Spotlight Case December 2007

1. Spotlight Case December 2007 Elopement

2. Source and Credits • This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Debra Gerardi, RN, MPH, JDCreighton University School of Law • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Define elopement and differentiate it from wandering and leaving against medical advice • Identify leading risk factors for elopement • Describe strategies for preventing elopement and steps for responding after a patient elopement has been identified • Identify legal risks associated with elopement

4. Case: Elopement A 61-year-old man with a history of chronic pancreatitis and cardiomyopathy attributed to alcohol was admitted for chest pain, acute on chronic renal failure, and altered mental status. After being treated for his worsening cardiomyopathy and renal failure, his mental status began to clear.

5. Case: Elopement On the morning of anticipated discharge, the patient was not in his room at the time of the physician visit. Such behavior was typical for this patient, who was known for being one of the hospital's “frequent flyers.” However, when he did not return 3 hours later, security was called to locate him.

6. Terminology • Elopement — When a patient, who is incapable of adequately protecting him or herself, leaves the health care facility unsupervised and undetected • Often at risk for serious harm, including death • Wandering — When patients aimlessly move about within the building or grounds without appreciation of their personal safety • Also leads to safety risks due to the decreased capacity of the patient See Notes for references.

7. Leaving “Against Medical Advice” • “AMA” (against medical advice) — When a patient decides to leave a facility after being informed of and appreciating risks of leaving without completing treatment • Fully competent patients are legally able to discharge themselves without completing treatment • Physician should inform patient of the risks associated with leaving • Ideally, conversation is noted in medical record and patient is asked to sign a form indicating awareness of these risks American Jurisprudence. Lawyers Cooperative Publishing; 2002.

8. Elopement • Now a reportable sentinel event • Primary contributors to elopement are breakdowns in patient assessment and team communication The Joint Commission Web site.

9. Assessing Risk of Elopement • Does patient have a court-appointed legal guardian? • Is patient considered to be a danger to self or others? • Has this patient been legally committed? • Does this patient lack the cognitive ability to make relevant decisions? • Does patient have a history of escape or elopement? • Does patient have physical or mental impairments that increase their risk of harm to self or others? National Center for Patient Safety.

10. Responding to Elopement • Ideally, units have place for patient to sign out or communicate with staff prior to leaving • Time elapsed since patient noted missing and initiation of search depends on local policies • Often dictated by when “it becomes reasonably certain the patient is missing without authorization” University of Texas Health Science Center at Houston and Harris County Psychiatric Center.

11. Responding to Elopement“Code Green” • Notification of the operator by unit staff indicating a Code Green/Elopement • Notification of security with description of missing patient and pertinent clinical information • Notification of the patient’s physician • Immediate search of the unit and surrounding area by unit staff University of Texas Health Science Center at Houston and Harris County Psychiatric Center.

12. Responding to Elopement“Code Green” (cont.) • Immediate search of hospital and grounds by security personnel • Notification of patient’s family by physician • Notification of police by security as appropriate • Notification of appropriate administrative personnel See Notes for references.

13. Patients with Diminished Capacity • An immediate organizational response or Code Green should be initiated when any patient with decreased mental capacity has left unit or treatment area without authorization • Patient may be readmitted rather than returned to unit • May depend on time elapsed • Providers should be familiar with local policies See Notes for references.

14. Case (cont.): Elopement Ultimately, the patient was found outside the emergency department, with ED discharge instructions in his hand. The patient had told ED staff that he was recently discharged and was waiting for a ride. He was brought into the ED. Because he was a “frequent flyer” there and complained of pain, he received his “usual” 1 mg of intravenous Dilaudid and 2 liters of intravenous hydration, and was promptly released with oral pain medications.

15. Case (cont.): Elopement Even though the ED staff had noted the patient to be mildly confused, in the course of his ED visit, no one questioned the presence of a hospital ID bracelet and hospital gown. Additionally, the hospital computer system failed to recognize that the same patient had been admitted simultaneously to both the inpatient floor and the ED.

16. What Went Wrong? • Failure to initiate a system-wide search shortly after patient was noted to be missing • Either lack of clear policy regarding elopement or failure to follow available policy • Failure to communicate event across organization, including ED • Lack of risk assessment and prevention measures

17. The Missing Patient—Legal Implications • Competent patient leaving “AMA” • Cannot be held against their wishes • Doing so damages trust and impacts the reputation of the facility • Providers would be at risk for claims of assault, battery, or false imprisonment American Jurisprudence. Lawyers Cooperative Publishing; 2002.

18. The Missing Patient—Legal Responsibility • Legal duty to exercise reasonable care and attention for patients’ safety as their mental and physical conditions may render them unable to look after their own safety • Legal duty to adequately supervise and observe patients and to maintain safe conditions on the premises See Notes for references.

19. The Missing Patient—Liability • Liability can ensue when there is • Negligent administration or failure to administer medications • Failure to notify the physician of changes in the patient’s condition • Failure to properly search for the patient following elopement See Notes for references.

20. Steps to Prevent Elopement • Place patient on an observation protocol • Room patient close to nursing station • Partner patient with a roommate • Perform routine risk assessment • Request family member or nursing assistant sit with the patient • In mental health facilities may use automatic door locks, alarms, diversion activities American Jurisprudence. Lawyers Cooperative Publishing; 2002.

21. Using Technology to Prevent Elopement • Use of radiofrequency (RF) devices • Wrist bracelets linked to signal detection devices within unit can trigger an alarm when patient wanders too far from room • Alarm can be linked to systems that automatically lock doors • May reduce need for one-to-one monitoring of at-risk patients by half See Notes for references.

22. Successful Prevention • Overarching goal is safe patient care • Must link adequate assessment, precautions, good team communication, and updated technology, with immediate system response • Such an approach can improve outcomes, reduce costs, and limit liability for care providers and the organization

23. Take-Home Points • Elopement is a serious event that requires a system-wide, organized response • Breakdown in team communication and patient assessment are the top contributors to elopement events • Patients should be assessed for elopement risk on admission and throughout their hospitalization

24. Take-Home Points • Patients at risk for elopement should be put on special preventive precautions • Response to elopement by patients with diminished capacity should be immediate and include unit staff, security, and, when appropriate, local authorities