Introduction

Patients undergoing ambulatory surgery are typically discharged on the day of the procedure, but psychomotor impairment from sedative and anesthetic drugs may linger and prevent them from safely driving or walking home. Current regulations, accreditation standards, and professional guidelines continue to require that patients be accompanied by a responsible adult following anesthesia or sedation; however, some patients may not be able to arrange an escort, leading to procedure delays and cancellations, and highlighting barriers to healthcare access. This manuscript details contemporary evidence, regulatory expectations, and risk-reduction strategies. The identified literature provides limited information to facilitate evidence-based decision-making for unaccompanied discharge after ambulatory surgery; however, the literature offers important considerations and contextual information to support decision-making.

Discussion

Considerations for Patients

Suitability for Discharge

Patient readiness for discharge may be assessed by patient recovery scoring systems alongside other criteria. Guidance states that the patient should be hemodynamically stable and alert; that symptoms of pain, nausea, and dizziness are addressed; and that psychomotor control has returned. Scoring tools may be used as part of the discharge protocol but should not be the sole determinant of readiness. There may be other requirements related to the patient’s individual needs and the type of procedure performed.1

Effects of Anesthesia

Patients may experience numerous effects related to anesthesia, including cognitive and psychomotor dysfunction and poor recall.2 Driving may be impaired, dependent on types of sedation used and comorbidities.3 These effects must be taken into consideration when planning for discharge following procedures during which sedation is used to mitigate risk for these patients.

Health Equity

The ability to meet discharge criteria for sending patients home with a responsible person may create barriers to access, especially for patients who are unhoused or otherwise underserved. Health equity–related barriers to safe discharge should be assessed as part of preoperative planning. Ayandeh et al. suggest specific medications that have rapid onset and short durations as best suited for patients with these barriers.4

Responsible Person Definitions, Regulations, and Standards

For patients who have undergone sedation or anesthesia, the U.S. Centers for Medicare & Medicaid Services require they be discharged with an accompanying responsible adult regardless of planned transportation method, unless exempted by the attending physician.5 The American Society of PeriAnesthesia Nurses defines a responsible adult as one that is physically and mentally able to assist the patient and understand discharge instructions.6 Pennsylvania code also requires an escort for patients who receive sedation or general anesthesia, and a medical decision regarding escort for those who receive local or regional anesthesia.7 Clinical guidance iterates that patients should not be discharged without an accompanying adult, but the physician responsible for the patient may make case-by-case decisions to exempt them from this requirement.8

Risk-Reduction Strategies

Unaccompanied discharge may result in legal liabilities for hospitals and clinics, and organizations should implement risk-mitigation strategies. Organizations should review discharge policies to ensure that they address alternatives for patients who do not have a responsible adult to accompany them at discharge. Discharge policies should incorporate federal, state, and local regulations, and should focus on safe patient outcomes. In addition, organizations should partner with legal counsel to verify that the informed consent policy related to unaccompanied discharge is in compliance with associated regulations and standards.

The American Association of Nurse Anesthesiology (AANA) recommends the following policy considerations when discharging patients after anesthesia or sedation2:

  • Determine whether a responsible adult is required to accompany the patient home.

  • Determine whether a responsible adult is required to stay with or be available to the patient for a predetermined period of time following discharge.

  • If a responsible adult is not available, determine the organization’s requirements for discharge and transportation home.

  • Advise the patient and responsible adult that patients who received sedation or anesthesia should not operate a vehicle due to the potential for psychomotor impairment.

  • Ensure patients plan for a responsible adult to transport (or accompany them in an alternative mode of transport) and assist them to their next destination. Provide instructions to patients at the time of scheduling and verify the plan before their procedure.

For patients who are not candidates for unaccompanied discharge, AANA recommends the following2:

  • Determine whether medical transportation can be arranged.

  • Determine whether the patient will instead be admitted for observation.

  • Determine whether the procedure should be rescheduled.

In addition, AANA recommends that the facility develop a specific discharge consent form that unaccompanied patients can sign to document the patient discussion regarding the risks of leaving unaccompanied and the patient’s acceptance of those risks.2

Exceptions and Alternatives to Accompanied Discharge

Local Anesthesia or Ultrashort-Acting Sedation

Exceptions to accompanied discharge are possible with documented capacity. Expert reviews9 and a white paper by the American Society for Gastrointestinal Endoscopy10 provide detailed discussions of suitable case scenarios for unaccompanied discharge (e.g., after sufficient recovery from ultrashort-acting sedation).

Taxis/Rideshares

Unaccompanied discharge, often with third-party transportation (e.g., taxis, rideshare services), may facilitate ambulatory surgery. A pilot study found that 100% (n=31) of patients who used rideshare nonemergency medical transport were able to be discharged following the procedure without incident.11

However, the practice does not fully address safety concerns. Commercial transportation providers may not be aware of the patient’s condition and need for necessary precautions or may not react adequately to an adverse event (e.g., a fall); also, impaired patients may not be able to communicate properly in case of an event. Rideshare services offer no guarantee that a driver is capable of or willing to help a patient when they require assistance, and drivers are not required to demonstrate competence in the face of a medical or other emergency.2 Thus, careful consideration is necessary when deciding to discharge patients without an escort, as it can compromise patient safety and raise liability issues for the healthcare organization.

Against Medical Advice (AMA)

According to the American Medical Resource Institute, if a patient wants to be released to a rideshare company despite the healthcare provider’s determination that the patient should be discharged to a responsible adult, the organization should consider taking the following steps12:

  1. Notify the surgeon.

  2. Have the patient sign an AMA form.

  3. Complete a patient safety event report.

Conclusion

The safest default remains patient discharge with a responsible adult after anesthesia or sedation. Exceptions must be rare, structured, and supported by augmented safeguards. Escort policies should be embedded in resilient discharge systems that emphasize planning, communication, verification, and continuous learning.

Disclosure

The authors declare that they have no relevant or material financial interests.

About the Authors

Anna Thomas (athomas@ecri.org) is a principal safety consultant at ECRI with extensive experience in safety event analysis, causal analysis education, and system-level patient safety strategies.

Jackie Ferenschak (jferenschak@ecri.org) is a risk management analyst at ECRI who specializes in topics related to patient safety and healthcare risk management.