Change of Scenery: Just What the Doctor Ordered

May/June 2013

Change of Scenery: Just What the Doctor Ordered


Figure 1. The Reflecting Pond at The H. Lee Moffitt Cancer Center and Research Institute on the campus of the University of South Florida. Photo by Nicholas Gould
Figure 1. The Reflecting Pond at The H. Lee Moffitt Cancer Center and Research Institute on the campus of the University of South Florida.
Photo by Nicholas Gould

Being hospitalized should not necessarily preclude a patient from going outdoors independently, that is, without the assistance or supervision of a healthcare staff member. Nonetheless, reconciling the need to ensure patient safety with the patient’s desire to enjoy the therapeutic benefit of being off the unit and outdoors can create conflict for patients and healthcare providers. Patients may encounter unintended safety concerns such as exposure to inclement weather, temperature extremes, interruptions in care, or the potential safety risks associated with patients leaving the hospital buildings (Schultz et al., 2011). Hospital administrators and managed care companies may argue that a patient who is well enough to go outdoors is well enough to go home. On the other hand, going out daily is beneficial for some patients (Nedu?in et al., 2010). Such attention to patient well-being is regarded as compassionate and patient centered. The development of effective off-unit and outdoor policies and education of healthcare providers and patients are essential for creating and maintaining a safe and supportive environment for patients. This paper presents an overview of the various factors that were taken into account in the development of a process that allows patients at a cancer center to leave their inpatient unit and go outdoors.

According to the Centers for Disease Control and Prevention (2009) inpatients hospitalized for cancer care have an average length of stay (LOS) of 6.3 days. A patient with a hematological malignancy may have an LOS of 14.8 ± 23.3 days (Suda et al., 2006). Individuals with extended lengths of stay in a hospital often experience psychological distress (Aitini et al., 2007; Berman et al., 2008; Ell et al., 2005). In addition to the physical suffering that may come with a prolonged LOS, the cancer patient may experience a break with the past and disruption in the routine of daily living. Patients may feel lost and suffer from fear, anxiety, withdrawal, and depression (Aitini et al., 2007).

The belief that nature is beneficial for human health has existed for thousands of years. Research shows that there is a proven therapeutic benefit to being outdoors (Jacobs et al., 2008; Maller et al., 2009; Ulrich, 2001). Parks and other natural environments play a vital role in human health and well-being. Evidence of planned restorative gardens can first be found in the European medieval monastic hospices, where patients’ cells bordered and had a direct access to an arcaded courtyard (Nedu?in et al., 2010; Ulrich, 2001). Florence Nightingale (2003) believed that providing natural elements, such as flowers and plants, aided patient recovery. The physiologic and psychological benefits of hospitalized patients going outdoors are well researched (Clay, 2001; Maller et al., 2009). Ulrich (2001) demonstrated that just looking at plants and gardens contributes to promoting recovery or restoration of health. Researchers at the University of Michigan found memory performance and attention spans improved by 20% after people spent an hour interacting with nature (Berman et al., 2008).

Our Center
The H. Lee Moffitt Cancer Center and Research Institute (the Center) is an academic medical center designated by the National Cancer Institute as a Comprehensive Cancer Center. It is located in west central Florida on the campus of the University of South Florida (USF). The Center’s mission is to contribute to the prevention and cure of cancer. The Center is dedicated to providing compassionate and effective patient care and has embraced the concept of patient- and family-centered care. The Center is licensed for 206 hospital beds and is tobacco-free.

The Center’s Tampa Bay location benefits from year-round weather conditions that are often conducive to being outdoors. The Center’s lush tropical grounds are park-like and provide a comfortable environment that invites patients and families to spend time outdoors. Meandering pathways lead patients to tranquil areas that are relaxing and beautiful. The grounds include sunscreens, walls, and plant materials to alleviate the harsh effects of the sun.

Determining which patients may leave the unit independently, i.e., without a healthcare staff member in attendance, while not jeopardizing their safety was a goal set by the Center. While the risks to critically ill patients imposed by transport within the hospital from one unit to another are well documented in the literature (Day, 2010; Esmail et al., 2006; Fanara et al., 2010), little is published that addresses the morbidity and mortality risks resulting from non-critically ill patients independently leaving the unit to go to public areas within the hospital. Some nurses felt strongly that they should be allowed to use critical thinking to determine which patients could independently leave the unit. Others thought that an assessment tool was needed to determine patient suitability. Risk management suggested that a physician’s order was necessary but agreed it was not practical to obtain an order every time a patient wanted to go off the unit. The Center had experienced “near miss” safety events involving patients independently leaving their units. There was variability in nurses’ decision-making about which patients were deemed appropriate to leave the unit and for how long. Additionally, patients were not given specific information regarding where they were permitted to go. The lack of a risk-stratification tool for patient assessment and guidelines for where patients could go compromised the quality of care. As a result, a decision was made to develop a standard policy and assessment tool used for clinical decision-making.

Transport Stability Scale
An interdisciplinary team consisting of nurses, respiratory therapists, radiology technicians, physicians, security staff, patient advisors, and risk managers sought to improve clinical decision-making and communication of a patient’s level of stability to independently leave their unit. In order for the tool to be most useful, it needed to be easily incorporated into the nurse’s work flow, address the most important decision points for clinicians and patients, and have been found to be robust in validation studies (Koopman et al., 2008). Validated stability scales were almost nonexistent in the literature. For this reason, it was not possible to develop an evidenced-based assessment tool that was supported by published research. Nonetheless the preference was to use standardized criteria endorsed by experienced clinicians to reduce unwanted or inappropriate practice variations.

A Transport Stability Scale developed by Ward, Corcoran, Mueller, and Ford-Weaver (2004) at Barnes Jewish Hospital at Washington University was adopted and modified. This scale utilizes a color-coded chart to help identify and communicate a patient’s level of stability for intra-hospital transport. Three categories (green, yellow, and red) were intended to provide guidance for transporting a patient within the facility by a staff member. Nurses may use the tool to identify whether a physician or additional healthcare workers should accompany the patient based on the patient’s level of stability during transport. In the Transport Stability Scale, green identifies those patients who may be accompanied by a patient transporter; yellow identifies patients who need a higher level of care and accompaniment by a registered nurse (RN) or physician; and red identifies unstable patients who require an RN and physician during transport.

For use in our Center, the tool (Figure 2) was modified to capture key indicators that relate to an oncology patient’s level of stability for intra-hospital transport (e.g., vital signs, chemotherapy/vesicants infusions, neurological status.) A new category was added to identify a patient who may independently “transport” themselves to designated areas off the unit and outdoors and was color-coded green. Our yellow category signifies that the patient may be off the unit but must be accompanied by a member of the Transport Department, an oncology technician, or other equivalently qualified employee. The red category is designated for patients who are clinically unstable and need a registered nurse, respiratory therapist, and/or physician to accompany them during transport.

May Travel Alone
(Must have Physician Order)
Travel with Transport Staff, OnT or other qualified Employee
Requires RN, RT, or MD”
Vital Signs (Within 30 min. of travel) – Stable per baseline   – Unstable
– Requires intervention
Respiratory Status – Oxygen therapy if baseline and stable (verify volume remaining) – Oxygen therapy (verify volume remaining)
– Chest Tube
– Oxygen requiring frequent titration
– Ventilated
– Life threatening status
– Requires continuous monitoring
Cardiovascular Status – Arrhythmia BUT not new onset or life threatening – General anesthesia administered > 1 hour ago – Unstable hemodynamics
– Telemetry
– New onset or life threatening arrhythmia
– Unstable MI
– Vasopressors/cardiac drips
– General anesthesia administered < 1 hour ago
– Chest pain
Lines/IV Meds   – Stable with PCA
– Stable with epidural line
– First dose of new IV medication
– PA line
Blood Components     – Blood components infusing
Chemotherapy/Vesicants/Hazardous Drugs   – Vesicant Therapy – Potential for drug reaction
Drains     – Ventricular drain
Equipment/Fall Risk   – High-Risk Fall Precautions
– Needs assistance with equipment
Radioactive Implants   – From Radiation Therapy to unit (with Radiation Staff)  
OR/SCU/DRC/ Radiology – Outpatient high risk/invasive procedures: Discharged with responsible adult. – To OR
– DRC and Clinic to Floor – stable
– SCU to Floor ?*note exceptions
– PACU to Floor – stable
– To Radiology- stable
– From Radiology – post diagnostic imaging, thoracentesis/paracentesis, drain placement
– From OR
– To SCU
– From SCU *epidural, new trach, chest tube, score of 3 or less on Sedation/Agitation Scale
– To and from Radiology- unstable
– From Radiology- post lung biopsy and any procedure with change – in LOC
Behavioral Management   – Any adolescent patient
– Confused but calm and cooperative
– History of non-compliance with policy
– Confused
– Combative
– Suicidal

Figure 2. Moffitt Intra-institutional Transport Stability Scale

Assessing the health status of the patient immediately prior to independently leaving the unit is paramount to determining that the patient is stable to leave the unit. The functional capacity of a hospitalized cancer patient varies in accordance with the diagnosis, presence of cancer-related pain or other co-morbid conditions, and current treatment (Barsevick et al., 2006). Transient cognitive dysfunction related to medications including chemotherapy, fatigue, or alteration in activities of daily living may impair the patient’s functional status (Schubert et al., 2008). However, cancer should not be considered as an inevitable cause of severe cognitive and physical impairment. Older cancer patients have considerably better physical function than persons of the same age from the general population (Given et al., 2001). These factors warrant the use of an individualized patient assessment using a standardized assessment scale each time a patient leaves the unit.

Off Unit and Outdoors
In the process of developing our tool, named the Intra-Institutional Transport Stability Scale (TSS), it was recognized that patients and their caregivers needed to be educated and involved intimately in this process. To facilitate this, upon admission patients are educated on the process for leaving the unit, including the specific steps outlined below. Realizing that some patients’ desire to leave the unit is based upon the desire to smoke or use tobacco products, their instructions also include the fact that the Center’s campus and the surrounding portions of the university property are “tobacco-free.” Tobacco users are offered tools and treatment to help overcome their tobacco dependency. When patients are found smoking in the prohibited areas they are asked to extinguish their smoking materials.

A physician’s order is required for all off-unit and outdoor privileges. A patient activity order that allows for “activity as tolerated” permits the patient to be off the unit and/or outdoors provided that the patient is assessed immediately prior to leaving the unit and meets the applicable criteria in the Intra-Institutional Transport Stability Scale (TSS).
Patients are requested to notify their nurse of their desire to leave the unit so that the nurse and patient may collaboratively plan the patient’s care. The patient is assessed in accordance with the TSS within 30 minutes prior to leaving the unit. A map of the Center’s campus, which designates the indoor and outdoor public areas that the patient may visit, has been added to our previously developed patient education tool and is provided to the patient. The Center’s Rapid Response Team and Code Blue Team have the capacity to respond to all of the hospital’s public and dedicated patient outdoor areas. Patients may go outdoors during daylight hours only.

The patient is asked to sign out on a log book and return to the unit within one hour. The log includes details of time, where the patient intends to visit, name of family member or friend accompanying the patient if applicable, and cell phone number (optional). If a patient has not returned to the unit within an hour and a half of leaving, a systematic process of locating the patient begins. This process, the Center’s Patient Elopement Plan, includes steps such as overhead paging and collaborating with the security staff to search the facility and grounds. Hourly Rounding, conducted by the RNs and oncology technicians, helps make certain that large gaps of time of not visualizing the patient do not pass, thus aiding the prompt recognition of the delay in a patient returning to the unit.

Going outdoors is not only harmless for some patients but may be demonstrably beneficial for their health and well-being. The success of the off-unit and outdoor policy requires shared accountability between staff and patients. All staff members need to take part in consistently and compassionately enforcing the policy. Equipping patients with an understanding of the process for going off the unit and outdoors is vital if patients are expected to be involved in preventing harm that may be associated with leaving their unit independently. Since inception of the Transport Stability Scale 12 months ago the Center has not experienced any events of patient harm, patients being off the designated campus areas, or patients being off the unit beyond the 1-hour time. Standardized risk assessments provide the nursing staff with established guidelines for determining whether or not a patient may independently and safely leave the unit. If adequately educated and provided with consistent processes, patients and staff are more likely to build trusting relationships and ensure safe patient care.

Diane Garry has been the patient safety officer, in the Department of Quality and Patient Safety, at the Moffitt Cancer Center in Tampa, Florida, for the past 12 years. She has more than 15 years of experience in quality and patient safety. Garry may be contacted at

Tina Mason has been an oncology clinical specialist at the Moffitt Cancer Center for the past 15 years. Mason has her master’s degree as an oncology clinical nurse specialist and a post-master’s certificate as an oncology nurse practitioner. She holds advanced certification for both. Mason can be contacted at

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