ms. Bezaire. The policy should delineate a clear chain of command and plan of action at every level.

For example, the first step might be to communicate with coworkers in the immediate area and perform a thorough internal search, including under beds, in closets, in stairwells, on rooftops, and in ventilation ducts. The search should then gradually expand outward and include local authorities if the person isn't found soon.

Rehearsing in advance helps ensure a smooth response in an actual emergency, said Ms. Bezaire. Elopement drills and staff training should be conducted regularly. In addition, staff should hold debriefing sessions after an incident to reflect on the causes and whether anything could have been done differently.

“From a liability and safety standpoint, the more you can give direction and tell people what the appropriate steps are, the better,” said Ms. Bezaire.