VHA National Center for Patient Safety

A Toolkit: Patients At Risk for Wandering

This toolkit is designed to provide an overview of patients "at risk" for wandering, as well as a variety of interventions to prevent patients from wandering or becoming missing from VA facilities and grounds.

Think of it as a quick reference you can use to support your efforts.

The suggested interventions range from the most desirable to the most restrictive. It’s impor­tant to consider that each patient is an individual with particular characteristics. A specific measure may work for a particular patient, while it may not work for another. Some measures may need to be used at specific times of the day or under certain circumstances.

The best approach is to be flexible and creative. You may want to consider a combina­tion of the suggested interventions. Try to involve the patient and family as much as possible. Also remember that a patient may have a variety of disorders to take into consideration. Ensure that underlying conditions are assessed through a complete history and physical. And always assess the patient first!

Cognitive Aids and Resources

Three cognitive aids, including a poster, are available below, as well as a number of resources available online.

Definitions

These definitions are drawn from the VHA Directive 2010-052, Manage­ment of Wandering and Missing Patients.

Wandering patient: 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.

Missing patient: An at-risk patient who disap­pears from the patient care areas (on VA property), or while under control of the VHA, such as dur­ing transport.

Absent patient: A patient who leaves a treat­ment area without the staff’s knowledge or per­mission (after checking in), but who does not meet the at-risk criteria outlined for a missing patient and is not considered at risk. According to recent data, this appears to happen most often during patient transport, staff and/or patient communica­tion, or some ambiguity in the process.

At-Risk Patients

Patients are considered “at risk” if, at a mini­mum, they:

• Are legally committed
• Have a court-appointed legal guardian
• Are considered dangerous to self or others
• Have a history of wandering or being missing
• Lack cognitive ability (either permanently or temporarily) to make relevant decisions
• Have physical limitations that increase their risk

At-risk patient assessments for cognitive impairment must be carried out and recorded in the health record in all of the following circum­stances:

• At the time of inpatient admission, dis­charge or transfer between units or settings
• As a component of each initial and annual outpatient evaluation
• When there is a reported change in mental status for any reason

At-risk patients can sometimes exhibit the following behavior:

• Anxiety/stress
• Confusion
• Depression
• Hallucinations/delusions
• Pacing
• Wandering
• Verbalizing intent to leave
• Restlessness

Preparations

A preliminary missing patient procedure, at a minimum, should include:

• Designating persons who can perform a clinical review of a patient’s chart when they have disappeared.
• Designating who may declare a patient “missing or “absent” and what level of search is required.
• Designating a “Search Command Post” and publishing the duties of “Search Coordinator
  • Ensuring command responsibili­ties and procedures are covered on a 24/7 basis.
  • Ensuring time frames and level of each search based on local circum­stances are published.
  • Designating persons who will notify relatives or guardians and are responsible for communicating with them until a patient is found.
  • Establishing criteria to determine when a missing patient search is unsuccessful.
  • Assigning specific staff to given areas to ensure that all areas are searched, and to avoid random or uncoordinated searches.
  • Developing “A Patient Search Grid” that contains all pertinent information and times, directions for searching indoors, directions for searching outdoors, and search team grid assignments

• Note Attachment B, “Preliminary and full search for the missing at Risk Patient,” and Attachment C. Patient Searches using grid sectors,” of VHA Directive 2010-052, “Management of Wandering and Missing Patients.”

Interventions

Before providing a number of inter­ventions, here are a few suggestions for communicating with at-risk patients:

• Speak clearly
• Use a calm voice
• Make visual cues to re-enforce your words
• Make eye contact
• Get their attention by motion or touch
• Look for facial signs of understanding

• Ask yes or no questions and use short simple phrases

First-Degree Interventions

Include diversional activities, such as:

• Aromatherapy
• Change of staff
• Familiar objects
• Family, volunteer, group
• Hobbies
• Pet therapy
• Reading/music/movies
• Rocking
• Social interaction
• Walks/regular exercise
• Orientation/reorientation to unit
• Purposeful focused activities

• Therapeutic touch

First-degree interventions can also include monitoring activities, such as:

• One-on-one monitoring
• Medication review
• Escorts, sitters

• Location checks

Second-Degree Interventions

Focus on environmental enhancements:

• Therapeutic decor (i.e., aquariums, aviaries, plants)

• Soft door barriers/door knobs

Third-Degree Interventions

Include environmental designs:

• Color schemes to identify unit
• Location maps
• Circular unit design
• Clearly marked signs that can be easily read
• Clearly marked patient’s room
• Lighting change
• Offer a quiet room
• Reality orientation board

• Camouflaged doors (exit signs must remain)

Fourth-Degree Interventions

Emphasize a different set of environmen­tal designs:

• Locked unit
• Door alarms
• Tracking system
• Seclusion room

Conclusion

As previously stated, this toolkit may be used as a starting point to support and develop your missing patient program. The safety of our Veterans during their care is of paramount importance. Wan­dering patients may endanger themselves, and so we owe it to them, as well as to their families, to minimize harm in every way possible.

Helpful References

The Birmingham VAMC Healthcare Failure Mode and Effect Analysis (HFMEA) studied the process of identifying and searching for the absent patient verses the missing patient.

VHA National Patient Safety Improvement Handbook, VHA Handbook 1050.01, 3/4/11. All adverse events require reporting and documentation using the “WebSPOT” software application; the type of review required is determined through the Safety Assessment Code (SAC) Matrix scoring process (see App. B).

The National Council of Certified Dementia Practitioners/International Council of Certified Dementia Practitioners offers a wide range of tools, to include the Dewing Risk for Wandering Assessment Tool and the Dane County (Wisconsin) Elopement Risk Assessment Tool (click to "Elopement Risk Assessment Tool"on the site). *†

The National Institute for Elopement Prevention and Resolution*†

AHRQ: Wandering Off the Floors: Safety and Security Risks of Patient Wandering*†

Cognitive Aids

• A pocket card: 4.5 x 3-inch pocket-sized card, Recognizing the Signs for Potential Wandering and Missing Patients
• A detailed two-sided 8 x 11-inch fact sheet, Cognitive Aid for At-Risk Wandering and Missing Patients
• An 11 x 17-inch poster, based on the pocket card,  Recognizing the Signs for Potential Wandering and Missing Patients

*By clicking on these links, you will leave the Department of Veterans Affairs Web site.

†VA does not endorse and is not responsible for the content of the linked Web site.

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