Emergency Management Plan for Newborn Abduction Maureen Gordon Shogan, MN, RNC

CLINICAL ISSUES Emergency Management Plan for Newborn Abduction Maureen Gordon Shogan, MN, RNC Since 1983, 111 newborns have been abducted by strangers from hospitals in the United States. In Canada, five abductions from hospitals have been reported since 1990. Emergency management plans for newborn abduction must be in place in every institution that cares for newborns and seeks accreditation from the Joint Commission on Accreditation of Healthcare Organizations, which requires multidisciplinary planning of critical incident response procedures, staff education, mock newborn abductions, and evaluation of response during the mock incidents. Prevention strategies such as staff and parent education and physical environment security measures have led to a marked decrease of newborn abductions in the United States in the past 10 years. JOGNN, 31, 340 346; 2002. Keywords: Emergency management plan Newborn abduction Mock drills Accepted: October 2001 We re missing a baby! I can t find him anywhere! These are dreaded words for any nurse working in a birthing center or neonatal unit. Since 1983, 111 newborns have been abducted by non family members from hospitals in the United States (see Table 1). The majority were abducted from hospitals (see Table 2). Five of those children are still missing (C. Nahirny, National Center for Missing and Exploited Children, personal communication, November 13, 2001). Five abductions have been reported in Canada since 1990 (ChildFind, 2001). Because most staff have never experienced a newborn abduction, assuring competence in responding to such an emergency is challenging. Multidisciplinary planning of critical incident response procedures, staff education, mock newborn abductions, and evaluation of response during the mock incidents are required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2001a). Nursing staff can implement proactive strategies to prevent abduction of a newborn from the hospital, including staff and parent education, unit policy to assure protection of the family, and physical environmental security (JCAHO, 1999). To respond to abductions effectively, nurses should develop and practice an emergency management plan. The purpose of this article is to describe nursing actions necessary to prevent and respond to newborn abduction. Case Study A newborn is missing! This morning there was a heavy-set woman asking when the babies go out to their mothers. Do you think...? Immediately the charge nurse notifies security and the nursing supervisor of a possible abduction. Simultaneously, all staff are alerted and begin looking for the baby on the Mother-Baby unit. Two staff members go to the Mother-Baby unit exits until security personnel arrive. The charge nurse tells the unit secretary to call the operator and announce Code Pink on the hospital public announcement system. The baby s nurse asks the mother when she last had her baby and if she knows where her baby might possibly be. This nurse stays with her and moves her to a private waiting area with her family. Security personnel monitor the entrances to the Mother-Baby unit so that no one can leave or enter. It is change of shift, but all staff are required to stay in the Mother-Baby unit. 340 JOGNN Volume 31, Number 3

TABLE 1 Newborn Abductions, 1983 2001 State a Number of Cases Alabama 3 Arkansas 2 Arizona 3 California 31 Colorado 5 Connecticut 2 District of Columbia 6 Delaware 1 Florida 14 Georgia 8 Illinois 11 Indiana 2 Iowa 1 Kansas 3 Kentucky 2 Maine 1 Maryland 9 Massachusetts 2 Michigan 6 Mississippi 3 Missouri 4 Nevada 1 New Hampshire 1 New Jersey 4 New Mexico 4 New York 10 North Carolina 4 Ohio 6 Oklahoma 3 Oregon 2 Pennsylvania 5 Puerto Rico 4 Rhode Island 1 South Carolina 5 South Dakota 1 Tennessee 4 Texas 28 Virginia 3 Washington 3 West Virginia 1 Wisconsin 2 Note. Information provided by C. Nahirny, National Center for Missing and Exploited Children (personal communication, November 13, 2001). a States not listed had no abductions reported. TABLE 2 Location of Newborn Abductions a Family Members, 1983 2001 An emergency department employee who heard the overhead page notices a woman in a lab coat entering the parking garage carrying an odd-shaped sport bag that appears to be moving. The woman is looking over her shoulder and scanning the parking area as she is getting into her car. The employee notifies the security staff from the parking garage phone, giving them her location, the woman s description, and the license number of the vehicle. Security simultaneously notifies local law enforcement authorities and sends a hospital patrol car to the vicinity of the garage. Meanwhile, the nurse manager informs the hospital administration and the community relations department of the abduction. A staff member stays near the mother s room, allowing no one to enter. Within hours of the incident, local police apprehend the abductor with the unharmed newborn a few miles from the hospital. Because all staff acted quickly and proceeded according to hospital protocol, this newborn was soon reunited with his parents. To facilitate a timely and organized emergency response, this hospital staff probably benefited from a mock newborn abduction drill and were knowledgeable about the emergency response plan. Although the emergency plan was carried out as written and the newborn was returned unharmed, both the parents and staff experienced emotional trauma from the emergency. Thus, group or individual counseling is indicated for all involved in the critical incident of abduction. JCAHO Requirements by Non Location Number Percentage Health care facilities Mother s room 62 33 Nursery 16 9 Pediatrics 17 9 On premises, location not specified 16 9 Total from hospitals 111 59 Abductions from homes 77 41 Total newborn abductions 188 100 Note. Information provided by C. Nahirny, National Center for Missing and Exploited Children (personal communication, November 13, 2001). a Birth to 6 months. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) stipulates that an emergency May/June 2002 JOGNN 341

TABLE 3 Emergency Response Plan for Newborn Abduction in the Hospital Setting Action Rationale 1. Notify nursing supervisor and hospital security. If Security can assist in securing and searching the area and will security staff are not available, immediately call local notify local law enforcement. police. Security personnel should immediately search the exterior of the unit and secure areas of egress. 2. Call for overhead page of a predesignated code word spe- This allows staff to secure all hospital exits. Particular attencific to newborn abduction (Code Blanket, Code Green, tion will be paid to anyone carrying luggage, a gym bag, Code Stork, etc.) to alert all staff. bulky clothing, or packages. Any individual leaving the area is questioned. 3. Question the parent of the missing newborn regarding other possible locations of the newborn. 4. Secure the area where the newborn disappeared (mother s Forensic evidence at the crime scene and documentation of room or nursery area). Secure the mother s and baby s patient care should be preserved. paper chart. 5. Move parents and family (but not belongings) to a private Move the patient to ensure privacy. The mother s nurse can room away from the birthing unit. The mother s nurse monitor her condition and provide support. should continue to provide care. 6. Notify the unit nurse manager if not present at the time of the incident. 7. Alert the hospital spokesperson or administrator, who The media can assist in apprehension of an abductor, who should develop a plan to inform the local media. Only may show off the newborn. Acquaintances of the abductor the hospital spokesperson should speak with the public may have suspicions, if the woman has not been known to or media regarding the incident. be pregnant. When the public learns the generic abductor profile or description of the abductor (if known), a newborn may be quickly found. Media should not portray the abductor as a hardened criminal; this may frighten the abductor into hiding or fleeing. 8. Nurse manager briefs the staff. Staff then bring babies to This will prevent mothers from hearing the news via the their mothers and tell them of the incident. media or law enforcement. 9. Notify the lab to hold newborn s cord blood. Cord blood DNA will be compared with that of the newborn when recovered. 10. Hold a mandatory debriefing session after the incident. Involved staff may experience posttraumatic stress disorder. 11. Notify other birthing units in the area. Request copies of Suspects may have been assessing other unit layouts and surveillance videotapes or digital discs from their units. routines. 12. Notify community agencies, including offices of vital The abductor may attempt to procure a birth certificate or statistics, social services, pediatric ambulatory care, hos- obtain aid for the newborn from WIC or AFDC. pitals, and urgent care centers. Note. From For Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions (6th ed.) by J. Rabun, 2000. Copyright 2000 by the National Center for Missing and Exploited Children, Alexandria, VA. Reprinted with permission. management plan addresses four phases of emergency management activities: mitigation, preparedness, response, and recovery. Initiation of the plan must include a description of how, when, and by whom the emergency plan is activated (JCAHO, 2001a). These emergency plans must be developed by a team of professionals that include nursing administration and education, security, social services, risk management, law enforcement, and public relations specialists. Together they must assess the risk for newborn abduction. The abduction risk assessment includes the unit layout, areas that are accessible to the public, entrances and exits, alarm and surveillance systems, staffing patterns, and staff knowledge regarding prevention of newborn abduction (Rabun, 2000). Proactive measures should be instituted to prevent the opportunity for abduction and the escape of an abductor. An emergency plan must be formulated and reviewed with staff in a mock abduction drill. In the event that a newborn is abducted, a detailed and realistic response plan can expedite newborn recovery (see Table 3). Once the plan has been written, mock drills and their evaluations will identify the need for changes to ensure that the plan is realistic for the setting. Newborn abduction is considered a sentinel event (JCAHO, 1999), defined as an unexpected occurrence 342 JOGNN Volume 31, Number 3

involving death or serious physical or psychological injury or the risk thereof (JCAHO, 2001a). It is an incident that requires immediate investigation. Agencies that are JCAHO accredited are encouraged to report incidents to JCAHO. A thorough root cause analysis and action plan must be prepared and submitted to JCAHO within 45 calendar days of notification of the event. The joint commission will then evaluate the hospital s analysis and plan for reducing the risk of reoccurrence. Areas to be reviewed to assess the root cause for newborn abduction include staffing levels, orientation and competency assessment of staff, communication with family as well as among staff members, physical environment and security systems, and processes. If the plan is not acceptable to the joint commission, the hospital will be placed on Accreditation Watch (JCAHO, 2001b). Since 1983, 111 newborns have been abducted from hospitals in the United States. Staff Education Hospital personnel are the primary key to preventing newborn abductions. The prevalence of abduction, abductor profile, and possible abductor behaviors (see Table 3), means of abduction, and the hospital emergency plan (see Table 4) should be included in the orientation of all new staff. Educational programs for hospital staff, such as Safeguard Their Tomorrows, are essential (National Center for Missing and Exploited Children, 1998). Review of this information should occur annually in the form of posters, videos, online posttests, or competency review testing. All personnel who work on birthing units, including residents, laboratory technicians, respiratory care practitioners, and social workers, should be alert for visitors who match the typical abductor profile and behaviors. These staff members should know their responsibilities in the event of an abduction. Holding a mock newborn abduction drill is one method to assess the competence of nursing and security staff in their response to a critical incident. Drills that place staff in real-life situations should be conducted regularly at different times of day. Putting the written plan into action allows for outcome evaluations of such drills ( Hospital Drills Test Staff Response, 1996). The manager of the birthing center and security personnel should be the only staff to plan the mock abduction. The mock abduction may be conducted using various scenarios. A health care professional who has delivered a baby can assist by allowing her baby to be the TABLE 4 Abductor Profile Characteristics Female between the ages of 12 and 50 Large build or overweight for height Married or involved in a failing relationship May have experienced a pregnancy loss (miscarriage, stillbirth, adoption) Lives in the community where the abduction takes place Often emotionally immature, compulsive, with low self-esteem May be feigning a pregnancy and have told acquaintances that she is pregnant Typical abduction strategies Visits birthing centers asking detailed questions about procedures and unit layout Plans the abduction and then acts quickly when opportunity arises Impersonates medical, nursing, laboratory, volunteer, social work, or photography personnel With an accomplice or alone, may create a disturbance, such as pulling fire alarm or starting a fire, to distract staff Calls mother by her first name, learned from crib card or unsecured medical record Befriends the mother and stays for several hours to establish her trust Removes the newborn from the mother s room by saying the baby needs lab tests, vital signs, photographs, weight, etc. Removes the baby from the unit in a sport bag or under a coat Once the abduction has occurred, considers the baby to be her own Note. From For Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions (6th ed.) by J. Rabun, 2000. Copyright 2000 by the National Center for Missing and Exploited Children, Alexandria, VA. Reprinted with permission. missing baby. A mother who is unfamiliar with hospital practice should not be asked to lend her baby, in that participation in a mock incident may be very anxietyprovoking. Another scenario involves having a person unknown to staff dress in scrubs or a lab coat and carry a doll wrapped in a blanket or a large duffel bag out of the unit. The nurse manager or security guard can observe the number of staff who question the abductor about carrying a newborn or about the contents of the bag. Critiquing the mock abduction with all staff is a learning experience that brings a rare event, perceived as it will never happen to us, to reality. Assessments of the May/June 2002 JOGNN 343

mock incident should include the initial staff response to the abduction, the time to secure exits, and the time to apprehend the abductor. By repeating the mock abduction within a few months and utilizing a variation of the incident, managers and educators can assess improvement in response. Parent Education In Hospital Because 55% of newborn abductions occur from the mother s room, it is essential to educate parents about their role in keeping their newborns safe (Rabun, 2000). It is important to provide verbal and written information about newborn security to parents at all points of contact. These include prenatal classes, preadmission assessments, and admission to all perinatal areas. Security information should be posted in mother-baby patient care areas to reinforce teaching. Parents should be taught to Give the baby only to hospital personnel with proper photo identification. Accompany any person who removes the baby from the mothers room, if desired. Never leave the baby unattended. Keep the newborn in direct line of sight of parents or nursing personnel. Instruct every mother to never let her baby out of her sight and to call the staff to take the baby when she showers, uses the rest room, or naps. Keep the baby on the far side of the room away from the doorway. This makes it more difficult for the abductor to move the baby unnoticed by the mother. Question any stranger who enters their room. Call the nurse s station immediately to report a stranger or to confirm the identity of anyone who is not properly identified and claims to be a hospital employee. Become familiar with physical characteristics specific to their newborn such as birth marks, cerulean (mongolian) spots, or familial characteristics such as scalp hair configurations or Darwin s tubercles on the ears. This information will assist with later identification. After Discharge Since 1989, four newborns have been abducted from their homes as a result of the abductors use of newspaper birth announcements (C. Nahirny, personal communication, November 13, 2001). It has been suggested that institutions discontinue publication of birth notices in local newspapers (JCAHO, 1999). In addition, abductors have been known to locate newborns soon after hospital discharge by seeing yard decorations announcing the birth. Since 1983, 77 newborns have been abducted from their homes (C. Nahirny, personal communication, November 13, 2001). Parents should be taught to Never publish their address with birth announcements in newspapers or on the Internet. Avoid yard decorations such as storks or balloons or large pink or blue floral wreaths. Be assertive and request to see photo identification of health care personnel who wish to enter the parents home. Parents should know the date and time to expect health care visitors at their home. Unit Policy Each newborn or birthing unit must have policies and procedures to provide a safe environment and decrease the risk of newborn abduction. Legal ramifications may occur if parents allege that the hospital is negligent in providing safety and security for newborns (American Health Consultants, 1998). Newborn security is addressed with written policies regarding newborn identification at delivery, personnel and parent identification for access to newborns, newborn transport within the hospital, parent education, birth information given to the media, Internet birth announcements, unit access, and electronic newborn security systems. The thread of newborn security may be woven into several protocols throughout the institution. Newborn Identification at Delivery Immediately after delivery, each newborn receives an identification bracelet with date and time of birth and mother s name. The number on the newborn s bracelet An emergency plan should be formulated and reviewed with staff in the form of a mock abduction drill. matches that of the mother. Another bracelet with matching number may be given to a person designated by the mother. Only these banded individuals may transport the baby. The newborn s footprints may be taken shortly after birth. When properly done, these may lead to identification of an abducted newborn upon recovery. Many states, however, no longer mandate footprint use for identification (Washington Administrative Code, 1992). Photographs should be taken of each newborn as soon after birth as feasible. These photographs can be kept in the baby s chart. If a newborn is abducted, the media can use 344 JOGNN Volume 31, Number 3

the photos to mobilize the public to assist in finding the baby and identifying him or her after recovery. Hospital Personnel and Parent Identification Hospital personnel and physicians who transport the newborn must have photo identification worn above the waist that is current and resembles the bearer. Stickers or pins should not obstruct the photo or name. Some units have photo identification that has a colored sticker or border specific to the birthing unit staff. These unitspecific identifiers should be available for students and temporary nursing personnel. Other options include separate identification badges or photo identification holders that encase the card in a strip of color and can be counted at each shift change (similar to narcotics control). Proactive measures should be instituted to prevent opportunities for abduction as well as the escape of an abductor. Secure parent identification is accomplished by avoiding posting mother s name where it is visible to visitors on baby s crib cards or census boards. Medical records, medication forms, and active computer screens should be visible only to hospital personnel. Leaving open charts or active screens in hallways gives the possible abductor immediate access to the mother s first name. This enables the abductor to feign familiarity with the mother and gain her trust. Newborn Transport Within the Hospital All newborns should be moved in their cribs. No baby should be carried in arms. If any newborn is in an individual s arms, staff are alerted to ask who the individual is and where they are going with the newborn. Staff should be trained in how to approach individuals safely. The risk of violence from an abductor increases when he or she is approached (Burgess et al., 1995). Security personnel, local law enforcement agents, or mental health counselors are resources who can provide training expertise. At discharge, a staff member must accompany the newborn and his or her parents to their car. If this does not occur, the staff is alerted to individuals who may be removing a baby from the hospital. Birth Information Provided to the Media Many institutions post pictures of the newborn and family on the Internet so that friends and family around the world may share in the parents joy. However, it is the responsibility of the institution to place only the parents and baby s first names. This way, a possible perpetrator will not be able to trace a new baby to the parents address via the phone book or other Internet sites. Unit Access Nursery and mother-baby units are considered securitysensitive areas by JCAHO, and control of access to patients in those areas is crucial. Access control may range from signs stating authorized personnel only to sophisticated swipe cards or key pad access (Roll, 1999). Strategies to control access include installing selflocking doors to staff changing areas and making them accessible only via key pads or swipe cards and limiting access to the entire birthing and newborn areas, using swipe card or key pad access. This is particularly important for units with direct outside street-level entrances. Unit exits and stairwells can be equipped with alarms and time-delay locks, and video cameras can be placed so that the faces of individuals leaving units or buildings can be identified. Signs within the birthing and neonatal units should alert the public that the areas are monitored by video systems (Quayle, 1997). Newborn Security Systems Many newborn security systems are available to hospitals, which can promote such systems in marketing to the public (Geller, 2000). Some systems have sensors that are attached to the baby s identification bracelet or cord clamp. An alarm is set off if the bracelet or clamp activates receivers placed near exits. Others have an alarm that is activated when the sensor is removed from the baby. The electronic systems must be turned on and in working order ( New Infant Security System, 1999). Other systems are keyed so that the whereabouts of the newborn are known at all times. When institutions are marketing or interviewed by the media, details of the system must not be shared with the public, which compromises the security of the system. Security systems may give staff a false sense of security if they rely totally on the equipment. If the system alarms when staff do not remove newborn devices at discharge or move a baby to another department for testing, the staff will become accustomed to false alarms and not react to a real situation promptly. Since 1997, six newborns have been abducted from institutions with sophisticated newborn security systems in place (C. Nahirny, personal communication, November 13, 2001). In one instance, the wiring on the security system malfunctioned, and a door failed to lock when the baby s bracelet triggered an alarm. When the door remained unlocked, the abductor removed the baby from the maternity unit under her coat (Manier & Hanna, 2000). In another instance, the abductor May/June 2002 JOGNN 345

removed the device from the newborn before passing through a detector (C. Nahirny, personal communication, November 13, 2001). Nursing Implications In 1999, there were no reports of newborns abducted by non family members in the United States. This improvement may be a result of the recent emphasis for staff and parents on the safety and security of newborns. As a result of staff education and review of agency precautions to reduce the incidence of abduction, hospitals have also increased the use of time-delayed egress on exits, surveillance video cameras, and coded access to secured areas. Use of mock codes utilizing emergency plans can increase staff awareness, improve response to an abduction, and reinforce the need for preventative strategies. All nursing staff working with newborns and their parents must be knowledgeable about the typical abductor profile and constantly be alert for individuals fitting the profile. Nurses also are responsible to empower parents both prenatally and during the hospital stay by teaching them how to protect their newborns from possible abduction, both in the hospital and after discharge. RESOURCE National Center for Missing and Exploited Children, 699 Prince Street, Alexandria, VA 22314-3175. Web site: http:// www.missingkids.com 1-800-THE-LOST. REFERENCES American Health Consultants. (1998). Prepare for the worst: Fortify newborn security. Hospital Peer Review, 23(10), 180. Burgess, A. W., Burgess, A. G., Dowdell, E. B., Hartman, C. R., Nahirny, C., & Rabun, J. B. (1995). Infant abductors. Journal of Psychosocial Nursing, 33(9), 30-37. ChildFind. (2001). Guarding against abduction in the health care sector. DISCribe Ltd. Retrieved March 7, 2001, from the World Wide Web: www.discribe.ca/childfind/educate/ infant.hte. Geller, M. (2000). Infant abduction in the hospital setting. Quality, Risk, Cost, 16(5), 1-4. Hospital drills test staff response to infant abduction. (1996). Hospital Security and Safety Management, 17(5), 10-12. Joint Commission on Accreditation of Healthcare Organizations. (1999, April 9). Infant abductions. Sentinel Event ALERT, 9. Oakbrook Terrace, IL: Author. Joint Commission on Accreditation of Healthcare Organizations. (2001a). Emergency management comprehensive accreditation manual for hospitals: The official handbook. Retrieved July 2, 2001, from the World Wide Web: www.jcaho.org/standard/ecer.html. Joint Commission on Accreditation of Healthcare Organizations. (2001b). Sentinel event policy and procedures. Comprehensive accreditation manual for hospitals: The official handbook. Retrieved July 30, 2001, from the World Wide Web: www.jcaho.org/sentinel/rcamatrx.html. Manier, J., & Hanna, J. (2000, May 4). Baby alive when hidden from police. Chicago Tribune, Internet Edition. Retrieved July 16, 2001, from the World Wide Web: www. chicagotribune.com/news/metro/chicago/article/0,2669, 2-44644,FF.html. National Center for Missing and Exploited Children. (1998). Safeguard their tomorrows: A resource to help prevent infant abductions. Evansville, IN: Mead Johnson. New infant security system combines technology, training, patient care. (1999). Hospital Security and Safety Management, 19(9), 1-3. Quayle, C. (1997). Robbing the cradle. Health Facilities Management, 10(8), 20-29. Rabun, J. (2000). For healthcare professionals: Guidelines on prevention of and response to infant abductions (6th ed.). Alexandria, VA: National Center for Missing and Exploited Children. Roll, F. G. (1999). Nursery crimes: Get tough on infant security before someone robs the cradle. Health Facilities Management, 12(9), 28, 30, 32. Washington Administrative Code. (1992). Core service Low risk patient and newborn care. WAC 246-388-290. Retrieved November 16, 2001, from the World Wide Web: http://www.mrsc.org/wac.htm. Maureen Gordon Shogan is a neonatal clinical nurse specialist at Deaconess and Valley Medical Centers, Spokane, WA. Address for correspondence: Maureen Gordon Shogan, MN, RNC, 5726 N. Sutherlin, Spokane, WA 99205-7553. E-mail: shoganm@empirehealth.org. 346 JOGNN Volume 31, Number 3