Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Dr. Alicia Hutchings, PhD, RN, CNE


Dr. Alicia Hutchings, PhD, RN, CNE

Dr. Vanessa Loyd, DNP, PhD, RN

Kathryn Finder, MSN, RN


Persons admitted to acute care, inpatient psychiatric facilities often pose a threat to themselves or others, a situation which could quickly devolve if they were to leave treatment prematurely. There is a need for an elopement risk assessment with appropriate interventions correlating to level of risk. An acute care, inpatient psychiatric hospital implemented an elopement risk assessment tool in March of 2020. This quality improvement project used an observational descriptive design and comprised of a retrospective chart review, aimed to determine the effectiveness of the risk assessment tool on decreasing elopements. Charts of those that eloped in 2019 (n=8) and all admitted patients in 2020 (n=407), were reviewed for risk factors and interventions in place. After implementation of the elopement risk assessment tool, rate of elopement decreased by 50% (p = 0.001) in March through April of 2020 as compared to 2019. It was found that 97.5% of patients admitted between March and April 2020 had risk assessments documented at some point during their stay. In patients who were found to be moderate risk (n=69), 28 had elopement precaution orders, two had photographs in EPIC, 6 had strategic bed placement, and level of risk was communicated to the treatment team for 52 patients. Of those found to be high risk (n=60), 42 were placed on elopement precautions, eight had their photograph in EPIC, 12 were in strategically placed beds, and 53 patient’s level of risk was communicated to the treatment team. Statistically significant risk was found in patients who were involuntarily committed (p = 0.004), had a diagnosis of cognitive disorder (p = 0.048), were disoriented (p = 0.005), and documented to be exhibiting risky behaviors (p = 0.022). The risk assessment tool brought greater awareness to staff of the potential for elopement, patient, public, staff and facility safety has been improved, and with further research there is potential adaptability of the tool to other areas of the hospital.