Wandering and elopement technologies: a guide.

Editor's Note: Two years ago, ECRI, a nonprofit agency that has been involved in health care risk management for some 30 years, turned its focus on safety in long-term care. It assembled a Continuing Care Risk Management System, consisting of risk analysis articles, questionnaires, forms, checklists, on-line services, telephone consultations and a newsletter, all addressing safety concerns specific to nursing homes, subacute and rehabilitation units and assisted living facilities. ECRI gave Nursing Homes permission to reproduce an excerpt from a risk analysis article on commonly used technologies to control resident wandering and elopement. The excerpt follows:

Electronic Technologies

When used correctly, electronic devices (e.g., door alarms, video cameras, patient tracking devices) can greatly reduce the incidence and severity of potentially dangerous elopements. Beyond simple exit alarms that are activated when anyone passes through, many facilities now use elopement protection devices that are triggered only when certain individuals attempt to exit. These devices have battery-powered identification bands, anklets, or other "triggers" with built-in transmitters that cause an alarm to sound only when an individual wearing the trigger attempts to leave a secured area, thereby not restricting the free movement of other residents. Although most commonly used in nursing facilities, they are becoming more common in the rehabilitation field.[1]

The greatest drawback to any alarm system's effectiveness is misuse (e.g., staff disengaging or ignoring alarms, patients removing triggering devices). Cost is often cited as a deterrent to purchasing electronic wandering and elopement control systems. Their cost, however, must be weighed against the repeated cost of searching for wanderers and the increased potential for serious losses. Wrist bands and other devices on clothing that trigger alarms to warn staff that a resident is leaving a room or facility do not, in and of themselves, restrict freedom of movement and are not considered restraints under Federal Medicare and Medicaid nursing home regulations.[2]

Experts recommend contacting other user facilities before purchasing any electronic wandering-control system. Suggested questions to ask include.[3]

* Does the system work in all weather conditions?

* Has it actually prevented or reduced patient wandering?

* Does it break down? How often?

* How are repairs accomplished? How are replacement parts obtained?

* How frequent is service required?

* If you have to do the installation yourself, is it as easy as the manufacturer says?

* If the manufacturer does the installation, is it satisfactory?

* What complaints have you made to the company? How did it respond?

* How reliable are the manufacturer's sales or service people?

* What is the cost of maintaining the system? What do the triggers cost, and how often do they need to be replaced? What is the cost of batteries or electricity?

* What are the nursing staff attitudes toward the system?

* How do nurses respond when an alarm sounds?

* Has staff frustration ever led to the system being shut off? How often?

* What staff training will be needed?

* How many false alarms are there? For example, does electrical interference complicate the system?

In getting names of previous customers from the manufacturer, try to match them with your own facility (e.g., similar size, number of floors, number of exits, location of residents).

Door Alarms

Door alarms have a twofold purpose -- to create a deterrent for the eloper and to notify staff. Alarms must be reliable. If a system is set up to detect only the presence of certain residents, for example, make sure false alarms do not occur. Anytime an alarm sounds, it must be attended to. Even a few false alarms may result in less staff diligence. Staff sometimes fail to respond when an alarm sounds, assuming that it is an authorized use of the exit.

Obviously, an alarm system is useless if no one follows through and investigates. All facilities should have firm, written policies regarding exit alarms. When staff members hear an alarm, they must investigate immediately. Alarms should not be able to be reset from a remote location such as a nursing station; they should reset only at the door. Obviously, alarms must be loud enough for staff to hear. When designing a system, take into account that there might be no one at the nursing station when the alarm sounds (particularly at night).

Locking Systems

Local fire codes and the fire marshal should be consulted before a decision is made to lock any exit doors. Doors that lock when certain persons approach or require special procedures for opening (e.g., coded locks, magnetic locks, cardreading systems) can be fire hazards without appropriate release mechanisms built in and may not be permitted. In some buildings and in some jurisdictions, doorlocking systems can be wired so that door locks are automatically turned off when the fire alarm system is activated. Local licensing may be required.

In March 1994, the Health Care Financing Administration (HCFA) issued a Life Safety Code (LSC) interpretive update to the guidelines for LSC surveyors with respect to locked doors in long-term care facilities and psychiatric hospitals.[4]

The guidelines allow locked exit doors in psychiatric hospitals and intermediate care facilities for the mentally retarded (ICF/MR), provided that all locked exit doors are keyed to a master lock and ALL staff carry a key on their person at all times while on duty in the facility. If a surveyor finds that any staff member does not have a key on his or her person, then special locking arrangements may be required.

The guidelines further allow doors to wings in a health care facility to be locked to accommodate persons with special needs (e.g., persons with Alzheimer's disease) if the following caveats are observed: (1) The lock must release upon loss of power or activation of the building fire alarm. (2) Any required fire protection system (e.g., smoke detection system, sprinkler system) is tied into the fire alarm system. (3) There is an override system, such as a digital keypad, push-button release, or key locks, depending on the nature of the individuals served in the wing. If key locks are used, ALL staff must carry keys on their person at all times. (4) Locked doors must not be used to replace staff or in violation of resident rights provisions of the Federal regulations.

References

[1.] Electronic article surveillance systems in health care -- An update. Hosp Secur Saf Manage 1995 Jan; 11(9);5-10.

[2.] 42 CFR 483.13. Resident behavior and facility practices interpretive guidelines.

[3.] Supra note 32.

[4.] Health Care Financing Administration. Additional Guidance to Surveyors Life Safety Code. Memorandum. March 10, 1994.

Action Recommendations

* Establish protocols to identify potential wanderers upon admission to nursing, rehabilitation or other continuing care facilities.

* Continue wandering assessment into the first few days of the resident's stay -- remember that elopement attempts are most likely to occur in the first two to three days.

* Carefully document in the resident's chart all admission information received from the residents family or from other institutions, and the results of independent assessments or observations with respect to wandering, confusion or elopement attempts.

* Document notes on safety precautions taken at the time (e.g., additional supervision, room placement, electronic triggering devices, restraints).

* Make sure all caregivers are aware of an individual's propensity to wander. Ensure communication of wandering or elopement attempts from one nursing shift to the next.

* Implement the wandering prevention and management strategies appropriate for your facility.

* If electronic devices and alarms are used, ensure that staff are trained in their use, and investigate each time they are activated.

* Consult local fire safety regulations before installing any automatic locking device on exit or other doors.

* Have a protocol in place to locate missing patients or residents. Ensure that all staff are familiar with the procedure. Conduct drills regularly.

* Review restraint and seclusion policies for violent or psychotic patients in all facilities. Ensure that these patients are closely supervised.

* Ensure that adequate documentation is completed.