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

Patients may request or even demand to leave the floor after a healthcare provider has determined that doing so would be unsafe and/or undermine the timely and efficient delivery of care. In these cases, shared decision-making (SDM) can help identify acceptable solutions within the identified constraints. SDM combines the physicians’ experience, expertise, and knowledge of medical evidence with patients’ values, needs, and preferences for care.¹⁹ If patients continue to request to leave the floor after the restriction has been communicated, physicians should discuss whether the current treatment plan should be renegotiated to include a relatively minor modification (eg, a change in the timing or route of administration of medication). If inpatient care cannot be provided safely within the patient’s preferences for movement and attempts to accommodate the patient’s preferences are unsuccessful, then a shift to discharge planning may be appropriate. A summary of this decision process is outlined in the Figure.

Of note, physicians’ decisions about the appropriateness of patient movement could conflict with the existing institutional procedures or policies (eg, a physician deems increased patient movement to carry minimal risks, while the institution seeks to restrict movement due to concerns about liability). For this reason, it is important for clinicians to participate in the development of institutional policy to ensure that it reflects the clinical and ethical considerations that clinicians apply to patient care. A policy designed with input from relevant stakeholders across the institution including legal, nursing, physicians, administration, ethics, risk management, and patient advocates can provide expert guidance that is based on and consistent with the institution’s mission, values, and priorities.²⁰

In mitigating the burdens of restriction on movement, hospitals may implement a range of options that address patients’ preferences while maintaining safety. Given the potential consequences of liberalized patient movement, it may be prudent to implement these safeguards as a compromise that addresses both the patients’ needs and the hospital’s concerns. These could include an escort for off-floor supervision, timed passes to leave the floor, or volunteers purchasing food for patients from the cafeteria. Creating open, supervised spaces within the hospital (eg, lounges) may also help provide the respite patients need, but in a safe and medically structured environment.

Returning to the introductory case example, we now present an alternative outcome in the context of the practices described above. On the morning of the scheduled TEE, a nurse noted that the patient was missing from his room. Before the staff began searching for the patient, they consulted the medical record which included the admission discussion and agreement to expectations for inpatient movement. The record also included an informed consent discussion indicating the minimal risks of leaving the floor, as the patient could ambulate independently and had no need for continuous monitoring. Finally, a physician’s order authorized the patient to be off the floor until 10 am. The patient returned to his room at 9:45 am and underwent a normal TEE, after which he was discharged home with outpatient follow-up.