Case Objectives

• 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.

The Case

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, the patient was improving and was being managed on the medical-surgical floor. Initially he had been confused in the setting of alcohol withdrawal, but by hospital day 6 his mental status was clear and the patient was nearing discharge.

On the morning of hospital day 6, the patient was feeling "cooped up" and "needed a change of scenery" 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.

When he returned to his room an hour later, the patient 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 unit while hospitalized.

The Commentary

Patient wandering, patient elopement, and patients leaving health care facilities (HCFs) against medical advice are closely related and challenging incidents facing caregivers and health care facility leadership. 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."(1) Others have defined wandering as referring to a patient who "strays beyond the view or control of staff without the intent of leaving." Elopement, on the other hand, is defined as "a patient that is aware that he/she is not permitted to leave, but does so with intent."(2) Patient elopement and patient discharge against medical advice have been covered in previous AHRQ WebM&M commentaries, and these resources provide important related content.(3,4) The patient in this case appears to have been wandering with the intention of returning. This scenario provides an opportunity to outline the challenges and issues surrounding patients who wander away from clinical supervision.

Frequency and motivation for patients to wander

There is little evidence documenting the prevalence of patient wandering in health care facilities. Yet, we do know that discharges against medical advice comprise up to 6% of discharges of general medical patients in acute care hospitals.(5) It would seem likely that wandering would be at least as common as leaving against medical advice.

Limited evidence describes what specifically motivates patients to wander while in an acute care hospital. Some patients become claustrophobic in the hospital and are simply motivated by the need to have a change of scenery. Especially in patients with prolonged hospitalizations, there often is just a need to "get some fresh air." Certainly, for patients with a history of tobacco use, wandering is often driven by a need to smoke. The nationwide trend to create smoke-free campuses may have exacerbated the problem. Similarly, patients with other substance abuse disorders may wander to fulfill cravings; in particular, patients who inject illegal drugs may be motivated to wander as peripheral or central intravenous catheters make for easy administration. Lastly, some patients may be motivated to wander to manage important life events that they feel they cannot miss. For example, if patients feel well enough they may want to leave to pay rent or attend important meetings.

Harm related to wandering incidents

Patient wandering can be extremely dangerous for patients. Often, due to acute illness, patients may be physically weaker than their normal state or less able to navigate hospital surroundings. Patients who wander beyond their assigned ward or unit without assistance place themselves at risk for specific complications, including 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, and in extreme cases, death. Although fatal cases are rare, they are in the news occasionally and involve patients who are ultimately found dead either inside the medical facility or nearby.(6,7) The death often results from exposure to the elements (too hot or too cold) or issues related to the illness that brought them to the HCF.

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.(8) If patients have dementia or do not have decision-making capacity (are "eloping"), then certainly hospitals are responsible for their safety. But if a patient is competent to make decisions and wandering with the intent to return, ascertaining the hospital's responsibility is more complicated.

Patients who are not on legal or medical holds generally have the right to leave their unit; hospitals are not prisons and should not be viewed as such. Therefore, HCFs may implement reasonable rules to allow patients to safely leave units, balancing patient safety and legal risk with patient rights and autonomy. The goal would be to minimize the risk to patients while allowing for patient autonomy.

Reducing the risk

There are a range of options for reducing the risk of patient wandering including (i) patient assessments, (ii) physical security, (iii) policies pertaining to patients off unit, and (iv) response plans for recovering wandering patients.

Patient assessments

Assessments are critical in determining the risk of wandering incidents. The VHA Directive provides sample criteria and frequency for patient assessment.(1) Such assessments should be conducted on a regular basis to evaluate and monitor patients' cognitive status. The VHA recommends that assessments be performed during inpatient admission, discharge, or other transfers, as an element of each initial and annual evaluation for outpatients, and when a change in mental status is reported. According to the VHA, patients are considered at-risk if they are legally committed, considered dangerous, severely disabled due to mental disorder, appointed a legal guardian, unable to make appropriate decisions, and have physical limitations that raise their risk.(1)

Physical security

HCFs may choose to implement physical security measures and design elements that decrease the potential for elopement and reduce risk to patients. These might include locked units, radio frequency identification alarms (similar to infant tagging alarm systems), motion sensor alarms, and cameras. These systems can be very effective in reducing the potential for wandering. When patients at risk for wandering are admitted to medical units not designed with these physical security measures, the risk for wandering is elevated. Other design elements that reduce the potential for elopement include placement of staff areas to provide visibility to exits and elevators, controlled access to elevator lobbies, and way-finding designs that direct patients and visitors to staffed exits.

A more complete discussion of patient assessments and physical security measures can be found in a previous AHRQ WebM&M commentary on elopement.(3)

Safe and reasonable rules

Numerous creative and rigorous steps have been taken by HCFs to achieve this delicate balance. For example, many HCFs require patients to inform staff (e.g., the bedside nurse) when they are leaving the unit. Some HCFs take added measures including issuing a specially colored "Patient Off Unit" hall pass to patients authorized to leave the unit. A unit log is maintained with the time the patient obtained the pass and time of return to the unit. These passes have the patient's floor and time to return on the pass so that other staff members can easily identify them. HCFs should carefully consider and limit how far patients may travel if they choose to issue patient off unit passes. The further outside beyond the walls of the HCF, the more the risks increase.(9)

Other institutions establish clear policies that limit the time a patient may be off unit without observation. For example, at least one hospital allows patients to be missing from their room or their hospital ward for one hour. After one hour, they are officially discharged from the hospital. This hospital policy is clearly communicated to patients at the time of admission and strictly enforced.(10)

Challenges HCFs face when implementing more restrictive off-unit policies

Implementing a "hall pass" policy or an alternative system that allows patients to leave the hospital unit has some practical challenges. Below are a few of the challenges, along with suggested policy considerations:

• Who will issue the pass? Many nursing units do not have clerical staff on duty at all times and this can place the burden of issuing the pass onto the bedside nurse. The patient's bedside nurse would probably need to be consulted prior to the pass being issued anyway, so this may not be overly burdensome.
• How long should patients be allowed to leave the floor? HCFs should consider allowing off-unit privileges for no more than an hour unless there are special circumstances.
• What happens if patients do not comply with the off-unit policies? Patients not willing to comply with these policies should be counseled and, if their behavior continues, should be considered for discharge (when possible).

Response procedures

Even if some preventive measures above are implemented, patients may still wander from hospital units. HCFs should create specific procedures for responding to patient wandering, as this is an important mechanism to reduce harm. The VHA Directive also provides excellent recommended search procedures including assigning one individual to be responsible for coordinating the search; identifying areas for searches, both indoors and outdoors; notifying local authorities; and delineating the search team and detailed grid search procedures.(1) Staff must be trained and drilled to the established preventive and response procedures.

For this case, it does not seem that the hospital had a clear policy to handle patient's needs or desires to leave assigned units. It is possible that a policy utilizing a "hall pass" structure may have prevented the harm—that is, when requesting the hall pass, nurses or other providers may have identified the patient as high risk for harm and made sure he was accompanied by staff.

Take-Home Points

• Patient wandering refers to a patient who goes beyond the view or control of staff without the intention of leaving the health care 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 their underlying disease.
• Hospitals may be legally responsible for wandering patients who are harmed.
• Specific policies and procedures, such as establishing an "off-unit hall pass" system, may be effective in providing a reasonably safe environment while respecting patients' rights.

Thomas A. Smith, CHPA, CPP

President

Healthcare Security Consultants, Inc.

Faculty Disclosure: Thomas A. Smith has declared that neither he, nor any immediate member of his family, have a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. Management of Wandering and Missing Patients. Veterans Health Administration. Washington, DC: Department of Veterans Affairs: December 3, 2010. VHA Directive 2010-052. [Available at]

2. DeRosier JM, Taylor L. Analyzing missing patient events at the VA. TIPS (Topics in Patient Safety). November/December 2005;5:1-2. [Available at]

3. Gerardi D. Elopement. AHRQ WebM&M [serial online]. December 2007. [Available at]

4. Hwang SW. Discharge against medical advice. AHRQ WebM&M [serial online]. May 2005. [Available at]

5. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168:417-420. [go to PubMed]

6. Associated Press. Report: Orders to watch patient Lynne Spalding not recorded at SF General. NBCBayArea.com. February 3, 2014. [Available at]

7. Garske M, Summers D. Missing hospital patient's body found in canyon. NBCSanDiego.com. June 1, 2013. [Available at]

8. Hospitals and asylums. In: American Jurisprudence. Vol 40A. 2nd ed. Rochester, NY: Lawyers Cooperative Publishing; 2002:Sec 27-62.

9. UNC Health Care Policy: Elopement/patients off the Unit. July 2013. Policy No. NURS-559.

10. New policy details procedure for missing patients. Stanford Hospital and Clinics: Medical Staff Update Online. February 2003;27(2). [Available at]