When patient elopements at Penn Medicine Rehabilitation increased in fiscal year 2023, an interdisciplinary team reviewed the data to identify opportunities to reduce these events.
Elopements are high-risk events, as patients can incur harm or injury during them. Rehab defines elopement events as when patients leave the hospital premises outside of therapeutic committee activities. Upon further review of the events in FY23, it was discovered that they occurred more frequently but were not reported in the event reporting system.
Upon diving deeper into the events, the team noted that most elopements occurred between 6 p.m. and 9 p.m., and the most reported reason was to purchase food or snacks at nearby food retail establishments. Most often, staff were not aware the patient had left the floor. Penn Rehab did have a “patient outside” process that required an order from the provider, the patient staying on the property in the patient-designated outside area, the patient being accompanied by a family member or other visitor, signing out before they leave the unit, and returning to the unit within 30 minutes of leaving. The team discovered that most patients who left reported not being aware of the outside process.
The hospital implemented an action plan which included
- Closing the unit doors during peak elopement times
- Adding vending machines to the rehab unit in space accessible to patients
- Creating signs for the outside of the building that identify patient-designated areas with pictures and include instructions that patients are not to leave the premises and must return to the unit within 30 minutes
- Creating patient and staff education about the off-unit process and reviewing the process with patients upon admission
- Adding yellow tape to all hospital wheelchairs so inpatients will stand out if they are off the unit
- Educating all staff, including security, that if a patient is off the unit and alone, they contact the unit and bring the patient back to the unit.
The hospital is currently trialing Apple AirTags on hospital wheelchairs so if a patient does elope, they can be located quickly.
The initiative reduced inpatient elopement events from nine in FY23 to six in FY24. Of note, the team feels there were more events in FY23 that were just underreported. They continue to review each elopement event to learn from it and are working on additional interventions to continue reducing these events.
