Responding to Elderly Patient Elopement and Wandering: Part 2

In Part 1 of Campus Safety’s series on Alzheimer’s and dementia patient wandering and elopement, we covered the reasons why these patients wander and exhibit exit-seeking behavior, as well as the staff training and site design needed to address the risks associated with these activities.

In the second half of our coverage of this topic, we address the effectiveness and best practices of one-to-one patient monitoring, video surveillance, access control, RFID solutions and response plans.

Sitters Are Effective but Costly

Monitoring of a patient with Alzheimer’s disease or dementia by an aide, sitter or security officer who provides constant bedside observation is a common approach to ensure at-risk individuals don’t elope. This is particularly popular in hospitals that haven’t been designed specifically to house Alzheimer’s and dementia patients.

“Some organizations use a tremendous amount of one-to-one watches, ideally with an aide who can also do some care,” says Don MacAlister, who is chief operating officer for Paladin Security and PalAmerican Security, as well as a volunteer leader on the IAHSS guidelines council. “But at times, the behavior of the patient is such that their biggest risk is aggression and aggress6 ive elopement, in which case you often have a security person assigned to them for a shift, a day, a week or sometimes months. I’ve seen security people watching head-injured patients for months on end.”

Although one-to-one monitoring is very effective at preventing elopements and wandering and the injuries that often result (such as falls by elderly patients or suicides by behavioral health patients), it is expensive and can drain the resources of a security department. Fortunately, technology can help. Tele-monitoring or remote monitoring can be used by sitters to observe at-risk patients via security cameras. Additionally, Video surveillance is particularly helpful when an elopement does occur.

“If you’ve lost a patient who’s at risk, one of the first things that should happen is security immediately goes to the exterior cameras to determine, hopefully in a matter of moments, whether or not the person left the building,” says MacAlister. “One of the single biggest factors for having a really good external camera is how quickly and readily you can determine if a particular resident or patient has left the facility. If they have, that changes the whole search. The focus is on the outside. The police are helping. The transit, surrounding businesses, all of those things come into play much more quickly than if you have to spend two hours searching video.”

It’s because of cameras’ effectiveness in helping to find missing patients that MacAlister is a big proponent of high-quality external cameras that can confirm an identity.

“There have been all kinds of cases of people, especially in big facilities, wandering, getting lost, not being found for days and coming to their deaths inside the healthcare facility,” he says.

Multi-layered, Integrated Technologies Can Help

Other technologies also play a big role in preventing and mitigating wandering and especially elopement. Many hospitals take a multi-layered, integrated approach where access control, video surveillance, RFID systems and motion detectors all work together to keep patients safe.

Locks and access control are the obvious first steps. The technologies used often include access cards or keypads that require the input of specific codes to open the doors by authorized personnel. Without the correct code or access credential, patients can’t exit.

MacAlister points out, however, that appropriate access control of a unit doesn’t just involve locking the doors.

“How do you get families in and out?” he asks. “How do you get staff in and out? How do you get other care and support people in and out, whether it’s the pharmacy or lab or other folks associated with their care? You need to use good technology that allows people who are authorized to come and go from the unit without allowing the patients to leave.”

According to Paul Sarnese, who is Virtua’s assistant vice president of safety, security and emergency management as well as chair of IAHSS’ Delaware chapter, some systems involve having a patient wear an activator that is mounted on a wheelchair or walker that either triggers an alarm or secures a door when they get close to it.

“Many of these systems allow for a two-level alert: one being a loitering alarm when the patient approaches the area and the other being when the patient attempts to open the door,” he says. (RFID solutions will be covered later in this article.)

Buffer Zones Help Secure Front Entrances

Because IAHSS found that the main entry of a unit housing patients prone to elopement is the most vulnerable area of the unit, elopement buffer zones —sometimes called mantraps, sally ports or secure vestibules — are a particularly important design component. These work so that the second door of the zone will not open before the first door closes. They often are also on time delays and can trigger alarms when at-risk patients enter them or go near them.

Tom Smith, who is president of Healthcare Security Consultants Inc. and is currently chair of the IAHSS’ Council on Guidelines, notes, however, that it is important to call these exits “elopement buffers” rather than mantraps or sally ports.

“Identifying these configurations as an ‘elopement buffer’ has a much higher likelihood of gaining buy-in and acceptance from clinical and design staff,” he says.

RFID Tags, Wristbands and Ankle Bands Are Effective

Very often the access control systems of these units are integrated with RFID tags or bracelets that at-risk patients wear. Diane Hosson, vice president of protection solutions for Stanley Healthcare, points out that hospitals and nursing homes want the patient or resident experience to be as positive as possible, and that RFID solutions allow facilities to provide that positive, non-restrictive experience while at the same time keeping patients safe.

“They are wearing something on their arm or ankle that ensures they can move about freely within safe areas such as a department or courtyard,” she says. “If it’s an unsafe area such as an exit door or pool area in a long-term care facility, they would not be able to get into those areas.”

RFID solutions now incorporate software so that hospitals and other healthcare facilities can put a virtual fence around areas.

“It might be a patient’s room and two doors on either side,” MacAlister says. “It might be one side of the unit. It might be the unit itself. And then a breach triggers an alarm, usually at a security monitoring center or in some cases the nursing station so they can go retrieve the patient.”

Like all security solutions, however, RFID comes with its own set of challenges. If not installed and calibrated correctly, these systems can experience a significant number of nuisance alarms. Sometimes the tags fall off or are taken off by patients. To address this problem, some RFID solutions have tamper removal alarms that alert staff when the tag is removed.

Create and Practice Your Search Plan

Having a good search plan that can be quickly implemented after a patient escapes is another critical component of your overall elopement/wandering response plan. MacAlister recommends the plan have a staged structure.

The first stage involves a call to security, informing them that a patient is missing and describing the patient’s tendencies, such as wandering. Security then checks all common areas, including where the patient has wandered previously, such as the cafeteria. (Technology can help with the search. Note the comments about reviewing external security camera footage above).

If the patient can’t be located, the second stage calls for staff to search anywhere in the facility that’s not locked.

“The best way to do this is to have a plan that activates all the surrounding units to look for the patient in their surrounding areas,” MacAlister says. “The plan alerts the facilities people to look for the missing patient in all of the areas they frequent… tunnels, boiler rooms, all those kinds of areas where someone could wander. Security should check the grounds.

“Stage three involves searching every square inch of this site, and don’t assume that a locked door means the person didn’t wander behind it. The important piece is that the search is tailored to the risk presented by the patient who eloped or wandered, then that it’s thoroughly documented and that everyone understands the plan. You should quickly determine which type of search is most applicable.”

MacAlister believes that instead of the security department leading the search, the unit that lost the patient should be in charge because they know the patient and his or her tendencies the best.

It helps to have a photo of the patient that can be released to local law enforcement to help them identify the patient. Additionally, many hospitals have their Alzheimer’s and dementia patients wear gowns that are a specific color, which also could help first responders, as well as hospital staff, locate the patient.

“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,” says Sarnese.

Once the patient is located, the plan should cover how the patient will be brought back into the healthcare setting. Staff and security should review how the patient escaped and address those issues, closing any gaps that might be discovered.

The Time to Prepare Is Now

With the increase in the number of patients with Alzheimer’s disease and dementia, hospitals and nursing homes can’t afford to delay in preparing for this “Silver Tsunami.” Wandering and elopement by these patients is one of the biggest risks that any healthcare organization currently faces, and hospitals and long-term care facilities must make accommodations now.

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