patient safety quality healthcare

January / February 2012

Wander-Risk Patients: Best Practices for Hospitals and Assisted-Living Facilities

Older adults and senior citizens with Alzheimer’s disease and other forms of dementia are at elevated risk of wandering away from their medical care facility, which poses unique challenges for the hospitals and specialized care facilities that house these patients. Wandering puts them in harm’s way; they could fall, get into an accident, become a crime victim, or suffer from exposure to the elements.

There are four major steps in the commonly accepted clinical best practice for wander-risk patients:

  1. Identify which patients are at greatest risk of wandering.
  2. Correctly supervise at-risk patients.
  3. Identify and controll wandering triggers in the hospital environment.
  4. Treat the root causes of wandering.

In the first phase, various information-gathering methods should be used to assess a given patient’s risk of wandering. While the staff at dedicated homes for the aged will be acutely aware of the possibility of dementia in an elderly resident, hospitals and other treatment facilities may not realize right away that a new patient has symptoms of dementia, especially if the condition has not yet been officially diagnosed. Elderly patients should be screened for memory problems, delirious behavior, and disorientation. The patient should also be closely observed so that any gradual or sudden changes in their cognitive functioning, mood, or mental clarity are quickly noted. If possible, members of the patient’s family and his or her current or former caregivers should also be interviewed to determine whether the patient has been diagnosed with a dementia-related condition, displays dementia-related symptoms, or has any previous history of wandering behavior.

If, after a careful and complete evaluation, a patient is deemed to be a wandering risk, it is incumbent upon hospital staff to supervise the patient properly. There are numerous supervision techniques that can be used on dementia patients to inhibit them from wandering. First, and most importantly, the patient should never be left unsupervised while he or she is awaiting any type of medical treatment or test. If the patient is going to remain in the hospital or care facility for an extended period of time, careful thought should be given to room placement. In general, it is best for patients with a risk of wandering to be placed in rooms that are located in areas with high staff traffic, and it is ideal if the patient’s only route out of the facility forces him or her to walk past a nurse’s desk or supervisory station. The patient should be checked on regularly and, if necessary, be put under constant supervision. Another technique commonly used in hospital settings is to put the at-risk patient in different-colored gowns to make it easier for staff to identify him or her in a crowd. Finally, staff can encourage high-risk patients to remain inside the healthcare facility by getting a recording of a voice familiar to the patient, such as that of a close loved one or family member, and playing encouraging messages on a loop.

One of the most challenging characteristics of dementia-related wandering is that it can be brought on by specific environmental triggers. Thus, it is centrally important for healthcare facilities with patients who are at risk to implement measures designed to reduce or eliminate the presence of these triggers. Constant foot traffic, activity, and noise are known wandering triggers, as these distract, confuse, and irritate dementia patients, who will then wander off in search of quiet. Also, limit or eliminate the patient’s exposure to what clinicians call "exit cues." Basically, an exit cue is anything that signals to the patient that an exit is nearby; these include elevators, escalators, staircases and, of course, doors. Researchers have also found a relationship between wandering and visual cues related to the world outside the care facility, which include shoes, regular clothing, motorized vehicles, and suitcases. Also, because some dementia patients end up wandering off when they were initially on their way to the bathroom and forgot what they were doing, clinic and hospital staff should also ensure that bathrooms are highly visible and easily accessible. Finally, staff should be aware that the side effects of certain medications commonly given to elderly patients can cause wandering behaviors, so a review of a given patient’s treatment regimen is a good idea if wandering occurs--and especially if it occurs on multiple occasions.

Nursing staff should also use personalized strategies to address the underlying and specific causes of a given patient’s wandering habits. If possible, speak to the patient’s family members and previous caregivers to see if there are unique reasons that the patient wanders away. Some dementia patients believe they are searching for loved ones, or that a reunion with a lost loved one is imminent; others believe that they still hold full-time jobs and must go to work or have a specific errand to run. It is also fairly common for wandering patients to believe they are en route to perform previous responsibilities, such as caring for a child or other loved one, even if they have been free of that responsibility for many years. In other cases, the patient is simply frightened, confused, or restless and is seeking an environment with fewer stimuli. Another sign that a patient may be at elevated risk for wandering is an expressed desire to go home even though the patient already knows (or should know) that he or she is at home in the assisted living facility. If the patient displays an inability to recognize familiar surroundings, returns from an outdoor excursion later than expected, pretends to be busy with a self-assigned task but gets nothing done, appears restless, or makes repetitive movements, he or she should also be considered at elevated risk for wandering.

 

Laguna Honda Hospital and Rehabilitation Center has been providing award-winning care to the diverse population of San Francisco since 1866. Laguna Honda Hospital faces the same challenges as many healthcare facilities do today: striving to provide excellent care and patient safety while operating on a budget. One of the toughest challenges for any healthcare institution is how best to care for patients who have Alzheimer’s or dementia and what to do if they wander from designated areas.

Staff at Laguna Honda Hospital knew they needed a system that could integrate with their existing wireless and overhead paging system already in place, track the location of patients, warn staff when the patient wandered out of a designated area, handle messages in multiple languages, and store multiple taped messages.

“Some patients respond better to a voice that is familiar to them,” explains Donna Valencia, nursing manager at Laguna Honda. “Our system has the ability to individualize the message, not just with the language, but even if a specific person would respond better with the voice of their mom, we can use that and record that voice.”

“It allows us to take better care of our dementia and Alzheimer’s patients, because with a wandering resident, they can easily walk out the front door,” explains Mike Llewellyn, chief operating officer at Laguna Honda. “We have 62 wooded acres here; they could be hard to find if they get outside. Out of 780 beds, we have a very small percentage with a wander issue, so we put in the new system just for a small handful of patients because it allows us to take care of them better.”

Staff at Laguna Honda is now able to observe how effective the new system is. “We can actually see how well the solution is working for certain residents and if we need to change the actual voice message or what it says,” explains Llewellyn. “We’re at the 120-day mark and the system has become extremely valuable to us. It allows the nursing staff to actually spend more time with the residents taking care of them and to keep better track of the residents when they are around campus.”

“The families [of the residents] see it as a positive way to take care of their loved ones,” explains Llewellyn. “They know that if the family member has a wander issue, their voice helps them return.”

Singlewire InformaCast, a mass notification and emergency communication platform, was integrated with Laguna Honda’s AeroScout RFID Tag and MobileView wireless system, the Cisco IP phone system, and the overhead paging system to send individualized messages to residents.

Regardless of whether or not the root causes of a patient’s wandering can be determined, there are other strategies and techniques that staff can use to reduce risk. It is imperative that the patient have a sense of community and belonging in the healthcare facility, and that he or she feels safe and at ease in the hospital or clinic. Room changes can cause panic and confusion in dementia patients, so they should be kept to an absolute minimum and implemented only when there are no other options. Provide the patient with soothing environmental stimuli, including soft lighting and calming music. Harsh, bright lighting and loud, clamorous music can cause a wandering-prone patient to go off in search of a more suitable environment.

In assisted living facilities, patients must be allowed to spend time outside, and beyond constant supervision of dementia patients and patients at risk of wandering, it is important to establish a walking path that loops safely within the facility’s grounds. Daily exercise and allowing the patient to move around have both been shown to diminish the risk of wandering, so permit the patient to engage in these activities to the greatest possible degree. To help patients pass the time, they can be given safe activities that occupy their attention without confusing or disorienting them. One of the most commonly used activities of this nature is sorting a set of objects, or encouraging the patient to look at familiar images, photographs, or photo albums. Other experts suggest that it is better to give the patient a task with purpose, and one that keeps them linked to their memories. The quintessential example of this is to allow an older female patient who used to be a nurse to make rounds with a current nurse at the facility. Anxiety is a known trigger of wandering, and dementia patients tend to become anxious when not engaged with a task at hand or a meaningful activity.

In some cases, the patient may be experiencing pain, which in turn prompts him or her to wander away. Nursing staff should be aware of this possibility and be sure to treat any underlying discomfort or pain, which may make the patient more prone to walking off. Incontinence can be a problem in patients with dementia and Alzheimer’s disease, especially if it goes undetected by nursing staff for a significant period of time, and can lead to wandering behaviors. Sound sleep hygiene practices should also be implemented to reduce the patient’s risk of sleeplessness and wandering at night. Restraining the patient physically should only be used as an absolute last resort, as this can cause extreme distress and increases the risk of patients injuring themselves while trying to escape the restraining device.

Hospitals and healthcare facilities must have protocols in place to be followed if a patient wanders off. In addition to working with local residents and police to find patients who have wandered away, it is good practice to ensure that a current photograph of the patient is easily accessible, and to keep articles of their clothing or other personal items in a sealed plastic bag so that canine search teams can quickly and easily pick up the patient’s scent. It is also the responsibility of the facility’s managers and administrators to regularly test patient search protocols to ensure effectiveness, and to be sure checks and balances are in place to quickly detect that a patient has gone missing. It is also highly recommended that patients who are deemed to be at risk of wandering be registered with the National Silver Alert program. This program, which is available online free of charge, allows loved ones and caregivers to electronically store important information about the patient, which may include a physical description and a current photograph, the patient’s medical records and medical documentation, their power of attorney information and living wills that were filed by or on behalf of the patient.

Some of preventive measures draw on electronic technologies that discourage wandering. Specialized pressure pads and sensors can be installed on patients’ beds and chairs to detect when they get up, which can be extremely effective in discouraging both daytime and nighttime wandering. Radio frequency transmitters and electronic tags can also be used to determine a patient’s distance from the facility and to broadcast his or her location if he or she wanders away or becomes lost inside the facility. Family members of patients in assisted living facilities also tend to consider the technology more humane and a more effective and compassionate way to reduce wandering and the risks of harm that come with it.

James Tonin is a freelance writer based in Los Angeles, California.

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