Discharge from day procedures

• Patients undergoing any day stay procedure that involves sedation or anaesthesia should be accompanied home by a responsible adult and be advised not to drive while under the effects of sedation or a narcotic.
• Ensure patients understand post-discharge management and risks. Set expectations early and provide information well in advance of the procedure.
• Design your discharge policies and procedures in line with professional and road safety guidelines to protect patient and public safety when the patient leaves your premises.
• Assess whether patients are well enough to be discharged. However, in most cases you cannot prevent a patient from leaving alone if they have been advised of the risks and insist on leaving against advice.

The Australian and New Zealand College of Anaesthetists (ANZCA) has issued a Guideline for the perioperative care of patients selected for day stay procedures (PG15) (DSP Guideline) that has been endorsed by the Royal Australasian College of Surgeons (RACS). This outlines good professional practice for facilities and medical practitioners providing procedures where a patient is discharged within 24 hours of having received anaesthesia or sedation.

Travelling home and post-procedure care

While the DSP Guideline sets out good professional practice, each situation needs to be assessed individually. There may also be policies in place at the hospital or practice that should be followed. If a patient does not have appropriate care arrangements, the decision to perform the procedure will generally involve weighing the relative risks of proceeding against delaying the procedure. If the risk of delay is unacceptable, consider performing the procedure in a hospital that can admit patients overnight.

The DSP Guideline outlines the criteria that should be satisfied before a patient is discharged:

• Patients should only be discharged when a responsible adult is available to transport them in a suitable vehicle. A train, tram, bus or other public transport is not suitable.
• A responsible person should stay with the patient at least overnight following discharge. This person must be able to make decisions for the patient’s welfare if necessary.

In addition, the patient should understand the risks of the sedation and procedure. The general principles of informed consent would apply to any risk of post-procedural complications. For more information please see Avant’s factsheet Consent: the essentials.

Make sure you:

• Warn the patient of the potential effects and safety risks of any medication.
• Provide the patient or their accompanying adult with written and verbal instructions about post-anaesthesia and post-procedural care. Explain signs to be aware of and include a contact number and location for emergency medical care if necessary.

Following that discussion, you should establish that the patient (or their responsible person) understands these requirements and intends to comply with them – particularly regarding public safety such as not driving.

In our experience, planning and patient selection can help avoid many medico-legal issues. For day stay procedures this particularly applies to the patient’s discharge and care

arrangements. Their suitability for anaesthesia in a day facility needs to be assessed in light of any comorbidities and medications. It also means considering any issues that may affect their post-procedure care.

For more detail on suitability considerations, see the DSP Guideline.

Practices providing day stay procedures need to have clear policies and protocols in place.

Always make the discharge criteria and expectations clear to a patient well before the planned date of the procedure. This should be discussed with the patient and can also be addressed in patient information packs or published on the practice or hospital website.

Inform the patient about the length of time before they may resume activities, such as driving safely or legally after the procedure, so they can plan appropriately.

Confirm the discharge arrangements with the patient when they arrive on the day of the procedure.

To help guide your decision making, it is helpful to consider potentially difficult scenarios and some options for how the practice or care team would manage them.

If the patient has no support person

If the patient has no support person and cannot arrange for one, it may be appropriate to delay the procedure. This will be a matter of clinical judgement.

You cannot detain a patient against their will, but they may choose to be admitted overnight if that is an option.

If the procedure does need to be performed on the day, consider the timing of the procedure. For example, it may be possible to perform it early in the list so the patient can stay under observation for as long as possible.

A process should be in place to manage any patients when it is unexpectedly unsafe to send them home on the day, such as admission or if a day facility only, a transfer by ambulance to a hospital for an overnight stay.

If support arrangements fall through

Consider whether you can delay the patient’s discharge until they can contact someone to collect them. Otherwise, you may need to advise the patient to remain under supervision until you are satisfied the effects of the sedation have worn off sufficiently for it to be safe for them to leave the hospital alone. Ideally, they should still travel home in a taxi or hire car, rather than driving or using public transport.

Clinical care always needs to be prioritised, so you may need to have arrangements to continue observations until the patient is fit to be discharged.

What if a patient insists on driving home?

If you become aware that a patient intends to ignore advice and leave the facility unaccompanied or drive themselves home:

• counsel them not to drive
• emphasise the risks they might be exposing themselves and others to.

Australian road safety authorities (Austroads) have guidelines on assessing fitness to drive following temporary conditions that set out health practitioners’ obligations. In general, if a patient insists on driving after having been administered a narcotic or sedation, practitioners have a duty to warn the patient not to drive until they are sufficiently recovered physically and mentally to be safe to drive. In such cases, there is no duty to report a patient to the licensing authority.

There is rarely a legal basis to detain a patient if they insist on leaving on their own. A patient can only be detained in hospital against their will if they meet the requirements for an involuntary admission under the relevant legislation in your state or territory.

If this does not apply and the patient insists on leaving, ask them to sign a waiver confirming that they have been advised to remain at the facility and/or wait for a responsible person, and their decision to leave alone is against medical advice.

If a patient is clearly impaired and indicates they will leave and drive, you may wish to alert the police.

Reporting your concerns

If you are concerned the patient may pose a serious health and safety risk to themselves or someone else, consider whether it is appropriate to breach the patient’s confidentiality and report the matter to the police.

Privacy legislation permits you to breach patient confidentiality where the disclosure is necessary:

• to lessen or prevent a serious threat to the life, health or safety of the patient or another person (in NSW the threat must also be imminent), or
• to lessen a serious threat to public health or safety.

This will depend on the circumstances and you can call Avant’s Medico-Legal Advisory Service (MLAS) for specific advice.

If you can do so safely, advise the patient that you may report them if they insist on driving in these circumstances. This may encourage them to reconsider.

Document any information or advice provided about discharge arrangements, along with the patient’s consent to the procedure.

Make a record in the clinical file of the name and details of the support person collecting the patient. Also note the time of departure.

If the patient insists on leaving alone, include in the clinical file their signed confirmation that they have left against medical advice and your clinical rationale for determining that they were competent when making the decision.

Australian and New Zealand College of Anaesthetists, Guideline for the perioperative care of patients selected for day stay procedures (updated July 2018)

Austroads, Assessing fitness to drive, (as amended to August 2017)

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.