Cant Go Home Alone Again Need Someone

Mr L, aged 49 and living lone, attends a 24-hour interval surgery for a colonoscopy and requests to exist discharged unaccompanied. He tells you he plans to drive home. How should y'all respond?

A mutual scenario in a range of practices

We regularly receive requests to our Medico-legal Advisory Service (MLAS) for advice on variations of this scenario. Calls come from anaesthetists, surgeons, GPs, do managers, and other practise staff and may relate to 24-hour interval surgery or other procedures requiring short-term sedation. Sometimes patients don't plan to drive themselves, but suggest taking a taxi dwelling unaccompanied.

At times it is clear when patients arrive for surgery that they plan to get out unaccompanied, or their arrangements may autumn through and the patient may suggest at the indicate of discharge they plan to go out without anyone to accompany them.

Importance of a discharge policy

This is a scenario with significant risks of harm for the patient, equally well as physician-legal risks for the practitioner. But it is also an awkward situation to properly accost at that bespeak in time. Instead we recommend all proceduralists and doctors administering sedating anaesthesia develop suitable policies and protocols around discharging patients following sedation.

Best practice guidelines

The Australian and New Zealand College of Anaesthetists Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures (ANZCA guidelines), terminal updated in July 2014, state at paragraph 12.four that:

"…the patient should exist discharged into the intendance of a responsible adult to whom written instructions should be given, including advice about eating and drinking, pain relief, and resumption of normal activities, too as nigh making legally bounden decisions, driving, or operating machinery."

The ANZCA guidelines also refer to ANZCA Recommendations for the Perioperative Intendance of Patients Selected for Twenty-four hours Care Surgery (2010), which make more detailed recommendations for day surgery, including having a responsible person able to send the person domicile in a suitable vehicle and a responsible person staying at to the lowest degree overnight post-obit discharge from the 24-hour interval care unit (sections 3.1 and 3.2).

An increasing number of hospitals adopt this position in their own policies that patients must be accompanied dwelling house and prospective patients are advised that if they do non have a responsible adult to collect them or take them home, their procedure will be postponed to a day when they can provide an escort.¹

Such a policy is implemented through discussions and assessments with patients, for example asking nearly discharge arrangements at the fourth dimension of admission and requiring patients to sign a disclaimer if they insist on leaving unaccompanied, acknowledging they do so against medical communication.

The policies and practices of such hospitals, together with the ANZCA guidelines, will probable grade part of what is considered accepted and standard practise. The Medical Lath of Australia has explicitly stated that it expects medical practitioners to follow the ANZCA guidelines.

Therefore, in the event that a patient suffered an injury considering he or she was discharged home lonely following sedation, a court will likely take guidelines and any policies into account and may well observe that the appropriate standard of care for day surgeries would be requiring patients who received sedation to take someone back-trail them to their home, whether or non they travel home in a taxi or a private machine.

Failure to exercise so might be judged negligent and liable in damages, or open to a complaint of unsatisfactory professional person comport confronting treating clinicians.

If y'all discover a patient plans to leave unaccompanied

If a patient presents for surgery and advises they have no-one to collect or accompany them it may exist advisable to reschedule their procedure for another 24-hour interval, or at to the lowest degree to ensure that their process is early in the list, so they can stay nether ascertainment for equally long as possible.

If arrangements fall through

Sometimes a patient's arrangements change at the concluding minute. If, when a patient comes to be discharged, they do non have a person to pick them up following surgery or sedation information technology may be necessary to delay their discharge until someone is contacted and able to collect them. Alternatively, the patient may demand to be brash to remain until you are satisfied that the furnishings of the sedation accept worn off sufficiently for information technology to be safe for them to leave the infirmary alone. Clinical intendance e'er needs to be prioritised, even where the unit of measurement or surgery is scheduled to close. Supervisory arrangements must exist maintained until the effects of the sedation have worn off and they tin can travel abode safely.

If patients are insistent that they exist allowed to leave infirmary unaccompanied you should ask them to sign a disclaimer confirming that they take been advised to remain in hospital and/or wait for a responsible person, and any decision to leave lonely is therefore made against medical advice.

Even in this state of affairs it is still important to emphasise to the patient the risks they might exist exposing themselves to and provide specific communication (for example that they must not drive for a specified period of time until the furnishings of the sedation have worn off because their reflexes may be impaired and they could exam positive for narcotics). Once again, this advice should exist documented in the course signed by the patient and/or in the clinical records.

Key lessons

• Clinical staff may be responsible for harms if patients are discharged under the influence of sedation.
• To manage these medico-legal risks, protocols should be adult and followed.
• Discharge arrangements should always be addressed during the consent procedure and again in process planning.
• Requiring patients to be accompanied home is becoming standard practice and should exist preferred policy following procedures involving sedation.
• The name or other details of the responsible person collecting the patient should be documented in the clinical file, forth with time of difference.
• If patients are unable to be accompanied, belch should be delayed until alternative arrangements can exist made. They should at least exist kept nether observation as long as possible until it is safe for them to travel home.
• If they still insist on leaving, ensure they sign a grade which documents the warning given and confirming they have left against medical advice.

Additional resources

Consummate our Risk IQ eLearning modules, Consent – the key problems and Documentation: on the record to obtain CPD points.

References

1. Run into for instance the policy published on the website of St Vincent's Individual Hospital, Sydney.

Article updated 11 Dec 2015.

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Source: https://www.avant.org.au/news/20151103-going-home-alone-discharge-from-day-surgery/

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