I don't have a definitive answer, but I can at least lay out some of the issues for you and highlight a recent ASGE white paper on this issue. This is the reference to the white paper that was published last year in October. Millions of endoscopies and colonoscopies are performed annually to evaluate GI complaints. There was in 2019, 7.4 million EGDs and 13.8 million colonoscopies. This is in deference to Neil, this is a US estimate. Most procedures are performed with sedation and the current standard of practice almost everywhere is that adults need to be escorted home after sedation. The Center for Medicare and Medicaid services, all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician. So there is an option to exempt people from this responsibility. The problem, you know, there's more and more people who are lonely without designated drivers and increasingly adults who need a sedated procedure, but can't secure a ride. It can be as many as one in four patients, particularly in safety net settings have transportation as a barrier. It's unclear exactly how we define responsible adult and possible reasons. There are some patient personality issues that may lead them to be more isolated than others. There's a greater decrease in intergenerational living. People don't live with their children or with the relatives. There's greater mobility. People are moving all across the country. People are delaying marriage. And so they're more frequently alone and not necessarily partnered. And they may have make a decision to keep health information private. So they don't want to share it with people who might be able to drive them. They don't want to share that information. There's no systematic data available on ambulatory endoscopy. The data is largely adapted or extrapolated from ambulatory surgery. In 2002, a British telephone survey of 240 same day surgery patients, almost 20% drove cars, drank alcohol, cooked food, or looked after children or iron clothes within 24 hours after surgery. And most of us are telling people not to do those things for 24 hours. In 2008, a Canadian telephone survey of 750 same day surgery patients with general anesthesia, regional anesthesia, or IV sedation, 4% drove, 2% drank alcohol within 24 hours after surgery. The concern is really that physicians and unit leadership may be uncomfortable exempting a patient from the CMS requirement. And people are very concerned, understandably, for taking on medical legal risk. The usual response is to say, no ride, no procedure. It creates a lose-lose situation for the patient. Some genuinely cannot secure a responsible adult. What if there's a, you know, what if you have an abnormal x-ray or CT scan, you have a mess, and it's very time sensitive to make a diagnosis. So there's potential medical legal risk from other perspectives, such as people may make claims that you denied them care. Obviously, for the GI unit or the GI physician, there's a lost appointment slot. If someone shows up and they don't have a driver, and you have to make a decision of whether to continue them in the procedure, continue doing their procedure, and lots of pressure to provide access and schedule and schedule patients. What kind of science is there? This is an example of a view from a driving simulator. Propofol-based sedation typically shows recovery of psychomotor function as early as two hours post-sedation, including recovery of driving skills. In 2006, there was an RCT of 100 patients undergoing endoscopy in Germany. They received either propofol alone or midazolam plus pethidine, which in the U.S. we call Demerol. Propofol demonstrated that the psychomotor and driving skills were near baseline within two hours after sedation. The midazolam and pethidine, significantly more lane deviations, time over the speed limit, missed stoplights, slower reaction time for unexpected events. There was a number of connection tests that was also done that showed no difference. So clearly, people getting propofol can recover a lot faster than people getting more traditional procedural sedation. A number of societies have looked at escort guidelines across different settings. The American Society of Anesthesiology says that a responsible adult is required. The American Association of Nurse Anesthesiology says also a responsible adult was required, but an algorithm is provided to address scenarios if no responsible adult is available. As we noted, CMS says unless exempted by the attending physician. Joint Commission requires it, and the Accreditation Association for Ambulatory Health Care requires it. The American College of Emergency Physicians doesn't really state what to do after someone's been sedated. There's no comment from the American College of Cardiology. The American College of Radiology says, and particularly Interventional Radiology Society says, yes, you need a responsible adult. The VA has comments that, yes, the responsible adult is required, but there are various alternative solutions proposed in situations in which no responsible adult is available, and the American College of Surgeons doesn't specify. This is one example of a legal case. In January of 1999, the patient had an endoscopy with Valium and Demerol. He signed a form that he would not drive and that his wife would pick him up. However, he did drive himself home. Nine days later, he returned for a colonoscopy with moderate sedation. He stated that a friend would pick him up, and the friend didn't. He signed AMA forms saying that he would not drive, but he actually did. He drove to another medical procedure, and then after that procedure, he attempted to drive home and was in a one-car collision, which resulted in his death, and then his estate tried to submit a lawsuit. The Ambulatory Surgery Center where he had the procedures was in Little Rock. His home was in El Dorado, Arkansas, 119 miles away. This whole case actually just makes us all very anxious to think about. The Supreme Court of Arkansas said that it disqualified the suit mainly because the expert witness was from Texas and could not speak to the standard of care in Arkansas. Texas standard of care stated that you should not sedate unless the driver is present, but the Supreme Court ruled that the unit must be allowed to depend on information provided by the patient. The unit could not hold someone for eight hours when it was apparent that no responsible adult would arrive. The unit did not discharge the patient. The patient left against medical advice. Regarding alternative options, such as a taxi cab or a call to the police or admitting to the hospital, the Arkansas Supreme Court said that the unit had no right or duty to impose such restrictions, and the court would not impose such restrictions. In Arkansas, the ruling was the patients must bear the responsibility for the consequences of following or not following such advice. What are the solutions? Find an alternative to responsible adults, use a taxi, or keep someone for prolonged observation, either in the recovery room of your ASC or with a hospital admission. The alternatives include solo discharge or using a nurse's aid. The alternative drivers include Lyft or Uber, patient appointment transportation, and HIPAA-compliant Uber. There's also possibilities of getting third parties to kind of participate as kind of attenders with the driver, and then prolonged observation, such as a hotel or a short stay admit or prolonged stay in the PACU. So solo discharge, this is for people who have no family or friends in the area. If they've met discharge criteria, particularly using a post-anesthesia scoring system or a highly reliable patient, the pros are this ensures access to care. The con is really that reliable is a subjective assessment, and it's hard to be sure. A nurse's aid would be a responsible adult caretaker who may or may not be available to accompany the patient It ensures access to health care, but there's uncertain qualifications for people in this role. A taxi, particularly for people who need no obvious assistance during transportation home, or if the patient is highly reliable. This does ensure access to care, but reliable is subjective, and we're not sure taxi drivers really fit in that role. The ride share, such as Uber or Lyft, this is, again, this issue with reliability and with meeting HIPAA requirements and med legal considerations. The hotel or short stay admission might be acceptable from a medical legal consideration, depending on how far away the hotel is, but there are definitely costs associated with this and resource utilization. Prolonged stay may be acceptable from a med legal consideration, but doesn't raise questions about resource utilizations. Does the nurse from the recovery room watch them the entire time? And there's vicarious liability if the patient's unattended, who takes responsibility for adverse outcomes. And most ambulatory centers are not staffed, late into the evening or overnight. So I think what the real message and take home is that you should engage your local risk management and legal team. The best defense is the best offense, so documentation during the entire process is critical. And you need to develop a strategy as soon as the problem is detected, and potentially even in advance. When do you detect the lack of ride? That is kind of the key driver. So if it's before a procedure, like days or weeks, review each of the possible solutions that I showed in table two. Consider non-endoscopic testing. We talked earlier about potentially fit or still DNA testing for people who are having trouble getting a ride. Consider doing endoscopy without sedation. It's important to collaborate with your patients, but you should be firm based on your own local policies. If it happens on the day of procedure and no sedation, consider things like maybe canceling the case and doing endoscopic testing, doing an unsedated endoscopy. There's general feeling that propofol is probably better than procedural sedation. And once you explain to patients the implications of what they're asking you to do, oftentimes they can identify rides. And after procedure with sedation, there's an option to just, if you find out after the procedure's over, discharge patients against medical advice. But it's really important that consistent, repeated, pre-procedure documentation is really key. So consider as a condition to participation in endoscopy, having patients sign all necessary paperwork before admissions for the procedure. So the real take home here is that this is still a bit murky. With the paper that was written, the white paper, we've tried to clarify the options and improve understanding of the policies. It is possible to work with your local risk management team to define your local policy. You're in a much better situation if you're actually adhering to the policy that you yourselves have created. And just because you do everything right does not mean you won't get sued, but it will help you from losing the case, as we saw with that Arkansas case. So I'll stop there. Thanks very much.

post-sedation escort

medical guidelines

social isolation

alternative transportation

risk management