Often neglected, the world of pediatric security can morph into a major risk

You need the same precautions as the labor and delivery department

Have you made your labor and delivery unit a veritable fortress with high-tech equipment and strict policies to prevent infant abductions, while leaving the back door wide open? Children in the pediatrics unit can be just as vulnerable as infants, experts say, but risk managers too often put all their focus on protecting the newborns while devoting relatively few resources to other young patients.

Risk managers have put a lot effort in recent years into preventing infant abductions from newborn areas, and the latest data show the work pays off. Health care risk managers started paying much more attention to the risk of infant abduction in the 1990s, and prevention efforts kicked into high gear in 1999 when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert about the danger.

Data indicate that infant abductions have dropped significantly. Infant abductions represented 3% of all sentinel events in 1996 and dropped sharply to less than 1% in 1999, then to less than 0.5% in 2003, according to JCAHO data.

A recent infant abduction occurred Dec. 25, 2003, at Beth Israel Medical Center in Newark, NJ, when a woman befriended a new mother, convinced her to take a shower, and then walked out with the baby after removing the child’s security tag. It was the first infant abduction from a hospital in 22 months, the longest stretch without any cases since 1983, suggesting that prevention efforts are working. The irony, however, is that the same hospitals with elaborate systems to prevent someone from walking off with a newborn may have virtually no systems in place to stop a stranger — or more likely, an estranged family member — from taking an older child from any other area of the hospital.

And abductions are not the only risk. Children also are at risk of being abused if access to pediatric units is not tightly controlled. The lack of pediatric security is a growing concern among some insurers, says Susan Chmieleski, APRN, JD, CPHRM, formerly director of health care risk management with the Chubb Group of Insurance Companies in Simsbury, CT. She spoke on the topic at the recent meeting of the American Society for Healthcare Risk Management in Nashville.

"Underwriters are going to ask about it," she says. "The problem these days is not necessarily the security of newborn and nurseries, but in pediatric units. A lot of hospitals don’t have dedicated pediatric units anymore, particularly in smaller hospitals, and the security of these kids is forgotten."

Serious liability risk

Abduction or abuse of a child is a highly emotional tragedy that will have far-reaching liability implications, experts say. The financial is great from lawsuits — almost certain to be filed after such an incident — but the losses will include more than money.

The organization will suffer extremely bad publicity in the community, possibly for years afterward, as people remember your hospital as the one in which a child was harmed. And an infant abduction automatically qualifies as a sentinel event with JCAHO. That means the event will prompt a nightmare of investigations and reports.

Information from the National Center for Missing and Exploited Children, which monitors infant abductions from health care facilities, indicates that the hospital is more likely to be sued in cases where the abductor impersonated a hospital employee than in those cases in which the abductor used another method to obtain the child.

Smaller facilities also may be more at risk now that people are more aware of the sophisticated security systems in larger hospitals, according to the center.

Hospital expands security to pediatrics

Some risk managers are realizing that tight security in the labor and delivery department is not enough. Kathy Haig, RN, director of quality resource management, patient safety officer, and risk manager at OSF St. Joseph Medical Center in Bloomington, IL, says her facility has spent about $10,000 in the past few years to expand security for pediatric patients and is planning a major upgrade soon.

"Everyone is so tuned in to babies. When you hear about abductions everyone thinks babies, but babies can be in peds too," she says.

The hospital had a sophisticated security system in obstetrics for several years before adopting similar precautions in pediatrics, she says. The improvement was spurred in part when Haig became risk manager and saw young patients in the hallways and doors left open on the pediatrics unit.

"I looked at that and said, C’mon guys, this just isn’t good,’" she says. "These are little kids, and we have to more careful."

The hospital’s precautions in pediatrics now mirror those used in the labor and delivery unit, with sensor tags on the children that set off alarms when they approach exits. Haig says she recently encouraged the director of obstetrics to put in a capital budget request to replace the entire system because it is about 10 years old and the original maker no longer services the equipment.

OSF St. Joseph’s also updated its policies and procedures to require the same sort of precautions in pediatrics that are common in newborn areas, such as checking the identity of all visitors and requiring that children never be left alone. The hospital expanded its Code Pink drills to include abductions of pediatric patients, not just newborn infants.

Sensors set off alarms, lock doors

The pediatrics unit has two sets of doors that could be used to exit the area, so both have alarms that are triggered by arm bands on the child, says Karen DeLong, RN, BSN, nurse manager for pediatrics. If a child with an armband gets within 10 feet of the door, an alarm sounds and the doors close and lock.

To reset the system, switches must be activated on two separate panels that are some distance apart, making it impossible for anyone to just reset the system and dash out the doors.

When patients must leave the pediatric unit to go to radiology, for instance, staff must hold the door open so they can get out, and then they have to do the same to get the patient back in.

"The alarms still go off, but that way we don’t have to take the bracelet off and put it back on every time," DeLong says. "A lot of the risk involves custody battles with one parent thinking they can slip in and take the child. And then there’s also the child who is feeling better, gets tired of being cooped up in the room, and wants to go exploring."

OSF St. Joseph usually has a small pediatric census, just a few patients at a time, but occasionally the pediatrics department will run out of the armband sensors. In that case, the policy is to put them on the youngest patients first.

In addition, OSF St. Joseph’s depends on a high level of awareness among pediatrics staff, encouraging them to be familiar enough with the family to know who should and should not be on the floor, and whether there are any family disputes that could be problematic. Once you bring the problem to the staff’s attention, everyone realizes how important it is to take these precautions with pediatric patients, Haig says.

"I can see how peds might be overlooked," she says. "But just imagine — the same infant you protected so tightly in the labor and delivery unit could be back in the hospital one week later on your peds unit. Why wouldn’t we need to provide the same level of protection?"

Why not indeed, notes Chuck Williamson, CHSP, LHRM, director of risk management and safety at Boca Raton (FL) Community Hospital, where a high-tech system reflects his belief that pediatric patients must be watched very carefully. The hospital has spent about $350,000 on security technology for pediatric patients in the past five years, and Williamson budgets for some type of improvement every year.

That investment includes 68 cameras and 38 access ports that require an electronic key card to open. The system is monitored at the hospital’s main security station that is located, by design, right outside the pediatric and newborn units. Access to the area is limited to those employees with reason to be there, along with visitors who have proper passes. When an employee swipes an identification badge to open a controlled door, the system automatically shows the security guard a live camera shot of the person at the door and the photo appearing on the identification badge. If they don’t match, the guard responds.

"This is more than most hospitals have. Our hospital is probably pretty far ahead of a lot of people, but we think it’s worth it," Williamson says. "No matter how much you think you have you can always improve your security. With children, you need both physical security and technology."

Don’t overlook system maintenance

Chmieleski says such high-tech systems are a great asset, but you should not depend on them as your only line of defense. Good policies and procedures are also necessary. For instance, what happens when a child leaves the safe confines of the pediatric unit? In Williamson’s facility, children are not allowed to leave the unit on their own for any reason. The patient must be signed out by a staff member, and a family member is encouraged to accompany the child at all times for testing or surgery.

"When a parent can’t go with them, someone from peds must go with the child and stay with them the whole time," he says. "That person cannot leave the child alone for any time at all."

If you use a sophisticated electronic system, Chmieleski says you should be sure to test the system frequently and document those checks. She recommends at least a basic system check every 24 hours.

Williamson also stresses the need for constant maintenance. At OSF St. Joseph, the high-tech security system is thoroughly tested every two weeks.

"There’s nothing worse than something happening and saying, Oh no, that camera’s not working today,’" he says.

Conduct regular drills

In any effort to prevent child abductions from health care facilities, drills are necessary. Regular infant abduction drills also are required by JCAHO. Boca Raton Community Hospital and OSF St. Joseph’s both include pediatric scenarios in their infant abduction drills, which require the entire hospital to respond. At OSF St. Joseph, the alarm is sounded with specific code words that alert the staff to what type of child is missing — an infant or older child.

Even if you can’t afford a technological upgrade right away, expanding your Code Pink drills to include older patients is one way to immediately improve your pediatric security, Chmieleski advises.

"Hospitals are pretty good about doing them in labor and delivery units, but make sure they are hospitalwide," she says. "It’s amazing how many people can get off the unit with these infants when we do these drills and are actually on their way out the doors of the hospital. An older child may arouse even less suspicion unless your staff is aware of the risk."