Home Alone good for a movie, not for seniors

Instructions should emphasize need for caregiver

Your older patient who lives alone did arrange for transportation to and from your surgery program, but you’ve just discovered that the driver has no intention of staying with the patient once he or she gets the patient home.

As a same-day surgery nurse or manager, you have a dilemma: Is the patient capable of caring for himself or herself following surgery? If not, what do you do to ensure the patient’s safety and protect yourself from any liability?

Same-day surgery programs will continue to see an increasing number of older patients. The U.S. Census Bureau reports that in 2011, the baby boom generation will begin to turn 65; by 2030, projections show that 20% of the population, or 70 million people, will be 65 or older.1

"We see a lot of older patients for cataract extractions," says Gen Parm, RN, MSN, administrator and chief executive officer of Florida Eye Clinic in Altamonte Springs, FL. "In our preoperative telephone call, we tell patients that they will need someone to drive them to and from their appointment and that they will need someone to stay with them for 24 hours following surgery."

Does this action guarantee that the patient will have a caregiver with them? "Probably not," Parm admits.

While the pre-op instructions may not ensure a caregiver, it does go a long way to protect the same-day surgery program, says John C. Gilliland, a health care attorney with Gilliland and Caudill in Indianapolis. A successful malpractice claim must show that the same-day surgery staff or surgeon had a duty to disclose concerns, breached that duty to disclose, created a negative effect by neglecting to disclose concerns, and caused damages, he explains. When patients are told in the pre-op telephone call that it is best to have someone with them following surgery, the nurse is telling those patients that the best way to ensure a safe recovery is to have a caregiver, he adds.

The same information also should be given in discharge instructions that the patient signs before leaving the same-day surgery program, suggests Gilliland.

"Be careful not to bury the recommendation for a caregiver in three pages of small type," he adds. "Ideally, your discharge form should have a line upon which you can write in the name of the family member or caregiver who will stay with the patient," he says.

You also should indicate if the patient states that there is no caregiver and that he or she does not need one, he recommends. This is further proof that the same-day surgery staff did not ignore the need for a caregiver, he explains.

Finding out before the day of surgery, or even on the day of surgery but before the procedure has begun, that the patient will not have anyone staying with them does give you time to make decisions, says Geoffrey Hibbert, RN, director of nursing at the Center for Special Surgery in Greenville, SC.

"We discuss the situation with the anesthesiologist and the surgeon to see if the procedure can be performed with a nerve block rather than another anesthesia," he says. "We also discuss the possibility of letting the patient stay in our facility longer than the normal time for recovery to make sure he or she is capable of being home alone."

If the surgeon and anesthesiologist don’t believe that an alternate anesthesia or a longer time in the same-day surgery facility will ensure the patient’s safety following surgery, and the patient has no family members or neighbors who can provide care, the other alternatives are delaying the procedure until a caregiver is available or admitting the patient to the hospital, Hibbert adds. "These are decisions that the surgeon or medical director makes based on the patient’s medical condition," he says. If the patient’s medical condition justifies hospital admission, insurance may cover the admission, he explains.

If clinicians at Florida Eye Clinic are worried that patients might be disoriented or unable to administer their drops, or if they have a coexisting medical condition, they will try to contact family members to explain the need for a caregiver, Parm notes.

"Although this situation is rare, we can also call a home health agency to provide short-term care for the patient," he says.

Because most insurance plans won’t reimburse for this type of home health care, be sure your patient is aware that there will be a charge to the patient for the service and that the charges will be explained by the home health agency, he suggests.

"There is a great value to talking with local home health agencies prior to needing them in these situations because every agency will not be able or willing to take on a patient for an afternoon," Gilliland suggests. "If you already have contacts with agencies that are willing to provide a home health aide to sit with the patient for a short time, you will not waste time in finding help for the patient who needs it."

Having a process in place to provide care for patients with no other caregivers is another way to protect your program from allegations of malpractice, he says.

The key is not to ignore the fact that having caregivers following surgery may be more important for the elderly than for other patients, Gilliland says.

"If you take a little time to consider the issue, put some simple processes into place to address the issue, and be ready to follow up when you or your staff have some concerns about a patient, then you create a win-win situation," he adds. "The extra attention to the patient’s needs once he or she leaves your facility not only reduces your liability risk, but also increases your level of patient relations."  

Reference

1. U.S. Census Bureau. Decennial Census Data and Population Projections. Washington, DC; 2000.

Sources

For more information about discharging elderly patients without caregivers, contact:

  • John C. Gilliland, Partner, Gilliland & Caudill, 3905 Vincennes Road, Suite 204, Indianapolis, IN 46268. Phone: (317) 704-2400 or (800) 894-1243. Fax: (317) 704-2410. E-mail: jcg@gilliland.com.
  • Geoffrey Hibbert, RN, Director of Nursing, Center for Special Surgery, 209 Patewood Drive, Suite 300, Greenville, SC 29615. Phone: (864) 527-7700. E-mail: ghibbert@centerforspecialsurgery.com.
  • Gen Parm, RN, MSN, Administrator and Chief Executive Officer, Florida Eye Clinic Ambulatory Surgery Center, 160 Boston Ave., Altamonte Springs, FL 32701. Phone: (407) 834-7776.