October 29, 2004

VUMC rolls out new missing-patients policy

Featured Image

From left, Katie Wilkerson, R.N., an infection control practitioner, Cindy Irwin, R.N., a clinical risk manager, Maria Fonseca-Kheshtl with utilization management, Tracey Bunch, an anesthesia technician, and Kelly Cole, R.N., talk about washing up during Hand Hygiene Awareness Day on Wednesday. Members of the VUMC Hand Hygiene Task Force visited patient care units to hand out cookies and spread the message that improved adherence to basic hand hygiene presents the biggest opportunity to reduce infections acquired in hospitals. The effort includes new annual training requirements, more alcohol gel dispensers for hand washing, ongoing monitoring of hand washing practices and other changes. Elements of the hand hygiene campaign have been under way since this summer at the Monroe Carell Jr. Children's Hospital at Vanderbilt.
photo by Dana Johnson

VUMC rolls out new missing-patients policy

A new policy concerning actions and notifications about absent patients will go into effect Dec. 1, with training set to begin Nov. 1. The policy affects all Medical Center faculty and staff.

Previously, procedures taken when a staff member suspected an infant, child or adult patient was missing was referred to as a “code Adam.”

The new policy breaks down the procedures into four areas, eliminating the universal title “code Adam.” The new codes are:

Code Pink — infant missing (younger than 12 months old )

Code Purple — child missing (1 to 12 years old)

Code Walker Adolescent — adolescent (13 to 17 years old)

Code Walker Adult — adult (18 years and older)

Mandatory training on the new policy will concentrate on the responsibility of each staff member during a missing person incident, and conditions which warrant issuing one of the four missing person codes.

“This represents a major shift in procedures for VUMC,” explained Cathy Ryan, a lieutenant with Vanderbilt Police who spearheaded the group which wrote the new plan. “It affects every VUMC employee.”

Staff training and communication about the new policy will begin Nov. 1 and will include the use of online training, a video presentation and other handout materials.

In addition to changing the codes for a missing person, staff will also now immediately call Vanderbilt Police to make initial notification instead of the hospital operator.

“We want staff who suspects an infant, child or adult patient to be missing to immediately dial 911 from an on-campus phone,” Ryan said.

“That will connect them with the Vanderbilt Police Department, who will ask the caller a number of questions to screen the call, and will then tell the staff member which code to communicate to the Vanderbilt operator for an overhead page.”

Criteria for announcing a missing person code as an overhead page will change as well. Ryan said that many of the situations where “code Adams” were announced as an overhead page in the last year will not meet the new criteria for announcing a missing person code.

“Someone who leaves AMA (against medical advice) is not necessarily a missing person if staff members know the patient left AMA, or know the patient's whereabouts. Those types of situations may not necessarily be announced as a missing person code under the revised policy,” she explained. “The new policy is more specific.”

The revised policy has been a system-wide effort, even having input from noted expert John Raben, vice president and chief operating officer of the National Center for Missing and Exploited Children.

“Raben came and did a presentation as well as an inspection of some of our facilities as part of the process of developing and reviewing this policy,” Ryan explained. “It was part of our overall effort to ensure we were putting the best possible policy and plan in place.”

Under the new policy, if a staff member suspects an infant, child or adult patient is missing:

• The staff member who is notified that a person is missing will dial 911 to speak with the Vanderbilt Police Department. The VUPD 911 communications specialist will obtain a description and location, and will communicate the appropriate code to be announced.

• After speaking with VUPD, the staff member will call the hospital operator to communicate the code to be announced along with a description and location.

• Role-specific notifications and responsibilities are detailed in the policy.

• If a missing person code is called, all VUMC faculty and staff have specific search responsibilities as defined by their role and location within the Medical Center.

• The incident command system is utilized to ensure a thorough and systematic search of the facility as well as the perimeter areas.

• VUPD will notify the hospital operator to announce that the Code is terminated when the missing person is located, or when VUPD, in consultation with the administrator on call, determines that the search within the facility is terminated.

• All questions from outside media will be referred to News and Public Affairs.

• Support resources for family members, as well as VUMC staff members involved in the incident, are included in the policy.

• Overhead announcement for missing person search announcement and policy activation is: Code Pink, Code Purple, Code Walker Adolescent or Code Walker Adult followed by unit identification and a complete physical description of the missing person.