Absconding – Prevention Guidelines

1. Introduction

Absconding is when a mentally ill patient goes missing from the ward/treatment unit secretly or without an agreement of care providers of the hospital and whose whereabouts are unknown. All over the world absconding of mentally ill persons are considered as a serious patient safety issue as they carry an increased risk of harm to self as well as the community (Holmes, 2016). Although absconding can take place in many different care settings, this module will focus on the absconding of patients under care in a mental hospital setting and discuss the person, clinical and treatment factors that may contribute to its occurrence.

National Institute of Mental Health (NIMH) is the apex body for treating mentally ill patients across the country. It looks after most of the patients from all nine provinces of Sri Lanka. These patients are detained in the hospital against their will under the Mental Disease Act of Sri Lanka (Weerasundera, 2012). According to the Mental Disease Act of 1956 patients can be admitted to the hospital voluntarily and involuntarily.

Mentally ill patients who lack insight are admitted involuntarily. They do not have the capacity to decide whether, they need admission and treatment nor can they leave the hospital. The responsibility of protecting a patient admitted involuntarily lies entirely upon the hospital staff. Therefore, under no circumstances should a patient be allowed to abscond.

2. The clinical and legal status of absconding

The decision to make a patient as having absconded from the care facility is depending on a person‘s

intent, his legal and clinical status (Patient Safety Education Program, 2019).

a. Person‘s intent - whether the person has expressed intent to the treatment and care providing

team that person wants to leave care.

b. Legal status – Whether the patient has got admitted voluntary or involuntary.

c. Clinical status – the level of risk that a person poses to self or others as well as the person‘s

ability to care for himself/herself.

3. Declaration of absconding

a. A person who got admitted involuntary and is missing from the care facility/unit may be considered to have absconded since their legal status is involuntary. b. An involuntary patient is missing from the care facility/unit and his clinical status consistent with a high risk for harm to self or others or an inability to care will be classified as the patient has absconded. c. A voluntary patient who has left the care facility/unit and his clinical status consistent with a high risk of harm to self or others also will be classified as to have absconded.

4. Contributing factors for absconding

Literature provides two categories of factors that have contributed to increasing the risk of absconding. The first category is related to the person (push factors) and the second category of factors is external to the person (pull factors) and includes the clinical culture and the treatment provided.

5. Factors related to the person (push factors)

Includes some demographic factors and clinical risk factors.

5.1 Socio-demographic factors 5.1.1 The age of the patient

Younger patients less than 35 years and elderly patients with dementia tend to abscond more than others. 5.1.2 Gender of the patient

Male patients pose a high risk to abscond than females 5.1.3 The race of the patient

Language barriers poses a risk to abscond

5.2 Clinical risk factors 5.2.1 Diagnosis of the patient

Patients with schizophrenia, borderline personality disorder, dementia, and psychotic disorder pose a very high risk of absconding. 5.2.2 Substance use and addiction

Patients with a history of substance use, 0alcohol dependence, smoking, and betel chewing are also associated with increased risk of absconding behaviour, presumably out of the need to

acquire

the substance. 5.2.3 Wandering behaviour

Patients with progressive cognitive impairment exhibit wandering behaviour and engage in exit-seeking that is characterized by a wilful intent to leave a secure treatment unit/facility without permission. 5.2.4 Intent to self-harm or commit suicide or homicide

Patients with a true intent on wanting to self-harm, die or kill others may seek chances to leave the treatment facility to carry out such an attempt. 5.2.5 Medication issues

When a person lacks insight due to the illness, in his view, he is neither ill nor requires treatment or intervention. Therefore, the introduction of pharmacological or other intervention in the care facility will cause the patient to seek means to disengage from the treatment or the intervention including absconding.

6. Factors external to the patient (pull factors)

6.1 Clinical culture

The policies, guidelines of the institution and attitudes and approaches that clinical staff bring to the care facility have a vast impact on the care outcome of the patients. As well as those cultural practices may lead patients to abscond from the care facility. As an example, nursing styles that are custodial rather than therapeutic may increase the risk of absconding, as well as clinical cultures that focus on blaming others rather than collaborative care.

6.2 Treatment-related factors

Absconding tends to occur in early days of admission to the institution where adjustment to the care facility is incomplete and the therapeutic relationship is not established. The risk of absconding is also higher during the transitions in care, referrals and shift changes.

Issues such as failing to take the time to understand the patient, establish trust with the patient, and include the patient in developing goals of care may underscore the importance of a recovery-oriented and culturally responsive focus of care that establishes a strong therapeutic relationship leading to attempts to abscond from the care facility.

6.3 Lack of homely environment such as leisure, entertainment, lack of favourite meals or beverages and selling places to buy such.

6.4 Home-related concerns, homesickness, social relationships or issues due to employment/unemployment, lack of visitors or ways to contact them are also associated with an increased risk of absconding.

7. Responsibilities of individual groups of staff

7.1 Medical Staff

Assessment and Review

To ensure a full medical assessment on admission with appropriate medication including PRN drugs/ sedatives

Review by the Medical Officers and consultants as frequently as necessary. Risk assessment should be done by the medical officer at the admission and if necessary, in the ward assessment process. It can be scaled up or down accordingly.

If transfer is considered to a less secure environment (rural unit or to intermediate care) medical staff should consider whether this will increase the likelihood of the patient absconding. E. g. Some patients may abscond to avoid ECT.

7.2 Nursing staff

Nurses have a key role to play in reducing the number of patients absconding and should carry out the following actions:

7.2.1 Risk identification/care planning

Absconding risk assessment (See Annexure II), identification of the level of risk and patient observation/care plan should be started with the joint assessment at the admission desk and

completed in the ward. The reassessment of risk needs to be carried out in the ward whenever needed until the risk is scaled down to ‗small‘. The nurses should ensure that the risk is fully recorded as follows: Identification signs of the patient Level of risk (using risk assessment tool) Whether the patient states the intention to abscond or go home Risk of violence (refer the management of violence guidelines) Risk of suicide (refer the suicide prevention guidelines) Where risks are identified in the assessment/care plan, the necessary actions must be immediately implemented after discussing with the multidisciplinary mental health care team to minimize the risk of absconding and others.

7.2.2 Observation (Please refer the observation guide below)

The risk level should be recorded on the whiteboards of the wards and then for each duty shift a member of staff should be allocated to observe the patient‘s risk as per observation guide. They should be observed constantly as the risk level indicates.

Type of supportive observation required e.g. patient behaviour and mental state.

Regular discussions with patients so that staff can assess when patients are not being honest (reintentions to abscond).

Need to accompany patients when they are at risk of absconding and visiting other areas on the site e.g. national hospital/ dental unit.

Where patients are attending appointments elsewhere the number attending should be counted on departure return.

7.2.3 Patient Information a. Lead them to understand their care plan on admission and at appropriate intervals b. Explain about the necessity of the x ray or medication prior to the procedure Medication restrictions and observations should be explained properly to the patient c. To identify a supporting person (another patient or member of staff) ensure that the patient knows that they can approach this person with concerns d. Explain what needs to happen before they can be discharged e. Maintain a good relationship with family friends and care providers.

7.3 Support Staff a. Support staff also has a major role in prevention of absconding as they should always be in the wards with the patients. They need to support ward nurses in observation of patients. They are often in close proximity to the patient and may therefore be the first to notice that patients want to abscond. This should be reported to the nurses or medical staff. b. Support staff is responsible for ensuring that entrances and exits to passageways are locked. This is very important in preventing absconding patients. c. Support staff will be given training to support patients and nurses in this important role.

7.4 Security Staff

Security staff have a role to play in preventing absconding patients by keeping the gates closed.

Security staff need to issue visitors passes to all outsiders who enter the hospital premises in order to differentiate absconding patients from visitors or other. However, if they suspect that any patient is absconding, they should: a. Ask the person who they are and if a patient, which ward they are from b. Retain the patient at the gate area c. Inform Director, AO, OPD doctor, SGNO immediately, relevant ward nurse d. Accompany patient to the OPD/WARD for identification

8. Absconding prevention strategies

8.1 Establishment of a strong therapeutic relationship with the patient

Establishment of a strong relationship and rapport between the patient and the clinician is essential in the first moment of the contact as it continues throughout the care process. Following strategies can be used to build the relationship and rapport with the patient. a. Introduce yourself to the patient and your role and the purpose of assessment in order to reduce the anxiety and uncertainty. b. Ask the patient how he/she wants to be addressed? c. Take time to listen to the patients‘ story and be empathically d. Assess the patient in a comfortable & private environment

8.2 Promote patient-centered approach instead of disease-centered approach

Some interventions and procedures may bring traumatic experiences for some patients.

Multidisciplinary care teams should not exert their power to control and treat the patient. Instead, the care team should make opportunities where power and control could be shared with the person and make him/her feel valued and respected. Hence, it is vital to involve patients whenever possible and their relatives as much as possible in developing care plans and strategies to prevent absconding.

8.3 Respect cultural differences

A person is usually deeply connected to the cultures which he/she brought up. It is important for the care team to be responsive to the patient‘s culture by engaging culturally similar personnel that can help the care team to understand the person‘s cultural perspective and develop strategies for improving the person‘s willingness to stay in the care facility.

8.4 Proper structuring of the patient‘s day

Scientific engagement of patients in recreational and leisure activities may help to reduce the absconding risk.

8.5 Minimization of restrictive procedures as absconding preventive measures

The balance between patient‘s rights and safety needs to be established depending on the risk levels.

Control measures used to prevent absconding for high risk patients may not be appropriate for moderate or low risk patients. The precautions should be as non-restrictive as possible and help the patient to engage in possible experience. As an example, a low risk patient can be granted a short leave using sign-in and sign-out book while a patient with a moderate risk could be referred to a

leisure activity where a member of the multidisciplinary team can monitor the patient while he/she is engaged in a positive therapeutic experience (Bowers, Alexander & Simpson, 2019).

8.6. Development of patient friendly physical environment

The hospital administration must endeavour to improve the physical environment of the instrument as the following measures may help the reduction of absconding of patients. a. Improvement of ward physical conditions including toilets, washrooms, dining rooms, seclusion rooms. b. Construction of buildings to improve bed capacity as per the master plan to implement the concept ―one bed for one patient‖. c. Facilitation of communication with family members and close relatives by means of establishing a prepaid telephone system within the hospital. d. Improvement of the menu, taste and presentation of hospital food and beverages preserving nutrition values. e. Improvement of the condition of the hospital cafeteria and food enabling patients themselves to enjoy a menu of different tastes once in a while.

Management of absconding includes the following methods; a. Use of intensive support b. Leave c. Sedating medication (Refer the guideline of chemical sedation) as well as containment methods such as; Seclusion (Refer the guideline of seclusion) Restraint (Refer the guideline of restraining) Increased observation levels (Refer patient observation No.10 of this guideline) Locking of ward doors or parts of units

9.1 Risk assessment for absconding at the admission and in the ward

It is needed to assess the risk of absconding of the patient while doing the joint assessment at the Out

Patient Department (admission) by the nurses using the risk assessment tool (Annex I) apart from the assessment of the admitting doctor.

9.2 Observation of moderate and high-risk patients for absconding

When the risk of absconding is high or moderate the ward-nurses need to assess the risk of absconding daily and observe the patient constantly according to the given observation guide. The monitoring frequency can be scaled up or down with the level of absconding risk of the patient. Seek medical advice for three times a day until the risk of absconding is settled. Consider review of the care plan with the multidisciplinary team when the risk of absconding is not settling for more than 72 hours.

9.3 Collection of patient identification characteristics

Patient identification characteristics may help hospital staff to identify the patient when absconded.

Therefore, it is vital to gather information and record on prominent signs of the patients (teeth, skin color, hairstyle and type, prominent skin scars, skin nevi and lesions etc.). Use of a non removable

and uncrackable bracelet with a GPS tracking is another option that needs to be considered at the institutional level.

9.4 Activation of search plan

10. Patient Observation levels

Use the following patient observation guide to observe patients in the ward with an increased level of absconding (nurse observation).

10.1 For patients with a high risk of absconding (when the risk assessment Score is 3)

Seek for medical advice of the ward medical team three times a day until the risk is settled. Review & revise the treatment & care plan whenever needed with the multidisciplinary team. With the instruction of the medical team and with your career experience, you may scale down or scale-up the patient observation level.

10.2 Level of close nursing observation should be decided as observation guidelines (level I to IV)

10.3 Intermittent observation (when the risk assessment score is 2 or less) a. An experienced or less experienced nursing officer can engage in observation at regular intervals. b. Observation time intervals can be determined by the nursing officer depending upon the risk factors and the behaviour of the patient. c. Keep observation at the determined intervals for another six hours. d. Whenever needed, review the treatment and care plan with the multidisciplinary team. e. If the risk level of the patient is improving, scale down the observation to ―negotiated‖.

10.4 Negotiated observation

When the risk level of the patient is one & the behaviour and insight is appropriate, nurses can negotiate the frequency of the engagement with patients.

11. Quality improvement

As outlined in the guideline, this is a part of the patient safety and quality improvement process of the institution. Improvement of the quality of the system will improve the positive relationship between the patient and the care provider. Further, incident reviews or audits within an organization can explore a number of factors to make recommendations for how a change of organizational procedures and policies need to roll-out.

12. Review of incidents 12.1 Find time to review cases of absconding with your ward care team. 12.2 Suggest senior management of the institution the ways to reduce the rates of absconding through planning units. 12.3 Forward unit suggestions to monthly clinical audit.