New technology makes wandering safer.

DEPARTURE ALERT MONITORS ARE BROADENING IN SCOPE AND ACCURACY

Technological innovations have led to the development of new wander monitoring systems which can substantially enhance safety management strategies for nursing facilities (NFs). The increased use of electronic systems and devices responds in part to federal legislation limiting the use of patient restraints. More importantly, in combination with other programs, they offer a new standard for cost-effective protection of wandering patients, while offering them increased freedom and mobility.

The range of suppliers now in the marketplace and the diverse technologies used makes deciding on the most appropriate devices, features and systems a daunting task for any Director of Nursing (DON). This article reviews the current approaches and trends in the applied technology and comments on the factors DONs must take into account when determining the needs of their institution.

Protecting the Wandering Patient

Of paramount importance to nursing facilities is the effective and acceptable protection of patients who have the risky tendency to wander off the premises unnoticed. Wandering patients -- ambulatory individuals suffering from Alzheimer's Disease (AD) or other forms of dementia -- pose serious threats to themselves and can affect the reputation of nursing facilities.

With designated wanderers comprising approximately six percent of the total long-term patient population, and with more than 50 percent of all nursing facility residents having AD or related disorders, such conditions pose a substantial, long-term concern. Equally threatening are media accounts of the sometimes tragic results which often accompany undetected patient wandering, significantly challenging the reputation of even the best run facility.

Traditional Approaches: Supervision and Restraint

Traditionally, the answer has been to continuously supervise chronic wanderers, with a less satisfactory solution being to physically or chemically restrain them. In contemporary facilities direct supervision procedures are no longer cost-effective, and could cost several thousands dollars per patient annually. At the same time, restraint methods are becoming socially undesirable, excessively restricting patients' independence and upsetting their dignity and quality of life.

Moreover, patients continue to either wander out of the facilities or become injured, leading to possible liability actions which can be financially disastrous. The $39.4 million lawsuit against a Texas facility following the death three years ago of a resident who had been strangled in a restraint device sent shock waves throughout the NF industry.

A growing groundswell of opinion against restraints, based on therapeutic and cost factors, mirrors the body of federal and state regulations against such practices. With the implementation of OBRA '87 reform, routine restraint of patients, either physical or with sedatives, can no longer be considered a long-term solution from any perspective. Efforts to better understand and react to individual wanderer motivations is a trend that will continue. In the interim, and central to a viable solution over the medium term, the answer is an electronic patient wandering system or the enhancement of existing devices and earlier systems already in place.

The Systems Approach

In simple terms, an electronic patient wandering system permits regular movement of staff, visitors and other residents in and out of the facility while tracking designated clients wearing "tags." This allows patients to move freely and comfortably within authorized areas. Unescorted wandering beyond safe areas or outside the facility causes an alarm and optionally a series of functions and actions to prevent repetition. Besides enhancing the safety of wanderers, the system allows the facility to realize considerable savings by reducing the need for staff to supervise or search for missing patients.

The Patient Transmitter: From Passive to Active

In all available systems today, the person to be monitored wears a device or tag which can be detected at the facility's exits. However, there are many different implementations of tags, and understanding the relative advantages and disadvantages of each is an important ingredient in choosing a system that meets a facility's needs. There are three general classes of tags: passive, transponder, and active.

Passive tags are one of the earliest forms used; the idea was borrowed from the retail article protection market. They are passive in that they do not emit any signals of their own, but rather disturb or modify an electrical or magnetic field produced at the door. They are inexpensive, require no battery and are waterproof. They have a limited range of operation so that the tag must be in close proximity to the receiver for detection to occur. Protecting an exit which has two or more doors may be expensive for both equipment and installation and may not be visually attractive. Finally, these types of systems do not distinguish the presence of more than one tag at the same time, nor do they identify each individual tag or person. In summary, you may not know how many persons left the facility or who they are, and because the tags are passive, you have no means of locating them outdoors.

Transponder tags are essentially passive until they enter an electrical field produced at the door, at which point they turn on and emit a signal. They are electronic and require a battery. Depending on the manufacturer, transponder tags may or may not have a unique identification and the system may not be able to detect multiple tags. Like passive tags, their effective working range is usually small, so protecting multiple door exits may, again, be costly or unattractive.

Active tags emit a signal all the time, so they don't have to be near a door to be working. This gives them the unique ability to be picked up anywhere, including outside the facility. Their effective working range can be quite large, making installation at multi-door exits as simple as at a single door. Some active tags identify each individual, and some systems can detect and identify more than one person going through the exit. Simpler active tag systems may be affected by outside noise sources such as electrical storms or equipment and have high false alarm rates. The newer systems use sophisticated methods to eliminate false alarms and achieve a high probability of detection performance.

Transponder tags and active tags are more expensive than passive tags, and require batteries, but offer more performance. Active tags are not limited in detection distance and are usually easier to install.

Individual identification permits a wanderer's pattern to be tracked, clearly indicating which "capture zone" they have entered, as well as differentiating one patient from another, even if there are multiple tags in a group. For staff of large facilities, this feature allows for efficient reaction and deployment when an alarm occurs.

Beyond the basic features provided by the tags, the rest of a wander monitor system can offer a wide variety of options and enhancements that can be customized to meet the specific needs and requirements of the facility.

Magnetic Door Locks, Pagers and Elevators

Systems can also include delayed magnetic door locks that meet NFPA regulations and prevent a door from being opened if an alarm occurs. They offer convenience because staff do not have to respond to an alarm, realizing that the wanderer is safely confined to the facility. They must be connected to facility fire and emergency systems, so that they release automatically when a fire alarm is tripped.

Advanced monitors can also signal an alpha pager or enunciate a digitized voice through an existing PA system, informing staff in other NF areas of an alarm. In multi-story buildings the monitor can also temporarily disable elevators in the area, ensuring the wanderer does not disappear onto another floor or outside.

Locating the Wanderer Outside

Newer technology focuses on locating the wanderer outdoors. Our firm, for example, markets active "intelligent" transmitters with individual IDs. This allows use of a hand held locator to pick up the outdoor transmitted signal and directs staff towards the patient. A signal strength indicator as well as an audible one provide further directional assistance. This device can prove especially useful as many outdoor wanderings occur in the evening or after dusk when visible discovery may be difficult.

Network Control and System Flexibility

In larger facilities, more flexible systems allow for various configurations of monitors to be networked to controllers, often located at nursing stations. Distributed processing of alarms is especially useful where a group of monitored exits is at remote distances from the nursing station. The use of centralized controllers is becoming more popular as many NFs begin to distribute security monitoring activities amongst multiple posts. Controllers also allow for the direct attachment of printers, permitting the creation of hard copy activity records.

A refinement of interest to DONs is the capability of incorporating PC-based software. This allows for the creation of system status reports, facility layouts, audit trails and historical reports of individual wanderer activities. The latter feature is especially useful as AD patients' personal wandering conditions can often be addressed by staff once their wandering habits and patterns are closely assessed. PC-based software also allows for further integration of other facility systems, such as Nurse Call.

Making the Right Choice

Patient wandering systems have a permanent place in the contemporary NF environment. Critical safety and liability concerns, as well as increasing regulatory requirements, make the use of a system designed to specific facility and patient needs a necessity. Choosing the system that's right for your facility requires that you understand what you need and ask very specific questions about performance, reliability and total costs. Booklets such as "Asking the Right Questions About Wandering Patient Systems" (available from our firm at no cost) are an important tool to decision-makers. No system, however, can replace a well-trained staff, sensitive approaches to understanding AD and related conditions, and fully implemented risk management procedures.

Brian Martin is President of Instantel Inc., which manufactures the WatchMate series of patient monitoring systems. He has over 18 years' experience in the design, development and marketing of products in the military, telecommunications, computer and instrumentation fields. For further information, call (1-800-267-9111).