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

Patients’ requests to leave the hospital floor should be evaluated systemically and transparently to promote fair, high-value care. First, a request for liberalized movement should prompt physicians that the patient may no longer require hospitalization and may be ready for the transition to outpatient care.⁸ If the patient still requires inpatient care, then the medical practitioner should make a clinical determination if the patient is medically stable enough to leave their hospital floor. The provider should first identify when the liberalization of movement would be universally inappropriate, such as in patients who are physically unable to ambulate without posing significant harm to themselves. This includes an accidental fall (usually while walking⁵), which is one of the most commonly reported adverse events in an inpatient setting.⁹ Additionally, patients with significant cognitive impairments or those lacking in decision-making capacity may be restricted from leaving their floors unescorted, as they are at a higher risk of disorientation, falls, and death.¹⁰

In determining movement restrictions for patients in isolation, hospitals should refer to the existing guidelines on isolation precautions for the transmission of communicable infections^11,12 and neutropenic precautions.¹³ Additionally, movement restriction for patients who are isolated after screening positive for certain drug-resistant organisms (eg, methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci) is controversial and should be evaluated based on the available medical evidence and standards.^14-16

When making a risk-benefit determination about movement, providers should also assess the intent and the potentially unmet needs behind the patient’s request. Patient-centered reasons for enhanced freedom of movement within the hospital include a desire for exercise, greater food choice, and visiting with loved ones, all of which can enable patients to manage the well-known inconveniences and stresses of hospitalization. In contrast, there may be concerns for other intentions behind leaving assigned floors based on the patient’s clinical history, such as the surreptitious use of illicit substances or attempts to elope from the hospital. Advising restriction of movement is justifiable if there is a significant concern for behavior that undermines the safe delivery of care. In patients with active substance use disorders, the appropriate treatment of pain or withdrawal symptoms may better address the patients’ unmet needs, but a lower threshold to restrict movement may be reasonable given the significant risks involved. However, given the widespread stigmatization of patients with substance use disorders,¹⁷ institutional policy and clinicians should adhere to systematic, transparent, and consistent risk assessments for all patients in order to minimize the potential for introducing or exacerbating disparities in care.

In order to work productively with admitted patients, strong practices honor patients’ autonomy by specifying when and how patients are informed of the institution’s expectations about and limitations to inpatient movement. For example, emergency room patients were less likely to elope when treatment expectations were established at the time of presentation by giving them information about wait times and triage protocol.¹⁸ Similarly, by preemptively discussing reasonable restrictions on movement as a part of informed consent for inpatient admission, physicians can establish patients’ expectations early in the admission process and foster a therapeutic alliance on the basis of the shared goals of safe and timely care.