A Pennsylvania healthcare facility asked PA-PSRS to address the issue of whether or not ambulatory surgery patients must have escorts who can accompany them home following the procedure. While some clinicians in the facility felt it was acceptable to let patients take a taxi or public transportation following discharge, others believed this was unsafe.
Recovery from anesthesia has three phases:
- Early: The period occurring from discontinuation of anesthetic agents to resumption of protective reflexes and motor function.
- Intermediate: The period when the patient meets discharge criteria.
- Later: The period when the patient returns to a preoperative physiological state.1,2
Effects of Anesthesia
While patients are discharged home when they fulfill discharge criteria, ambulatory surgery patients may not regain their preoperative physiological state at discharge. Patients in clinical studies demonstrate significant cognitive and psychomotor impairment after various types of anesthesia (general, regional, and monitored anesthesia care).1
For example, 20 patients who underwent left knee arthroscopic ambulatory surgery with general anesthesia were compared with a matched control group of 20 health subjects.3 Both groups underwent the following evaluation preoperatively and at 2 and 24 hours postoperatively: driving simulation performance; electroencephalographic (EEG) verified parameters of sleepiness; and subject assessment of sleepiness, alertness, fatigue, and pain. Compared to healthy individuals, patients showed impaired driving skills and lower alertness levels preoperatively and at two hours postoperatively. Sleepiness, alertness, and driving performance were worse at two hours after surgery. However, testing indicated that the patients were safe to drive 24 hours after general anesthesia.
In another study,4,5 103 outpatients were surveyed via telephone the day after an endoscopic procedure. A substantial number of patients experienced a postoperative problem; see Table for complete results.
Table. Postoperative Problems Experienced by Patients
While groggy, patients may injure themselves or others.6 They also may be unable to obtain help if a postsurgical complication arises.6 Patients who drive after receiving sedation or narcotics have been compared to people who drive while under the influence of alcohol.6
PA-PSRS reports also reveal some of the adverse outcomes patients experience following discharge from ambulatory surgical facilities (ASFs).7
Regulations/Guidelines/StandardsState regulatory bodies, accrediting organizations, and professional medical and nursing societies specify that ambulatory surgery patients have a responsible person accompany them home because of significant cognitive and psychomotor impairment after anesthesia and sedation.6
The Pennsylvania Code for ASFs requires that preoperative care shall include providing patients or responsible persons written instructions that include the following:
Upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort the patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether these patients require a responsible person to escort them home. [28 Pa. Code §555.22(c)(5)]
The postoperative care standards include the following:
Patients shall be discharged in the company of a responsible person if one is deemed necessary under §555.22(c)(5). [28 Pa. Code §555.24(e)]
These regulations do not define “responsible person.”
Medicare’s Conditions of Participation for ambulatory surgery centers indicate that all patients are discharged in the company of a responsible adult, except those exempted by the attending physician.8
The Joint Commission standards indicate that patients who have received sedation or anesthesia are discharged in the company of a designated, responsible adult.6 The Accreditation Association for Ambulatory Health Care (AAAHC) specifies that patients are discharged in the company of a responsible adult when they have received general anesthesia, regional anesthesia, or either moderate or deep sedation/analgesia.6
The American Society of Anesthesiologists’ (ASA) Practice Guidelines for Postanesthetic Care9 indicate that the following should be mandatory for all patients who have just received general anesthesia, regional anesthesia, or moderate or deep sedation: “As part of a recovery room discharge protocol, all patients should be required to have a responsible individual accompany them home,” to increase patient comfort and satisfaction and to reduce adverse outcomes.
Moreover, the 2003 ASA Guidelines for Ambulatory Anesthesia and Surgery recommend, in part, that patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult.6
The American Society of PeriAnesthesia Nurses 2004 Standards of Perianesthesia Nursing Practice specify discharge criteria that include:
- verifying arrangements for safe transportation home and
- reinforcing discharge planning with the patient and family or accompanying responsible adult.6
The Australia and New Zealand College of Anaesthetists 2000 Recommendations for Day Surgery4,5 require that a responsible person transport the patient home in a suitable vehicle (a train or bus is not usually deemed suitable). The responsible person should stay with the patient at least overnight following discharge from ambulatory surgery.
Responsible PersonTo be deemed a responsible person, such a person must be physically and mentally able to make decisions for the patient’s welfare if necessary. Moreover, the responsible person must understand the requirements for postanesthetic care and intend to comply with these requirements, especially concerning public safety.4,5
A taxi driver is not considered a responsible person for a sedated patient. While a taxi driver may get the patient to the patient’s home address, someone needs to be available to get the patient into the house, such as assisting a patient on crutches to navigate the steps.8
Role of Responsible PersonsResponsible persons can ensure that the patient arrives home safely and assist the patient with postoperative complications such as nausea, vomiting, dizziness, and pain.2 They can also request medical assistance in the event of an emergency.2 Another role of a responsible person may be reflected in the Association of periOperative Registered Nurses (AORN) Guidance Statement: Postoperative Patient Care in the Ambulatory Surgery Setting: “Discharge instructions should be reviewed with the patient and a responsible adult before discharge.”10
Effectiveness of Responsible PersonsThe literature is largely silent about whether a responsible person accompanying the patient home results in fewer adverse outcomes. One small prospective study at one tertiary care institution compared outcomes of 55 patients who had no responsible person with a matched control group of patients with a responsible person.2 The study did not find a statistically significant difference in outcomes such as emergency visits, readmission to the hospital within 30 days, or rates of unanticipated admission. Larger multicenter studies are required to further determine whether responsible persons are beneficial to patients discharged from ASFs.2
Risk Reduction StrategiesRisk reduction strategies begin well in advance of the ambulatory surgical procedure, with pre-procedure planning and intensive education.4,5 Safe discharge planning involves a comprehensive preoperative assessment, effective communication between the physician’s office, the ASF, the patient and family/responsible person, and strong patient/family/responsible person education.11,12
In the physician’s office when surgery is first discussed, the physician can inform the patient that a responsible person is required to take the patient home upon discharge.6,8 Such discussions can be documented on a form that becomes part of the patient’s medical record.6 This information can also be restated during preoperative registration and upon arrival to the ASF.8 This requirement can also be reinforced on the physician’s and the ASF’s Web site,6 as well as specifying this requirement in written preoperative instructions and/or in a patient brochure given to the patient.8
During calls the day before the procedure, the patient can be reminded that a responsible person will be required. At that time, any potential problems complying with this requirement can be identified,8 so that alternative arrangements can be made.4 Patients can be educated about what to expect after surgery, and that health insurance will not pay for an overnight hospital stay after the procedure.11,12 Patients can be referred to social services and community resources for transportation assistance.11,12 Some ASFs actually obtain the name and telephone number of the responsible person when surgery is scheduled.6 Other facilities require that the responsible person be present before the procedure and stay at the ASF during the procedure. If the responsible person cannot stay, the ASF obtains a telephone or pager number and calls the responsible person as soon as the patient reaches the recovery area.8 If the patient arrives at the ASF without arrangements for a responsible person, some facilities postpone or cancel the surgery.4-6,8,11,13
Planning in advance for challenging scenarios that might arise will help ASFs approach transportation and responsible person problems in a consistent manner. Consider the following strategies:
- Conduct a staff meeting and develop action plans to ensure safe discharge for all patients.8
- Compile a list of resources to call upon when transportation problems arise, such as community and church volunteer groups, van services, homeless shelters, and patient medical escort services.6,8
- Some hospitals offer a “hotel bed” where patients can pay a fee to stay in a hospital setting overnight without nursing care but with easy access to emergency assistance.6 Or, nursing homes or assisted living facilities may provide a supervised environment for such patients on a temporary basis.6
- Offer home health visits 4,5 or hire an agency nursing assistant to help allow the patient to go home safely.6
- If medically feasible, consider performing minor procedures with local or no anesthesia6 if transportation or a responsible person is not available to the patient.
A Creative Example
A medical center in Pittsburgh14 has arranged to pay a local ambulance company to take patients home. The ambulance staff are trained healthcare professionals and usually provide transportation in a four-wheel drive vehicle. This arrangement has been used on those few occasions when a patient has no one to escort them home, but a caretaker is available at their house to provide assistance.
Most ASFs do not use taxis because the driver is not considered a responsible adult in relation to a patient who has undergone sedation or anesthesia.6 However, when no other alternative exists, some facilities allow the patient to remain for additional hours at the ASF to allow the patient to recover more fully.6 If a taxi must be used to transport a patient home, it is prudent to call the home to make sure someone is at the house to meet the taxi.8
Against Medical Advice (AMA)
Some patients state at the time of admission that someone will be picking them up, but no escort arrives at the time of discharge. If a patient insists on driving home, the patient is technically not being discharged, but is leaving against medical advice.13 If the patient is impaired by drugs, the ASF should encourage the patient to remain until more fully recovered.8 Inform the patient that medical insurance may not pay for the procedure when patients leave AMA.6 Try to convince the patient that he/she is responsible for the safety of others, not just his/her own. Discuss the potential harm to innocent people if he/she drives under the influence of sedation/anesthesia.6 Strongly advise the patient against this highly unsafe course of conduct.13
However, ASFs cannot keep sedated patients against their will, as this may constitute false imprisonment.6 Healthcare workers cannot physically restrain the patient or keep his clothes or car keys.13 If patients insist upon leaving without an escort, facilities can call the patient’s home to confirm that the patient arrives safety and try to contact someone else at home who can assist the patient during the postoperative period.6 Facilities also can warn such patients that they will notify the police if they choose to drive; if the patient does drive, the facility can inform police of a potentially impaired driver on the road.6,8
While ASFs have a responsibility to ensure that a patient is discharged appropriately, the ASF does not have control of the patient’s actions once the patient leaves the ASF.8 At the time of admission, healthcare workers may rely on a patient’s statement that someone will be picking them up at discharge.13 The ASF has no responsibility to screen escorts ahead of time.8
ConclusionPatient safety is enhanced when the ASFs accomplish the following:
- Implement a written protocol regarding escorts which incorporates state regulations, accreditation standards, and professional organization guidelines,6,8 including
- under what circumstances is an escort required;
- when no escort, no surgery applies;13
- actions for unforeseen circumstances;
- a definition of responsible person;6,8 and
- what constitutes a safe discharge.
- Educate healthcare workers regarding this protocol.6,8
- Monitor compliance with the protocol.8
- Preoperatively, thoroughly instruct patients about why escorts are required.8
- Provide patients with preoperative instructions/brochure indicating that an escort is required postoperatively.8
- Ensure that staff follow the protocol to the best extent possible and acts reasonable in unforeseen circumstances.6
- Thoroughly document patient assessments and staff interventions6 to ensure that the patient has a caregiver until the patient is able to care for him/herself.6
Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anesth 2006 Sep;53(9):858-72.
Chung F, Imasogie N, Ho J, et al. Frequency and implications of ambulatory surgery without a patient escort. Can J Anesth 2005 Dec;52(10):1022-6.
Chung F, Kayumov L, Sinclair DR. What is the driving performance of ambulatory surgical patients after general anesthesia? Anesthesiology 2005 Nov;103(5);951-6.
Gall S, Bull J. Clinical risk: discharging patients with no-one at home. Gastroenterol Nurs 2004 May/Jun;27(3):111-4.
Bull J, Gall S. Safely home: safety issues surrounding the discharge of day patients post endoscopy. J. GENCA 2004 Jan;13(4):8-9.
Flowers L. Ambulatory surgery centers: tips for enforcing patient escort policies. OR Manager 2006 Jul;22(7):25-7.
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Mathias JM. Ambulatory surgery centers: what’s ASC’s obligation for escorts? OR Manager 2004 Mar;20(3):29-31,34.
American Society of Anesthesiologists. Practice guidelines for postanesthetic care. Anesthesiology 2002 Mar;96(3):742-52.
Association of periOperative Registered Nurses (AORN). AORN guidance statement: postoperative patient care in the ambulatory setting. Standards, recommended practices, and guidelines. Denver (CO): AORN 2005.
Flowers L. Ambulatory surgery centers are your elderly patients safe to go home? OR Manager 2005 Dec;21(12):21,23,25.
Burden N. Discharge planning for the elderly ambulatory surgical patient. J PeriAnesth Nurs 2004 Dec;19(6):401-5.
No designated driver: court refuses to place liability burden on discharge nurses. Legal Eagle Eye Newsl Nurs Prof 2005 May;13(5):1.
Medical center offers rides home to day surgery patients. Quality Improvement Report 2007 May;2(5):9.