Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Individual Position Statement and Policy Considerations
Introduction
With the increasing prevalence of outpatient surgeries and procedures requiring sedation or anesthesia, the issue of safe patient transportation continues to be a concern for healthcare facilities and providers.1-3 For patients who received sedation or anesthesia, transportation from a healthcare facility while accompanied by a responsible individual is important for patient and public safety.4,5 Patients may experience significant cognitive and psychomotor impairment for several hours following sedation or anesthesia, potentially compromising their ability to safely navigate their return home unaccompanied.5,6
Life situations that may make transportation with a responsible individual challenging include patients who are new to an area, who need to travel long distances, who do not wish to inconvenience family and friends, or who do not have a caregiver support system.4,7-10 Lack of transportation to seek medical care disproportionately affects minority populations, those living below the poverty threshold, Medicare recipients, and people with functional limitations.4,7,9,11 These patients are turning to ride-share, taxi services, or public transportation to transport them to and from their healthcare visits.12-17 However, ride-share services are only responsible for transportation of the patient. Ride-share drivers are not responsible for caring for the patient during transport or upon arrival at their destination.
Audience
This resource is intended for Certified Registered Nurse Anesthetists (CRNAs), also known as nurse anesthesiologists or nurse anesthetists, other anesthesia providers, members of the interdisciplinary team, administrators involved in policy development, and other interested stakeholders.
Position
The American Association of Nurse Anesthesiology (AANA) believes that patient safety is critical during any same-day procedure, particularly one requiring sedation or anesthesia. Patients should have a responsible individual, as defined by facility policy, who is able to safely transport the patient home or a facility needs to establish and implement policies and procedures in the event that an exception is made. Facility policy should comply with federal, state, and local law and regulations as well as facility accreditation requirements.
Age and the ability to drive are not the only factors that determine a responsible individual.5,18 An individual who may be considered for inclusion in a facility’s discharge policies is one that understands the discharge instructions, is physically and mentally able to make decisions for the patient's welfare, if necessary, is capable of providing post-procedure care at home, and can report any post-procedure or post-anesthesia complications.5,18,19 Within the policy, the facility defines who a ‘responsible individual’ may be and may make case-specific exemptions (e.g., a minor caring for their own child, an emancipated minor, a minor caring for parent).5,18
A taxi, ride-share service, or public transportation may be considered if the patient is accompanied by a non-driving responsible individual.18 Patients should not be permitted to
drive themselves home after the procedure or surgery, particularly if they received sedation or anesthesia.6,10,20-26
Purpose
This resource provides policy considerations for outpatient or same-day surgical settings regarding discharge planning specific to patient transportation. Alternative policy considerations for various situations are presented, as each facility will establish policies that best serve its patients.
Policy Considerations: Regulatory and Accreditation Requirements
Concern exists for patients undergoing sedation or anesthesia who do not have a caregiver to aid them in their transport home after a procedure.6,10,27 Healthcare facilities should consider both patient safety and potential legal liabilities when developing policies for post-procedure transportation. A comprehensive admission and discharge policy, developed by the interprofessional team, that addresses transportation and care at home can prevent case cancellation or a significant challenge on the day of the procedure. The policy is valuable to assist the team and patient in decision making that supports all parties involved. It also addresses patient safety considerations unique to the community served and the services provided, as well as options that balance the facility’s responsibility to the patient and the patient’s wishes. Engaging an interprofessional team in planning, policy development, and ongoing education helps foster maximum acceptance and consistent communication of the policy to patients.10
To optimize post-procedure patient safety and comply with applicable law, regulations, and accreditation standards regarding patient transport after discharge from an outpatient or sameday surgical setting:
Verify federal, state, and local law and regulations as well as facility accreditation requirements
Engage the facility’s legal counsel, risk manager and/or similar role to review and address liability and legal concerns related to patient discharge and transportation.
Hospitals28
CMS Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
§482.43 Condition of Participation: Discharge Planning
“The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.”
Interpretive Guidelines §482.43
“Hospital discharge planning is a process that involves determining the appropriate posthospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs.”
Ambulatory Surgical Centers29
Centers for Medicare and Medicaid Services (CMS) Condition for Coverage
§416.52(c) Standard: Discharge.
“The ASC must -
(3) Ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.”
Facility accreditors (e.g., The Joint Commission, Accreditation Association for Ambulatory Health Care [AAAHC], QUAD A) incorporate similar language in their facility discharge requirements.
If the facility provides or arranges transportation services, the policy should address compliance with relevant laws and regulations for safe transport, as addressed in some accreditation standards.
Policy Considerations: Discharge after Sedation or Anesthesia with a Responsible Individual
Instruct patients in advance of the procedure to make arrangements for a responsible individual to accompany them to the healthcare facility, drive them home or accompany them in a ride-share service, taxi, or public transportation, and be present or readily available to assist them at home.5,18,30
o Instructions may be provided in the surgeon’s or proceduralist’s office at the time the case is scheduled.
o Verify availability of a responsible individual during discussions or health history acquisition prior to the patient’s arrival at the facility.
o Discharge planning instructions should also be provided to the responsible individual who will be accompanying the patient home.
o If the responsible individual accompanying the patient home is not the same as the responsible individual/caregiver who will remain with the patient, the facility should contact the responsible individual/caregiver to review the discharge instructions and to answer any questions.18
Determine whether the patient’s responsible individual is present to pick up the patient or if they are considered a “no show” for various reasons.31
Determine whether a responsible individual is available to accompany the patient home.
Determine whether a responsible individual is available to remain with or be readily available to the patient for 12-24 hours.18
If not, what are your facility’s requirements for discharge and transport home?
Advise the patient and responsible individual that patients should not drive after sedation or anesthesia as mental alertness, coordination, and physical dexterity may be impaired.5
Policy Considerations: Determining if a Patient is a Candidate for Unaccompanied Discharge after Sedation or Anesthesia
The following policy considerations are presented to address the scenario where the patient does not have a responsible individual to transport or accompany them home. Figure 1 summarizes policy considerations, with more detail presented below.
1. Policy Considerations Flow Chart
Apply established decision pathway, which includes the following:
o The complexity of the procedure
o Whether sedation or anesthesia is required
o Patient sensory, mental, and physical limitations
o Patient comorbidities
The patient provides a plan for transportation home prior to or at the time of admission.
o The facility or the surgeon’s or proceduralist’s office may offer assistance to the patient to make transportation arrangements, such as using a medical transport to take the patient to their residence after the procedure.
o The patient may not drive home.
o Facility policy includes specific requirements for patients using ride-sharing, taxi, or public transportation services after sedation or anesthesia.
If the facility learns that a patient is not truthful about being accompanied home by a responsible individual when they arrive for their procedure, determine whether the patient is a candidate for unaccompanied discharge and proceed as dictated by facility policy.
If it is determined that the patient is exempt from being discharged with a responsible individual, document the reason for the determination in the patient’s healthcare record.
If the patient is a candidate for unaccompanied discharge
o Proceed based on the facility policy for unaccompanied discharge, including consideration for Phase 2 recovery time for increased observation.
o The facility policy may require a specific time period after discharge criteria are met that the patient must remain in the facility.
o The facility policy may require an evaluation by two clinicians prior to departure to determine that the unaccompanied patient is capable of self-care and acting on warning signs that require attention by healthcare professionals.
o If the patient is not a candidate for unaccompanied discharge.
o Determine if medical transportation can be arranged.
If so, does the patient have a responsible individual as a caregiver at home?
o Determine if the patient will be admitted for observation.
o Determine if the case will be cancelled and rescheduled.
The facility may develop a specific discharge consent form for unaccompanied patients in order to document the patient discussion regarding the risks of leaving unaccompanied and the patient’s acceptance of the risks.
Anesthesia-specific considerations
o The anesthesia professional should be involved in and have the ability to decide whether or not to proceed with the case when the patient will be unaccompanied after discharge.
Please note, however, that for CMS-certified ASCs the Conditions for Coverage indicate the exception is to be made by the attending physician.29
o If the decision is to proceed, anesthesia professionals may consider adjusting their anesthetic technique to use medications that will have shorter lasting effects on the patient.32 Considerations include, but are not limited to, use of infiltration or field block, regional anesthesia, and techniques to minimize or eliminate anxiolytic, induction agent(s), and/or opioid(s).
Informed Consent
o Engage the facility’s legal counsel, risk manager and/or similar role in the development of informed consent policies, procedures, and documentation
requirements, including discussion of the anesthetic and procedural risks related to being discharged without an accompanying responsible individual.
o A copy of the completed, signed informed consent form should be given to the patient and added to the patient’s healthcare record.
A patient may choose to leave against medical advice (AMA) after the surgery or procedure.
o Consult with the facility’s legal counsel, risk manager and/or similar role regarding AMA policies to guide policy development.18
o If a patient insists on driving home, the patient is technically not being discharged, but is leaving against medical advice.5,33
o Document the patient discussion of the rationale for the required care and the patient’s understanding of the risks to self and others associated with driving home and non-compliance.5,33
o While a facility has a responsibility to ensure that a patient is discharged appropriately, the facility does not have control of the patient’s actions once the patient leaves.5,30
Discharge Considerations
Patients recovering from surgery or a procedure may not be placed in a waiting room or area unless they have been discharged and are waiting briefly while the responsible individual who accompanied them brings a car to the entrance.29
The facility may determine additional discharge evaluation criteria, beyond the general post-anesthesia discharge criteria, for the patient who may be discharged without a responsible individual.
o The facility policy may require a specific period of time after discharge criteria are met that the patient must remain in the facility.
o Anesthesia professionals should work closely with the post-anesthesia care unit (PACU) or recovery room staff to evaluate the patient.
o Verify that the patient has stable vital signs and can complete tasks such as sitting up, dressing, and ambulating prior to discharge.
Discharge Instructions
o Confirm and document that the patient and responsible individual, if available, understand the discharge instructions.
o Maintain a copy of the provided document in the patient’s chart.
o Provide the patient both verbal and detailed, written, understandable discharge instructions.
o Discharge instructions may include, but are not limited to, the following:
▪ Medications
• Specify the name, purpose, dosage, frequency, and route for each medication that is new and/or continued. Address medications that should be delayed or discontinued. Address when the patient can resume any pre-operative medications.
• Discuss the pain management plan and any side effects of the pain management treatment with the patient and answer their questions.
• Emphasize the importance of adherence to labeling directions.34
• Discuss the safe use, disposal, and storage of opioids, if prescribed.
▪ Activity
• Instruct the patient not to drive, operate machinery or power tools, consume alcohol, make important personal or business decisions, or sign important document for the next 12-24 hours.34
• Encourage the patient to mobilize as able the day of the procedure according to the surgeon’s or proceduralist’s recommendations.
• Emphasize that hydration and nutrition are important to minimize dizziness or drowsiness to promote healing.34
• Discuss activities that may exacerbate or reduce pain and strategies to address pain management at home.
▪ Post-Discharge Safety Monitoring
• Provide follow-up care instructions with information on necessary supplies and treatment procedures required at home (e.g., dressing changes).
Instruct the patient and caregiver regarding the signs and symptoms that could indicate post-procedure complications.
• Provide appropriate names and phone numbers for routine followup and emergency care (e.g., surgeon’s or proceduralist’s office vs 911, emergency department).
References
1. Taylor D. Planning for Surgery’s Future: Ambulatory Surgery Centers Expected to Skyrocket. OR Management News. Updated Jan 1, 2024. Accessed Feb 28, 2025, https://www.ormanagement.net/Opinion/Article/12-23/Planning-for-Surgerys-FutureAmbulatory-Surgery-Centers-Expected-to-Skyrocket/72398
2. Surgical Procedures Continue to Shift to Outpatient. Outpatient Surgery. Updated Jun 6, 2024. Accessed Feb 28, 2025, https://www.aorn.org/outpatient-surgery/article/surgicalprocedures-continue-to-shift-to-outpatient
3. ASCs: A Positive Trend in Health Care. Ambulatory Surgery Center Association. Accessed Feb 28, 2025, https://www.ascassociation.org/advancingsurgicalcare/aboutascs/industryoverview/apositive trendinhealthcare
4. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health Oct 2013;38(5):976-93. doi:10.1007/s10900-013-9681-1
5. Should Patients be Accompanied When Discharged from Ambulatory Surgery? PA PSRS Patient Saf Advis 2007 Sep;4(3):100-3.
6. Ip HY, Chung F. Escort accompanying discharge after ambulatory surgery: a necessity or a luxury? Curr Opin Anaesthesiol. Dec 2009;22(6):748-54. doi:10.1097/ACO.0b013e328331d498
7. Silver D, Blustein J, Weitzman BC. Transportation to clinic: findings from a pilot clinic-based survey of low-income suburbanites. J Immigr Minor Health. Apr 2012;14(2):350-5. doi:10.1007/s10903-010-9410-0
8. Yang S, Zarr RL, Kass-Hout TA, Kourosh A, Kelly NR. Transportation barriers to accessing health care for urban children. J Health Care Poor Underserved. Nov 2006;17(4):928-43. doi:10.1353/hpu.2006.0137
9. Wolfe MK, McDonald NC, Holmes GM. Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997-2017. Am J Public Health. Jun 2020;110(6):815-822. doi:10.2105/ajph.2020.305579
10. Gist J, Muirhead L, Wiltse Nicely KL. Could Your Patient be Taking Uber or Lyft PostAnesthesia? A New Era for Transportation Policy and Practice Considerations. J Perianesth Nurs. Aug 2022;37(4):521-527. doi:10.1016/j.jopan.2021.10.015
11. Allan-Blitz LT, Samad A, Homsley K, et al. A pilot study: the impact of clinic-provided transportation on missed clinic visits and system costs among teenage mother-child dyads. Humanit Soc Sci Commun. 2022;9(1):319. doi:10.1057/s41599-022-01342-x
12. Sullivan E. Cities With Uber Have Lower Rates Of Ambulance Usage. Updated December 18, 2017. Accessed Feb 28, 2025, https://www.npr.org/sections/thetwoway/2017/12/18/571689807/cities-with-uber-have-lower-rates-of-ambulance-usage
13. Powderly H. Hackensack University Medical Center calls Uber to transport patients. Updated Apr 7, 2016. Accessed Feb 28, 2025, http://www.healthcareitnews.com/news/hackensack-university-medical-center-calls-ubertransport-patients
14. Yun Tan Z. Medical Providers Try Uber, Lyft For Patients With Few Transportation Options. Accessed Feb 28, 2025, https://khn.org/news/medical-providers-try-uber-lyft-for-patientswith-few-transportation-options/
15. Sullivan E. Uber Launches Service To Get People To The Doctor's Office. Updated March 1, 2018. Accessed Feb 28, 2025, https://www.npr.org/2018/03/01/589464779/uber-launchesservice-to-get-people-to-their-doctors-offices
16. Bose D. Mississippians can soon take free Uber rides to health department appointments. Updated Oct 20, 2023. Accessed Feb 28, 2025, https://www.yahoo.com/news/mississippians-soon-free-uber-rides-205507173.html
17. Kreimer S. Rideshare program could help more people get colonoscopies. Updated Aug 2, 2023. Accessed Feb 28, 2025, https://www.yahoo.com/news/rideshare-program-could-helpmore-135207306.html
18. American Society of PeriAnesthesia Nurses. What is the definition of "responsible adult?" If a patient does not have a responsible adult to accompany them at discharge, what do you suggest? Accessed Feb 28, 2025, https://www.aspan.org/Clinical-Practice/Submit-a-ClinicalPractice-Question/Clinical-Practice-Frequently-Asked-Questions
19. QUAD A. Medicare Ambulatory Surgical Center (ASC) Accreditation Standrds Manual. 8-K8. Version 9.0, Effective April 7, 2025.
20. Chung F, Kayumov L, Sinclair DR, Edward R, Moller HJ, Shapiro CM. What is the driving performance of ambulatory surgical patients after general anesthesia? Anesthesiology Nov 2005;103(5):951-6.
21. Horiuchi A, Nakayama Y, Fujii H, Katsuyama Y, Ohmori S, Tanaka N. Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation. Gastrointest Endosc. Mar 2012;75(3):506-12. doi:10.1016/j.gie.2011.08.020
22. Horiuchi A, Nakayama Y, Katsuyama Y, Ohmori S, Ichise Y, Tanaka N. Safety and driving ability following low-dose propofol sedation. Digestion. 2008;78(4):190-4. doi:10.1159/000187118
23. Telles JL, Agarwal S, Monagle J, Stough C, King R, Downey L. Driving impairment due to propofol at effect-site concentrations relevant after short propofol-only sedation. Anaesth Intensive Care. Nov 2016;44(6):696-703.
24. Summerlin-Grady L, Austin PN, Gabaldon DA. Safe Driving After Propofol Sedation. J Perianesth Nurs. Oct 2017;32(5):464-471. doi:10.1016/j.jopan.2016.01.005
25. Hetland A, Carr DB. Medications and impaired driving. Ann Pharmacother. Apr 2014;48(4):494-506. doi:10.1177/1060028014520882
26. Hao XW, Zhan YL, Li P, et al. Recovery of driving skills after endoscopy under propofol sedation: a prospective pilot study to assess the driving skills after endoscopic sedation
using driving simulation. BMC Anesthesiol. Jun 24 2023;23(1):223. doi:10.1186/s12871023-02122-z
27. Chung F, Assmann N. Car accidents after ambulatory surgery in patients without an escort. Anesth Analg. Mar 2008;106(3):817-20, table of contents. doi:10.1213/ane.0b013e3181609531
28. Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix ASurvey Protocol, Regulations and Interpretive Guidelines for Hospitals. Accessed May 22, 2018, https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
29. Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix LGuidance for Surveyors: Ambulatory Surgical Centers. Accessed May 22, 2018, https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R56SOMA.pdf
30. Mathias JM. Ambulatory surgery centers: what’s ASC’s obligation for escorts? OR Manager. Mar 2004;20(3):29-31,34.
31. Chung F, Imasogie N, Ho J, Ning X, Prabhu A, Curti B. Frequency and implications of ambulatory surgery without a patient escort. Can J Anaesth Dec 2005;52(10):1022-6. doi:10.1007/bf03021599
32. Martin DP, Warner ME, Johnson RL, et al. Outpatient Dismissal With a Responsible Adult Compared With Structured Solo Dismissal: A Retrospective Case-Control Comparison of Safety Outcomes. Mayo Clin Proc Innov Qual Outcomes. Sep 2018;2(3):234-240. doi:10.1016/j.mayocpiqo.2018.06.002
33. Flowers L. Ambulatory surgery centers: tips for enforcing patient escort policies. OR Manager. Jul 2006;22(7):25-7.
34. Ward RC. Outpatient Anesthesia. In: Elisha S, Heiner JS, Nagelhout JJ, eds. Nurse Anesthesia. 7th ed. Elsevier, Inc.; 2023:971-86:chap 42.
Adopted as Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Adult, Position Statement and Policy Considerations by the AANA Board of Directors July 2018.
Approved as Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Individual, Position Statement and Policy Considerations by the AANA Board of Directors April 2025.
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