“Just Getting a Cup of Coffee”—Considering Best Practices for Patients’ Movement off the Hospital Floor

A 58-year-old man with a remote history of endocarditis and no prior injection drug use was admitted to the inpatient medicine service with fever and concern for recurrent endocarditis. A transthoracic echocardiogram was unremarkable and the patient remained clinically stable. A transesophageal echocardiogram (TEE) was scheduled for the following morning, but during nursing rounds, the patient was missing from his room. Multiple staff members searched for the patient and eventually located him in the hospital lobby drinking a cup of coffee purchased from the cafeteria. Despite his opposition, he was escorted back to his room and advised to not leave the floor again. Later that day, the patient became frustrated and left the hospital before his scheduled TEE. He was subsequently lost to follow-up.

Patients are admitted to the hospital based upon a medical determination that the patient requires acute observation, evaluation, or treatment. Once admitted, healthcare providers may impose restrictions on the patient’s movement in the hospital, such as restrictions on leaving their assigned floor. Managing the movement of hospitalized patients poses significant challenges for the clinical staff because of the difficulty of providing a treatment environment that ensures safe and efficient delivery of care while promoting patients’ preferences for an unrestrictive environment that respects their independence.^1,2 Broad limits may make it easier for staff to care for patients and reduce concerns about liability, but they may also frustrate patients who may be medically, psychiatrically, and physically stable and do not require stringent monitoring (eg, completing a course of intravenous antibiotics or awaiting placement at outside facilities).

Although this issue has broad implications for patient safety and hospital liability, authoritative guidance and evidence-based literature are lacking. Without clear guidelines, healthcare staff members are likely to spend more time in managing each individual request to leave the floor because they do not have a systematic strategy for making fair and consistent decisions. Here, we describe the patient and institutional considerations when managing patient movement in the hospital. We refer to “patient movement” specifically as a patient’s choice to move to different locations within the hospital, but outside of their assigned room and/or floor. This does not include scheduled, supervised ambulation activities, such as physical therapy.

Practices that promote patient movement offer significant benefits and risks. Enhancing movement is likely to reduce the “physiologic disruption”³ of hospitalization while improving patients’ overall satisfaction and alignment with patient-centered care. Liberalized movement also promotes independence and ambulation that reduces the rate of physical deconditioning.⁴

Despite theoretical benefits, hospitals may be more concerned about adverse events related to patient movement, such as falls, the use of illicit substances, or elopement. Given that hospitals may be legally⁵ and financially responsible⁶ for adverse events associated with patient movement, allowances for off-floor movement should be carefully considered with input from risk management, physicians, nursing leadership, patient advocates, and hospital administration.

Additionally, unannounced movement off the floor may interfere with timely and efficient care by causing lapses in monitoring, such as cardiac telemetry,⁷ medication administration, and scheduled diagnostic tests. In these situations, the risks of patient absence from the floor are significant and may ultimately negate the benefits of continued hospitalization by compromising the central elements of patient care.