Patient Safety Tip of the Week

April 7, 2015    Missing Patients and Death

 

 

Though our first column on missing patients was 6 years ago (see our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”) there was considerable renewed interest in the topic after a patient was found dead 17 days after going missing at a San Francisco hospital in 2013 (see our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” and our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”).

 

Despite considerable discussion regarding lessons learned from that unfortunate incident, similar cases continue to occur. Several are described below:

 

An elderly patient suffering from dementia who wandered out of a scandal-hit hospital was found dead in a ditch a quarter of a mile from the grounds the next day (Duffin 2015). She was said to be a ‘known wanderer’, was able to walk out of the hospital, wearing only a cardigan and trousers. She was reportedly seen by a member of staff but not stopped. This was especially problematic since a report, following an inspection in June 2014, stated: ‘The support for patients living with dementia or who may have a learning disability was inconsistent.’ It also raised concerns about staff levels, saying there was a ‘heavy reliance’ on agency staff which, in some instances, ‘affected the delivery and continuity of patient care’.

 

A 69-year-old man with diminished mental capacity died from complications of hypothermia three days after he walked away from an assisted living facility (Bear 2015).

 

A 58-year-old man, hospitalized at a San Diego hospital because of head and neck trauma, went missing from the hospital and was found dead at the bottom of a nearby canyon 5 days later (CDPH 2014). This case has the most to learn from because the CDPH publishes the statement of deficiencies (SOD) and hospital plan of correction (POC). Because he was considered at risk for falling, he had both a bed alarm and a video monitor. The patient had confusion that would wax and wane. One morning the Video Monitor Technician notified a Clinical Care Partner (CCP) that the patient was getting out of bed. That CCP went to the patient’s room and found the patient to be missing. The CCP notified the RN, who notified the Charge Nurse. The Charge Nurse called the Security pager number twice and pressed a panic button twice while the CCP and RN went looking for the patient. The CCP, after searching the nursing unit, went down the elevator to the first floor and basement looking for the patient. When the CCP returned to the nursing unit, security was still not there so she contacted them by phone. The panic button was not working. Response by Security was delayed. Five days later the patient was found deceased at the bottom of a canyon adjacent to the facility’s parking structure.

 

The Director of Security said the pagers should not be used to contact Security in the case of an emergency. Instead, staff should press the panic button and dial 6111. There was actually no written process telling staff how Security should be contacted. In addition, the security technician had been aware that the panic button on that nursing unit had been non-operable for 8 days before it was fixed.

 

On later review of video tapes the patient was seen exiting the hospital via the front doors, wearing hospital gown, non-skid socks and a cervical traction device. Staff noted it was not uncommon to see patients leaving the building in gowns to smoke outside. So when staff ignore such occurrences it is really a form of “normalization of deviance” where a deviation of behavior is so common we consider it “normal”. That desire to smoke is a risk factor for patient elopement. In our December 2012 What’s New in the Patient Safety World column “Just went to have a smoke…” we joked about a scene in the Denzel Washington movie “Flight” in which 3 hospital inpatients all came to the same hospital stairwell to have a smoke. We wondered how often that might happen and that was soon answered: 18.4% of patients who smoke will smoke at some time during their inpatient hospitalization (Regan 2012).

 

The hospital’s Plan of Correction (POC) focused heavily on the non-operable panic button. They actually found that many panic buttons in other areas were also non-operable. The hospital ultimately upgraded to a version of the panic button that allows real-time notification of failure of communication/connectivity. Security immediately follows up. If a reboot of the computer fails to correct the problem a technician responds to fix it within 24 hours. Importantly, while the button is non-operable a sticker is placed over it indicating it is “non-operable” and having instructions on how to contact Security. Note that we’ve seen similar problems with panic buttons elsewhere, such as behavioral health units (see our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”). It is clear that any time you have a critical alert system you must ensure it is functioning at all times so programs like daily testing are a must.

 

But we might make a case that the heavy focus on the panic buttons was, in fact, too heavy. Panic buttons are a sort of “silent” alarm and they alert only a very few people and don’t really tell them what is wrong or what to look for. Some features of this case are eerily similar to the one at San Francisco General in 2013 (see our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” and our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”) though it should be noted this case actually occurred prior to the SFGH case. Valuable time was lost while a single person was searching for the patient. And in both cases it appears that too many people considered it the responsibility of “Security” to search for missing patients and no true system-wide response ever occurred. That should never be the case. While “Security” may command and coordinate a search, there must be a coordinated effort that involves staff from all parts of the hospital. There is no mention of the search protocol in the SOD or POC in the San Diego case.

 

When a patient is discovered to be missing a brief search of the local unit should be done. If the patient is not found immediately, the “code” for a missing patient should be issued. That is called to the hospital operator and announced over PA system. While most hospitals still use arcane codes for various emergencies, many are moving to “plain language” codes for these alerts. In the case of a missing patient a “plain language” code with the description of the missing patient has the additional advantage that visitors and other patients in the hospital might identify the missing patient. Once the “code” is announced the facility should have a predetermined search grid where every area of the hospital and surrounding grounds has a designated person to search it. A central command post is set up and staff call in to that post once they have searched their sector.

 

Yes, such procedures are disruptive. All the workers who participate in such searches have other duties and care for all the other patients cannot be abandoned. It’s just like responding to a cardiac arrest. But sector searches can be done in an expedited manner as long as the search sectors are not too large, staff know their responsibilities, and communication to the command post is simple.

 

Some facilities use an alternative system to alert staff to missing patients. They may use text messages sent out in a “blast” fashion to computer terminals and staff smartphones, the equivalent of the well-known “Amber alert” when a child in the community goes missing. This sort of system can have the advantage of including a description of the patient and perhaps a photograph. But the disadvantages are that it may take longer to implement and you lose the chance that a visitor or other patient might identify the missing patient.

 

In these incidents and other cases of missing patients we’ve discussed in the past, several themes recur:

 

 

All types of facilities need to develop policies and procedures for:

1)      doing an assessment for risk of wandering or elopement

2)      implementing risk reduction strategies for those patients at risk

3)      performing a prompt and thorough search when a patient is missing

 

 

Assessment for Wandering Risk

 

We refer you to our Patient Safety Tips of the Week for July 28, 2009 “Wandering, Elopements, and Missing Patients” for a discussion on the assessment of patients for risk of wandering. Also remember our comments above on the urge to smoke tobacco as a potential risk factor for wandering and elopement.

 

 

Reducing the Risk of Wandering

 

So what do you do when you identify a patient as being at-risk for wandering or elopement? It makes sense to put them in a room where staff would be more likely to see them exit the room (usually closer to the nurse’s station). Many floors have one or two rooms that are video monitored, a logical choice for such patients. Consider having the patient wear a gown that is a different color than the usual gowns so that all staff would recognize such patient as being “lost” if encountered in other parts of the hospital. One hospital we worked with used an off-purple color to flag such patients. The San Diego hospital in today’s index case began using orange colored arm bands to identify patients at high risk of wandering. But make sure your staff all know what those colors mean so they can take action if they see such a patient somewhere they don’t belong.

 

Potential exit doors on the unit should be fitted with appropriate alarms (that are functioning correctly) and with appropriate signage to keep the door closed. But also consider the downside of locked doors. Many units have doors that are locked automatically and prevent access to the unit. So you need to consider what would happen if a patient wandered out such a door and could not get back in. Such may have been the case in the SFGH incident previously described. We even recall once getting a cellphone call from a physician who responded to a cardiac arrest and got locked in a stairwell and could not get back in to any unit! Also consider that there are times when your locked doors will be automatically unlocked (eg. fire alarms) creating an opportunity for a wandering patient to leave the unit.

 

Consider keeping the patient in a room with a roommate or have family members stay in the room. Attention to the patient’s physical needs (food, water, warmth, pain management, toileting) are important. Letting the patient walk or exercise under supervision may be useful. Our Patient Safety Tips of the Week for July 28, 2009 “Wandering, Elopements, and Missing Patients” had links to several websites having resources related to management of the patient at risk for wandering.

 

Construction sites are particularly vulnerable for a few reasons. First, you often have outside workers there who are not thinking about patient safety. So they may leave doors unlocked. Second, construction sites have lots of opportunities for someone to injure themselves. So make sure you pay close attention to any sites at your facility with ongoing construction.

 

Be especially careful during patient transports. One of the items we recommend including in your “Ticket to Ride” checklist/communication tool for transports (eg to Radiology) is information about wandering risk.

 

Ultimately, we will look to technology solutions to help in cases of lost or missing patients. Technology already allows us to find our car keys, track our dogs, and locate hospital assets like wheelchairs so technology solutions to track patients are a logical direction. However, we’ll emphasize that technology will always be only part of the response to missing patients. It should never be the sole modality relied upon. The three most obvious technology tools are GPS, RFID, and Bluetooth. A VA analysis suggests GPS beats RFID in most scenarios (VA 2013). But the specific technology chosen will likely differ from facility to facility and may depend upon the need to integrate with other technology needs. For example, though GPS probably would be best for locating patients who have left the facility or hospital grounds, some hospitals may prefer RFID because they are using an RFID system for inventory tracking. Bluetooth would have limited applicability. Many of you probably already use low-power Bluetooth for tracking items like your keys (or maybe your TV remote!). But in the context of missing patients Bluetooth applications would most likely only be of use in alerting staff when a patient leaves the Bluetooth receiving area (about the size of a typical inpatient floor). Similarly, the bracelets used in newborns to prevent abduction can alert staff when a patient leaves the unit but are of little help in locating a patient once they have already left the unit.

 

Bed alarms are another technology that can alert staff when a patient gets out of bed. Their biggest applicability is in prevention of patient falls, though their success at even that has been less than stellar (see our January 2013 What’s New in the Patient Safety World column “Bed Alarms Fail the Test”). Our own experience with bed alarms has not been particularly good. We often see them malfunction or be improperly installed (see our Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions”) or be disconnected intentionally because they are alarming too frequently. In addition, as in the current CDPH case, patients may still end up leaving the unit despite using bed alarms.

 

How about low-tech tools? Multiple facilities, particularly long-term care facilities that care for many patients with dementia, often use tricks to disguise doors or otherwise encourage wandering patients to avoid doors. One Canadian hospital uses a door wrap in its continuing care facility that makes the door look like a cabinet full of things (Whitnall 2015). That helps prevent patient with dementia and wandering from going to the doors. Others have used the image of a “black hole” near doors to discourage wandering patients from going to the doors.

 

 

Performing a Prompt and Thorough Search if a Patient Goes Missing

 

Despite our best efforts to identify patients at high risk of wandering and absconding and implementing risk reduction strategies, patients will still wander and get lost. If a patient does go missing, doing a thorough search promptly is crucial. For those missing more than 24 hours, the death rate can be as high as 50% (VA 2013).

 

When a patient is discovered to be missing a brief search of the local unit should be done. Staff on the unit need to be notified as soon as a patient is missing. A very brief head count of patients and look in rooms on a unit and any adjacent closets, stairwells or elevators is typically done but this should last no more than a couple minutes.

 

If the patient is not found immediately, the “code” for a missing patient should be issued. That is usually called to the hospital operator and announced over PA system. While most hospitals still use arcane codes for various emergencies, many are moving to “plain language” codes for these alerts. In the case of a missing patient a “plain language” code with the description of the missing patient has the additional advantage that visitors and other patients in the hospital might identify the missing patient. Once the “code” is announced the facility should have a predetermined search grid where every area of the hospital and surrounding grounds has a designated person to search it. A central command post is set up and staff call in to that post once they have searched their sector.

 

Yes, such procedures are disruptive. All the workers who participate in such searches have other duties and care for all the other patients cannot be abandoned. It’s just like responding to a cardiac arrest. But sector searches can be done in an expedited manner as long as the search sectors are not too large, staff know their responsibilities, and communication to the command post is simple.

 

Some facilities use an alternative system to alert staff to missing patients. They may use text messages sent out in a “blast” fashion to computer terminals and staff smartphones, the equivalent of the well-known “Amber alert” when a child in the community goes missing. This sort of system can have the advantage of including a description of the patient and perhaps a photograph. But the disadvantages are that it may take longer to implement and you lose the chance that a visitor or other patient might identify the missing patient.

 

Key assigned staff should immediately go to a designated “command center” from which they will direct the response. Each unit (clinical and nonclinical) will have a specific predetermined area they must search in a systematic fashion. The command center must have an overlay grid of the buildings and surrounding areas and be able to mark off areas on the grid that have been searched. The search teams must have keys to their search areas since sometimes patients lock themselves into rooms inadvertently.

 

We also recommend early outdoor search since a patient can easily stray far from the building (or into automobile traffic) in a very short period of time. The search grid should include outdoor areas like parking areas, open spaces, bushes and shrubs, and any other adjacent areas where a patient might wander to. A typical grid sector might be 500 x 500 feet. Typically, the search teams comb a sector in a standardized direction (eg. south to north).

 

We also recommend that the local police department be notified immediately by the operator when the “missing patient code” is called (don’t forget to include them in your planning process and drills). Many facilities also use many security video cameras that are monitored centrally. Security staff may be able to scan those quickly to look for a patient exiting the building.

 

What do you do when you find the patient? First, be aware they are likely confused and be careful not to frighten them. Do a brief assessment as to whether they may have been injured. Notify the command center you have found the patient and either return them to their unit or to the emergency department. They should be evaluated by a physician at that time to determine whether any injuries have occurred. In the unfortunate circumstance where the patient is found dead, the scene should be left undisturbed because the authorities will treat it as a crime scene.

 

 

Staff Education and Drills

 

All your staff need to be aware of how to respond when a patient goes missing. That means not only describing their roles on their initial orientation but doing an inservice at least annually. Drills are critical for any event that is likely to be rare but critical when it occurs. Especially with relatively rare events, it is important that all staff know what to do during such emergencies and the best way to prepare for those is with drills. Yes, you can and should include education and training on missing patient alerts during orientation and annual reorientation but you have to periodically run a drill to see whether the responses are adequate and timely. During drills one may also see various nooks and crannies and other areas (eg. ventilation ducts) that a patient could get into, perhaps leading to some physical improvements to prevent such dangerous access.

 

From a few incidents we’ve seen or read about we had the suspicion that missing patient events were more likely on weekends and holidays. A VA study actually showed that was not the case, at least statistically (DeRosier 2005). But keep in mind your drills need to also be done on shifts other than a regular day shift and you also need to inservice staff, such as agency staff, that might be temporarily working at your facility. And that applies to administrators as well! Your administrators likely have a role all missing patient responses (eg. communicating with families, police, etc.) so they must know what their role is on weekends and nights, too.

 

 

Despite our best efforts to identify patients at risk for wandering and elopement and interventions to prevent such, it is impossible to prevent all such cases. In the San Diego incident, the patient had been flagged as being at risk for wandering, was put on a video monitor and was even seen getting out of bed on the video monitor, yet still managed to wander out of the hospital anyway. Therefore, it is imperative that every healthcare facility and organization have in place plans and procedures, known by all and rehearsed periodically, in the event a patient goes missing. Plans that consider missing patients the sole responsibility of “Security” are doomed to failure.

 

It’s always a good time for facilities to say “could that happen here?” and do a thorough review of your policies and procedures for missing patient incidents, including making sure you do appropriate drills for such incidents. You probably will be unable to prevent every potential elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal RCA (root cause analysis) within a short timeframe. There are always valuable lessons learned that hopefully can prevent other elopements in the future. But even if you’ve not already had a patient go missing it’s good to do a FMEA (failure mode and effects analysis) to determine your potential vulnerabilities. And make sure you do drills, with thorough critiques and debriefings following the drills. When you do your FMEA, consider also what happens to locking doors when a fire alarm goes off. You might even consider doing your missing patient drill immediately following a fire drill.

 

 

 

Our prior columns on wandering, elopements, and missing patients (many with links to other good resources):

 

 

 

 

 

References:

 

 

Duffin C. Dementia sufferer found dead in a ditch yards away from scandal-hit Stoke Mandeville Hospital after being allowed to wander off her ward. The Daily Mail (UK) 2015; 26 March 2015

http://www.dailymail.co.uk/news/article-3012626/Dementia-sufferer-dead-ditch-yards-away-scandal-hit-Stoke-Mandeville-Hospital-allowed-wander-ward.html

 

 

Bear J. Man dies of hypothermia complications after wandering away from Longmont assisted living facility. Times-Call (Longmont, CO) 3/31/2015

http://www.timescall.com/longmont-local-news/ci_27824131/fort-morgan-man-dies-after-wandering-away-from

 

 

CDPH (California Department of Public Health). Complaint Intake Number CA00357013. 2014

http://www.cdph.ca.gov/certlic/facilities/Documents/UniversityofCaliforniaSanDiegoMedCenter_090010580.pdf

 

 

Regan S, Viana JC, Reyen M, Rigotti NA. Prevalence and Predictors of Smoking by Inpatients during a Hospital Stay. Arch Intern Med 2012; 172(21): 1670-1674

http://archinte.jamanetwork.com/article.aspx?articleid=1389239

 

 

VA. VISN 8 Patient Safety Center of Inquiry, Tampa. Wandering and Missing Incidents in Persons with Dementia. Updated: October 24, 2013

http://www.visn8.va.gov/patientsafetycenter/wandering/

Wandering Resources.

http://www.visn8.va.gov/VISN8/PatientSafetyCenter/wandering/WanderingResources.doc

 

 

Whitnall C. Ross Memorial hopeful door wrap will discourage wandering patients

Image reflection of hallway cabinet installed on doors exiting the Continuing Care Program. MyKawartha.com March 15, 2015.

http://www.mykawartha.com/news-story/5476352-ross-memorial-hopeful-door-wrap-will-discourage-wandering-patients/

 

 

DeRosier JM, Taylor L. Analyzing Missing Patient Events at the VA. TIPS (VA Topics in Patient Safety) 2005; 5(6): 1-5

http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec05.pdf

 

 

 

 

 

 

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