In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we lumped together patient wandering and elopement or absconding. While the response each organization must take when a patient goes missing has similarities, there are definite differences between elopement/absconding and wandering.
Elopement implies intention. The term applies primarily to patients admitted to behavioral health facilities who leave the facility without notice. Wandering, on the other hand, is usually seen in patients with some degree of cognitive or executive impairment or impaired orientation, such as seen in patients with Alzheimer’s Disease or other dementias, head injuries, psychiatric disorders, developmental disabilities, acquired neurological disorders, etc. Today, our focus will be on the wandering patient.
A patient who had been reported as missing ended up in a New York hospital (Moore 2017). Police subsequently notified family where the patient was but when they arrived at the hospital, they were told he had disappeared again, wandering out in his white hospital gown, sky blue pajama pants and beige hospital socks.
A 50 y.o. disabled man walked out of an Atlanta hospital and was found 5 miles from the hospital more than 24 hours later bruised, still wearing a heart monitor and an IV, and confused (Jaquez 2018).
Last March a 71-year old man admitted to a Pittsburgh hospital with symptoms of a possible stroke went missing (KDKA2 2018) . He was believed to have walked out of the hospital at 9:20 p.m. and had not been seen since. His wife was about to pick him up just before he vanished. “She had gotten there around 9:50, and when she had gotten there, they said that he left around 9:20, took his IV out and left, and that’s the last time he’s been seen.” A search, including local police was initiated. His body was recovered from the Ohio River several days later (Luciew 2018). He apparently lived about 5 miles across the river from the hospital and some speculated he may have been trying to go home.
A patient with dementia and aggressive behavior was brought to a California hospital for psychiatric evaluation (CDPH 2017a). Disposition in the ER was planned admission as an inpatient, though he was housed in the ER Overflow area for several days. He was described as continuously attempting to walk out of the ER, anxious to go home, uncooperative some time, unable to follow simple directions, needing frequent redirection, agitated, wandering, and pacing. On the third day he was noted to be missing from the ER Overflow area. Two days later he was found dead, lying prone on a beach. The Medical Examiner determined death was the result of drowning.
At another California hospital (CDPH 2017b), an 81 y.o. man was admitted to a telemetry unit after a suspected MI. Because of a high fall risk score he had a bed alarm and was to receive hourly rounding. But because on the second hospital day he was ambulating without any difficulty and using the bathroom without any assistance, a nurse chose to disable the bed alarm. Sometime around 3AM a nurse was notified that the patient was no longer sending a telemetry signal. The nurse found the patient missing from his room and notified staff and security and a search was initiated by nursing and hospital security staff. The patient was found about an hour later at the bottom of an internal hospital stairwell, without a pulse, and could not be resuscitated.
At yet another California hospital, a 33 y.o. woman being held at the hospital on a 72-hour psychiatric hold (Van Derbeken 2018) (Montes 2018). She apparently was being treated on a bed in a hallway. She may have gone to the bathroom around 2AM but it is not clear whether anyone checked on her until she was found dead in a hallway at 6AM. This case is ironic in a couple regards. Just a week earlier, another dead body had been found in the power plant of this hospital (Newman 2018). That person was not a patient at this hospital but rather had gone missing from a Behavioral Health Center on the hospital’s 23-acre campus. And this was the same hospital where a wandering patient had been found dead 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”).
These cases are reminders that wandering patients are at significant risk of harm or death.
To prevent such disastrous outcomes there are three important steps:
1. Identify patients at risk for wandering
2. Intervene to minimize wandering and minimize risk of wandering to dangerous areas inside or outside the hospital
3. Have a plan in place for what to do if a patient goes missing
The first step is identifying those patients at risk for wandering. We have been unable to find a validated risk assessment tool for wandering. A formal search for wandering instruments a few years ago yielded 34 instruments (White 2013). Of these, one wandering-specific measure and four measures of behavioral change in dementia met their inclusion criteria. The ability of these to confidently evaluate the risk of getting lost remains uncertain. They concluded that further research is required to more fully evaluate the psychometric properties of the retrieved instruments.
Probably the most widely known wandering risk assessment tool is the Dewing Wandering Risk Assessment Tool (Dewing 2008) but there are others as well (ECME14 Elopement Risk Decision Tree, NYSHFA 2005, Sheth 2014) and there are numerous factors that are often seen in patients who wander.
In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we noted that many of the risk factors for wandering and elopement are also risk factors for delirium. So if you have been following this column and begun screening for delirium risk factors, you are halfway there! Alzheimer’s disease or any dementia may predispose the patient to wandering. Most of you recognize the term “sundowning” which we apply to those patients with dementia who become more confused and disoriented in new unfamiliar settings such as the hospital. Such patients may be prone to wandering and elopement. But any patient with impaired cognition may be at risk. This includes patients with psychiatric disorders, developmental disabilities, and acquired neurological disorders. But there are other risk factors or contributing factors as well. Many of the drugs we’ve talked about under delirium (particularly sedating agents) may contribute. A prior history of wandering or elopement (eg. at a long-term care facility prior to admission) should be a red flag.
Some standardized questions that appear on most wandering assessment tools are:
But keep in mind: things change during a hospitalization. Therefore, a single assessment for elopement/wandering risk on admission is not sufficient. That risk assessment must be repeated after surgery, at internal transfers of care, and any time there has been a significant change in the patient’s mental status or overall medical status. The same patients should have formal risk assessments for delirium and falls.
Part of identifying patients at-risk for wandering also includes how you flag them as being high risk. Most EMR’s (electronic medical records) have a field that can be used to flag such patients. In the old days we used to put colored stickers on patients’ paper charts. But wandering patients don’t carry around their paper or electronic medical record! So you have to flag them in some other manner. Most facilities use some form of color-coded clothing or color-coded bracelets. But both have their faults. A patient who wanders may be on a unit where they typically do not wear gowns at all (eg. a behavioral health unit or a “memory” unit). Or they may change into street clothing before wandering. Color-coded bracelets are helpful but you need to be sure all your staff (including temporary ones) understand what the color means. For years we’ve pushed for universal (or at least regional) color coding schemes but we are not there yet. You may have staff that work in more than one hospital and a specific color may mean something different at each hospital. Also keep in mind that such patients, even though they may be cognitively impaired, may be quite good at ridding themselves of bracelets or other devices!
The second step is intervention to minimize wandering and minimize risk of wandering to dangerous areas inside or outside the hospital. 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. For example, Yale-New Haven Hospital (Yale-New Haven 2017) has adults at risk of wandering and elopement wear yellow gowns.
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. 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. The references below (VA Toolkit: Patients at Risk for Wandering, Spencer 2008, Rowe 2008) also contain excellent points on care management of the patient at risk for wandering.
Internal patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and elopement or wandering risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for elopement may wander off easily while waiting in the radiology suite if not appropriately supervised.
In this day and age, use of technology to track at-risk patients makes a lot of sense. There are a variety of RFID, Bluetooth, or GPS devices (eg. bracelets, anklets) that can be used for such tracking. Heck, I can track my car keys or my dog with these devices! The RFID and Bluetooth devices are limited in range. But, if you have receiving devices for these technologies spread throughout your facility, you should at least be able to find a patient who is still within your facility or to identify an exit the patient may have taken out of the facility. GPS tracking devices obviously are more expensive but would be useful for tracking patients who have left your facility. But keep in mind that such patients, even though they may be cognitively impaired, may be quite good at ridding themselves of bracelets or other devices. Such systems should never be relied on as the sole means of monitoring such patients. And each day the system/device should be checked to ensure it is functioning properly.
What about bed alarms? Our own experience with these is mixed. Bed alarms trigger when a patient gets up out of bed. So they can help identify when, particularly at night, a patient gets up out of bed. But we’ve seen that such alarms tend to trigger so often, particularly with patients already prone to wandering, that they simply contribute to alarm fatigue and often get ignored, manipulated or discontinued.
We’ve sometimes discussed the value of having photographs of patients in the medical record. This is one circumstance where having a digital photo is very important. If a patient goes missing, it can be important not only to broadcast an alert in your facility but also to be able to include a photo to help staff recognize the patient. Such photos can also be given to local police or other authorities outside your facility that may be involved in a search for a missing patient.
Training of staff is very important. This applies not only to all your healthcare professionals but to everyone who works in the hospital, whether they have clinical expertise or not. They must be trained both to recognize the wandering patient and then to understand techniques (de-escalation, re-direction, etc.) that need to be used with such patients.
Cognitive reminders are for hospital staff, not patients! The VA National Center for Patient Safety has a Toolkit: Patients at Risk for Wandering that includes cognitive reminders such as pocket cards or posters that help remind staff how to interact with wandering patients. These stress the following points when communicating with patients:
• Speak Clearly
• Use a Calm Voice
• Make Visual Cues to Re-Enforce Your Words
• Make Eye Contact
• Get His/Her Attention by Motion or Touch
• Look for Facial Signs of Understanding
• Ask “Yes” or “No” Questions and Use Short Simple Phrases
You also need to make your staff aware of “tailgating” behavior. This is where a wandering (or eloping) patient waits for someone to enter/exit through a door and then he/she uses that door to exit.
We should also mention staffing issues as factors contributing to wandering patients leaving the unit or the facility. In several of the incidents noted at the beginning of today’s column, there were times when staffing was short (eg. lunch breaks, etc.). Also, we’ve mentioned in some of our other columns on behavioral health issues that change of shift is also a vulnerable period.
Your facility should have exit cameras at all your entrances/exits. You’ll see below that one of the first things in your search for a missing patient is to look at the playback on those exit cameras to identify whether a patient has left the facility.
Robin Hattersley-Gray, in an excellent 2-part series on wandering patients (Hattersley-Gray 2018a) (Hattersley-Gray 2018b), discusses many of the other environmental considerations that can promote or prevent a patient from exiting the unit or facility. Some of those, however, are aimed more toward “memory” units rather than general med/surg floors. These recommendations might include bumpers on the walls, lighted paths, painting doors like the walls so they look like one continuous scene, or even having curved walls rather than right-angle walls.
We’d also like to make the observation that many of the fatal outcomes for wandering or eloping patients occur in hospital stairwells. Motion-activated security cameras that link via WiFi to a variety of systems are so inexpensive today that hospitals could put them in virtually all stairwells. While the threat of alarm fatigue would preclude their use much of the day, they could be activated during hours when “normal” stairwell traffic is minimal (eg. after evening visiting hours have ended). The alarms can be tied into your central security room and those on individual floors can also be programmed to alarm at the nursing station on those floors (or to designated smartphones).
The third step is having a plan for what to do if a patient goes missing. (And, we probably should emphasize a fourth step: practice or drill for that plan!).
The response to a missing patient is critical. It must be rapid, well-planned, and thorough in order to find the patient before he/she suffers any harm. Some facilities have chosen to merge their infant abduction policy with the elopement or missing patient policy since the procedures may be very similar. But be careful – you don’t want your staff searching for a newborn by mistake when they should be looking for a wandering geriatric patient.
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 is typically done but this should last no more than a couple minutes. At that point the hospital phone operator should be notified and “code yellow” (or whatever name you use at your facility) should be announced over the public address system. It should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). Exits from the building need to be immediately locked (some doors may be locked from a central location) or manned by designated staff members. No one should be allowed to leave the building(s). The operator may notify visitors over the PA system that they are under no danger but need to avoid going near exits for the time being. 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. Don’t forget to look in all stairwells, parking lots, roofs, elevators, and closets.
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. We also recommend that the local police department be notified immediately by the operator when the “code yellow” is called (don’t forget to include them in your planning process). 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.
In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a directive in the VA system regarding management of wandering and missing patients (VHA 2010). The VHA directive includes recommendations about assessing all patients for risk of wandering or becoming missing while in treatment. It then describes what should be done when a patient is found to be missing, including both preliminary and full searches. It discusses designation of persons to be responsible for various aspects of the response to a missing patient, including “off-hours” as well as during usual business hours. Particularly useful is the discussion of the full search. This includes superimposing a grid map over a site and facility plot to delineate the search sectors. One individual is assigned responsibility to ensure all search grid sector assignments are made, the times and by whom grid sectors are searched, times and by whom each building is searched, times and to whom notifications and requests are made, and results of the searches. The recommendations include a description of both the indoor search and the outdoor search. It describes that each search team has a leader and how members of the search teams are to conduct their searches.
Someone on the unit from which the patient disappeared should be designated to send out a general email to all staff, describing the missing patient and including a photograph if one is present on the information system. The patient’s physician should be notified by the operator or staff on the patient unit. Someone needs to be designated to be in communication with the family as well.
Also in our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). The MHA recommends that the plain language overhead page be: “Missing person (of any age) + descriptor (and as appropriate, action for staff/patient/visitors.)” We think that including something about the action to take is important for both staff and visitors.
Hattersley-Gray (Hattersley-Gray 2018b) also has a recommendation we had not previously thought about: placing some of the patient’s personal items and garments in a sealed plastic bag can be very beneficial because a search dog can quickly identify the patient’s scent.
To facilitate the response to a missing patient, we recommend you have a readily available checklist that has all the steps you need to take and includes items such as the phone numbers of police and local agencies you must contact.
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.
Drills are critical for any event that is likely to be rare but critical when it occurs. Just as we’ve hammered home in our discussions about surgical fires, it is important that all staff know what to do during certain 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. You might also consider using a “secret wanderer” (person dressed as a patient in one of the special colored gowns) to see if staff identify them as a wanderer.
Staff education obviously is important but should be ongoing rather than just being delivered at annual orientation sessions. The Bay Pines (Florida) VA Hospital uses a creative reminder device on patient care areas that is shaped like a stop sign and uses the mnemonic “DON’T GET LOST” which stands for:
D Determine at-risk patients
O Observe for wandering triggers
N No-fall environment
T Teach staff/nonclinical support
G Get patient involved in activities
E Exit control
T Talk to patient and provide reassurance
L Low patient to staff ratio
O Offer food, drink and toileting
S Structure and routine
Ongoing surveillance is also important. When we do patient safety walkrounds we also incorporate much of what traditionally has been termed environment of care rounds. We look to see that doors and other accesses to dangerous places are locked and appropriately alarmed. We also look at windows leading to rooftops and make sure no one could open them and exit onto a rooftop.
You probably will be unable to prevent every potential disappearance or 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 root cause analysis within a short timeframe. There are always valuable lessons learned that hopefully can prevent other elopements in the future.
But don’t wait until you “lose” a patient. Review your current programs for wandering patients or those at risk for elopement. If need be, do a FMEA (Failure Mode and Effects Analysis) to determine your vulnerabilities and take steps to close the “cracks”.
See our previous columns on wandering, eloping, and missing patients:
Moore T. City hospital allowed patient with dementia to wander off: family. NY Post 2017; December 6, 2017
Jaquez N. Disabled patient who left hospital unnoticed is found more than 24 hours later. WSB-TV (Atlanta) 2018; August 7, 2018
KDKA2. Police Seek Help Locating Missing Man After Walking Out Of Hospital. KDKA2 CBS (Pittsburgh) 2018; March 23, 2018
Luciew J. Man who checked himself out of hospital is found dead in Pa. river. Penn Live 2018; Mar 27, 2018
CDPH (California Department of Public Health). Complaint Intake Number CA00358774; 2017
CDPH (California Department of Public Health). Complaint Intake Number CA00513129; 2017
Van Derbeken J. SFPD Investigating After Another Body Found in San Francisco General Hallway. NBC Bay Area 2018; June 5, 2018
Montes D (Bay City News). Patient who died unexpectedly at SFGH last week id’ed. San Francisco Examiner 2018; January 12, 2018
Newman M. Resident of SFGH campus reported missing ten days before she was found in a SFGH stairwell. Mission Local News 2018; May 31, 2018
White EB, Montgomery P. A Review of “Wandering” Instruments for People With Dementia Who Get Lost. Research on Social Work Practice 2013; 24(4): 400–413 First Published November 27, 2013
Dewing J. Dewing Wandering Risk Assessment Tool. Version 2 (September 2008)
ECME14 Elopement Risk Decision Tree
NYSHFA (New York State Health Facilities Association). Risk Assessment Elopement Decision Tree. Elopement Resource Manual. May 2005
Sheth HS, Krueger D, Bourdon S, Palmer RM. A New Tool to Asses Risk of Wandering in Hospitalized Patients. Journal of Gerontological Nursing 2014; 40(3): 1-6 February 2014
Yale-New Haven Hospital. Hospital issues new guidelines for elopement risk. The Bulletin (Yale-New Haven Hospital) 2017; February 2, 2017
VA National Center for Patient Safety. A Toolkit: Patients at Risk for Wandering. US Department of Veterans Affairs 2015; Last updated June 3, 2015
Spencer E. Policy for Assessment and Care Management of Patients who are at risk of Wandering in the Acute Care Setting. University Hospitals of Leicester. August 2008
Rowe M. Wandering in Hospitalized Older Adults: Identifying risk is the first step in this approach to preventing wandering in patients with dementia. AJN, American Journal of Nursing 2008; 108(10): 62-70
Hattersley-Gray R. Preventing Elderly Patient Wandering and Elopement: Part 1. Campus Safety 2018; March 15, 2018
Hattersley-Gray R. Responding to Elderly Patient Elopement and Wandering: Part 2. Campus Safety 2018; April 9, 2018
VHA (Department of Veterans Affairs. Veterans Health Administration). VHA Directive 2010-052. MANAGEMENT OF WANDERING AND MISSING PATIENTS. VHA 2010; December 3, 2010
MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011
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