What are your options when patients show up without an escort to drive?

Study shows accidents can occur — take steps to avoid liability

An outpatient surgery patient shows up without an escort to drive him home. Despite the nurse's insistence, the patient indicates he doesn't have anyone who can escort him. There is no cab or public transportation available. Reluctantly, the case continues, and the patient drives himself home.

A recent study indicates the results of this practice can be devastating.1 The authors discuss two malpractice cases of patients who were discharged without an escort after ambulatory surgery procedures. Both patients drove themselves, had accidents, and sustained serious injuries.

The authors recommend that patients not be discharged without an escort regardless of whether the patient receives general anesthesia, regional anesthesia, monitored anesthesia, or sedation. "Driving after ambulatory surgery cannot be considered safe, and caregivers need to verify a safe ride home," they say.

Think it can't happen in your facility? One survey indicated that 11% of anesthesiologists would be willing to anesthetize patients without an escort.2

Anesthesia providers may wrongly think that short-acting anesthetics will wear off by discharge, or that the amount of sedation isn't enough to affect the patient's psychomotor function, the authors say. Actually, psychomotor impairment and cognitive deficits are common postoperatively, they say.3-6

Educate surgeons, anesthesiologists, and nurses on the importance of escorts, the authors advise. Even after very short procedures, most patients aren't fully recovered by discharge, they say, citing other references.7-9 "Home readiness is not equivalent to street fitness," they say.

The accidents detailed in the study that fact, says Stephen Trosty, JD, MHA, CPHRM, risk management consultant in Haslett, MI. When someone is injured in such a case, the facility may be sued, he warns. The liability would be similar to a bartender who continues to serve patrons who have had too much to drink, then the patrons drive home and injure or kill themselves or others. "There have been cases in which liability has come back to the bartender and, in some cases, even to the bar," Trosty says.

The effect of an anesthetic is somewhat comparable to that of too much alcohol in the patients may be groggy, he says. "There's a reduced ability to react quickly, to recognize that there may be a problem that needs to be reacted to, and sometimes a reduced ability to stay awake," Trosty says.

Additionally, discharge without an escort is contrary to guidelines issued by professional bodies such as the American Society for Anesthesiologists, the authors say. These national guidelines don't distinguish between sedation, regional anesthesia, and general anesthesia, they point out. In all cases, a patient shouldn't drive for 24 hours after ambulatory surgery, the authors say.

The Association of periOperative Registered Nurses (AORN) has issued a revised 2008 recommended practice for monitored sedation that says the pre-op assessment should include verification of a responsible adult caregiver to escort the patient home.

Follow these four tips

Consider these suggestions to ensure patient safety and avoid liability regarding patient escorts:

In the preoperative registration process, verify that the patient has a driver.

At the preoperative visit or during the preoperative call, tell patients that they need to bring a licensed driver with them, Trosty advises. Verify the name and contact information for that person, sources advise. Tell patients that without an escort, they won't be allowed to drive home and they'll have to stay at the facility until the anesthetic has worn off, Trosty advises.

Another option is to tell patients and document that if they don't have an escort, they will be sent home by cab and expected to pay for it and arrange transportation back to pick up their cars, Trosty says. "Can you enforce it? Maybe yes, maybe no, but at least you can show the patient was informed," he says.

While most ambulatory surgery programs ask for the names of escorts and their phone numbers, Trosty suggests that you consider going a step further and asking for the driver's license of the escort, which can be copied for the patient record as a means of ensuring the escort is a valid driver. If the patient doesn't have an escort, ask him if there is someone he can call, Trosty suggests. "Tell them that unless someone comes, they won't be discharged," he says.

Document every time you give patients this information, Trosty emphasizes. "The more times you can demonstration the patient given information, the stronger position you'll be in," he says.

Inquire about an escort at every opportunity, advises Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist in the Center for Nursing Practice at AORN. "It's just continual asking," Ogg says.

Offer suggestions for an escort.

Nurses need to be creative about helping patients find a ride, Ogg says. An elderly patient may be living alone and have no family in the area. Ask if the patient might have a neighbor or religious organization that would assist, she says.

"Lots of churches have people on call to help with rides," Ogg says. "They might also be able to stay overnight as a caregiver."

A private duty nurse might be another option, she adds.

Some ambulatory surgery programs prefer a ride service where drivers have basic training such as bringing blankets and pills to make the ride more comfortable, driving directly to the patient's house, handling an emergency by calling 911, and assisting patients with mobility into the house.

Have patients sign a waiver of discharge against medical advice.

Cab rides are an option when there is not an escort, Chung and the other authors suggest.

Nurses should escort the patients to the cabs to ensure that they don't drive themselves, the author says. They also suggest that patients sign a statement of discharge against medical advice. This statement allows the facility to provide written information about why the discharge could be hazardous and what the consequences may be, the authors say.

The signed statement is necessary if patients are driving themselves home, Trosty says. "It becomes important at that time that the patient understand the risks imposed by their driving home and that there is acknowledgement that they assume this risk," he says. The statement should indicate the patient had been told ahead of time about the necessity of having someone to drive them home and that they voluntarily ignored the advice, "something indicating prior knowledge as opposed to hearing it for first time when they got there," Trosty says. "The patient can't come back and say, 'No one told me that.'"

Consider canceling the surgery.

At Toronto (Canada) Western Hospital, when there is absolutely no escort, the case is canceled, says Frances Chung, MD, of University Health Network and professor of anesthesia, Department of Anesthesia at University of Toronto. Chung is the lead author of the recent study.

Don't proceed with the case if you know the patient is intending to drive home, she advises. "Medically and legally, you may be in a bind somewhat," Chung says.

There are some instances in which the lesser of the evils is to cancel because if patient should get into an accident, and the staff members know he or she shouldn't drive, a claim may be made against the facility that costs more ultimately than a cancellation, Trosty says. If you've had the patient sign a statement agreeing to have an escort, you might have recourse to bill the patient directly for the lost expenses, including OR time and physician's time, he adds.

When there is high potential for injury, the stronger the need for more patient information and documentation and, "the stronger the case to require patient to do these things or to hold them there long enough to make sure the anesthetic is worn off," Trosty says.

References

  1. Chung F, Assmann N. Car accidents after ambulatory surgery in patients without an escort [Report]. Anes Analg 2008; 106:817-820.
  2. Friedman Z, Chung F, Wong D. Ambulatory surgery adult patient selection criteria — a survey of Canadian anesthesiologists. Can J Anaesth 2004; 56:481-484.
  3. Chung F, Seyone C, Dyck B, et al. Age-related cognitive recovery after anesthesia. Anesth Analg 1990; 71:217-224.
  4. Ward B, Imarengiaye C, Peirovy J, et al. Cognitive function is minimally impaired after ambulatory surgery. Can J Anesth2005; 52:1,017-1,021.
  5. Grant SA, Murdoch J, Millar K, et al. Blood propofol concentration and psychomotor effects on driving skills. Br J Anaesth 2000; 85:396-400.
  6. Sinclair D, Chung F, Smiley A. General anesthesia does not impair simulator driving skills in volunteers in the immediate recovery period — a pilot study. Can J Anaesth 2003; 50:238-245.
  7. Thapar P, Zacny JP, Choi M, Apfelbaum JL. Objective and subjective impairment from often-used sedative/analgesic combinations in ambulatory surgery, using alcohol as a benchmark. Anest Analg 1995; 80:1,092-1,098.
  8. Thapar P, Zacny JP, Thompson W, Apfelbaum JL. Using alcohol as a standard to assess the degree of impairment induced by sedative and analgesic drugs used in ambulatory surgery. Anesthesiology 1995; 82:53-59.
  9. Lichtor JL, Alessi R, Lane BS. Sleep tendency as a measure of recovery after drugs used for ambulatory surgery. Anesthesiology 2002; 96:878-883.

Sources

For more information on patients driving home, contact:

  • Frances Chung, MD, Professor of Anesthesia, Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto McL 2-405, 399 Bathurst St., Toronto, Ontario, Canada M5T 2S8.
  • Stephen Trosty, JD, MHA, CPHRM, Risk Management Consultant, Haslett, MI. Phone: (517) 339-4972. E-mail: strosty@comcast.net.