Welcome to a discussion on transportation barriers and endoscopic procedures. ASG recently published a white paper on this topic addressing the barriers, legal challenges, and strategies for GI endoscopy units. Tonight you'll hear from the authors of this paper, who will also take your questions. My name is Eden Essex, and I will be the announcer for this session. You'll be able to submit questions and comments throughout the event via the Q&A box, and we'll address those questions and comments after Dr. Kwok's presentation. A recording of tonight's session will populate your GI LEAP account in the near future, so you can review the content anew or watch it with others. Now it is my pleasure to introduce our presenter, Dr. Carl Kwok. Dr. Kwok is an interventional endoscopist with Kaiser Permanente Southern California. He has served as a member of the ASG Quality Assurance and Endoscopy Committee and is the lead author of the ASG white paper addressing transportation barriers and endoscopic procedures. I will now hand the proverbial floor over to Dr. Kwok. Thank you so much, Eden, and the entire team. I wanted to extend my sincerest appreciation and gratitude for all registrants for this topic this evening, and we'll try to keep it practical and somewhat lively. Definitely plenty of time to ask questions and share best practice tips and practices across the country. So as many of us in the audience are aware, millions of endoscopies and colonoscopies are performed annually across the country in order to evaluate GI complaints. In 2019 alone, there were over 20 million upper and lower endoscopies performed in the United States. As is the custom, most of our procedures are performed with some type of sedation. And as a result, our current standard of practice is to request that adults be escorted home after sedation. And the reason for this is the Center of Medicare and Medicaid Services, CMS, has a policy which states that all patients are to be discharged in the company of a responsible adult, except for those patients exempted by the attending physician. Well, if that were airtight, watertight, then this webinar would be pointless. But clearly that is not the case. Increasingly, we have noticed in many practices, including our own here in Southern California, that more and more adults are finding challenges and difficulties in securing a ride to and from their endoscopic procedure. And in fact, this was actually studied very recently in a safety net hospital survey, where up to one in four individuals surveyed in the study were listed transportation as a barrier to successful initiation and completion of their endoscopic procedure that was deemed medically necessary. Now, this, of course, brings up a very important question of what is a responsible adult? Interestingly and curiously, this is not explicitly defined in federal regulations, but one prevailing thought is an individual at least 16 years of age or over. Although, of course, this is well-meaning, there leaves a lot of nuance and interpretation, particularly when we're trying to call our fifth, sixth, seventh string individuals for those in those situations that cannot secure a ride. Now, there are many purported hypotheses and reasons, potential reasons, why increasingly adults are not able to secure a responsible escort home. Of course, there is the certain situations where the adult patient themselves do not feel that it is important. They feel that they could simply just get the procedure and go home on their own devices, on their own accord, without an escort. That does happen, not all the time, but, you know, we've seen it certainly in our own practice as well. But there are many, many other potential reasons for this, including but not limited to decreased intergenerational living, greater mobility, delayed marriage, and certainly those individuals that want to keep their health information private from other individuals. All of these appear to be contributing to the anecdotally increasing number of patients who seem to have difficulty securing a ride for their procedures. So, currently, there is no widespread, large-scale systematic data on ambulatory endoscopy and the challenge that we face. A lot of this is very much anecdotal at present time. But what was interesting is, you know, there were two actual telephone survey studies six years apart. The first was conducted in the UK. The second was conducted in Canada. And what you can see here is that, you know, it's not easy. There are individuals who, after general anesthesia, for example, in the UK study, you know, about 20% of the respondents actually undertook risky activities that were in direct contrast to what was advised to them. So, for example, drinking alcohol, cooking food, looking, caring for children, ironing clothes. And similarly, in the Canadian study in 2008, you know, same thing. A certain percentage of individuals immediately after surgery received general anesthesia, drove cars, drank alcohol within 24 hours of surgery. The concern, even though there seems to be a safety valve release from the CMS regulation, is that, to be transparent, physicians and unit leadership may not feel comfortable just exempting a patient from the CMS requirement. You know, there may be, you know, a concern, certainly a potentially real concern of a medical legal risk that may result if a person is released to his or her own accord after a procedure without an adult escort. So, one potential response to this can be very dogmatic. You know, simply, you know, no ride, no procedure. The problem with this is that, you know, the issue of not being able to secure an adult escort home is not going to go away, number one. You know, I personally have been in practice for over 12 years, and I've seen it throughout my entire career, again, anecdotally, more often now than in the earlier years of my practice. And this truly is, in the worst case scenario, a lose-lose because, you know, for the patient, some individuals genuinely do not have anyone that can help them. They may be in their older years, they may not have family or friends nearby, and they genuinely cannot secure a ride. Now, there are others, of course, that may have, you know, the ability to, but that's a different discussion. We'll get to that later on in the talk. And more importantly, what do you do with these individuals that happen to have a time-sensitive diagnosis? For example, occult blood in the stool, and for whatever reason, they cannot secure an adult escort home. We can't simply just, you know, not offer dogmatically, not offer these procedures because there's medical legal risk on the other side. I mean, there is a potential claim of denial of care in those instances. Now, for the GI unit and the GI physician, this also is a lose because, you know, it potentially results in a lost appointment slot if this issue is detected on the same day of the procedure. And it may actually increase access demands and pressures, and every single one of our practices, I'm confident, ours included, you know, is facing, you know, real struggles and challenges dealing with patient care access, especially post-COVID era. So every single appointment slot matters and counts. Now, I'm happy to report that there seems to be some increasing interest in the science behind monitoring anesthesia care, for example, with propofol. There was a study that actually was a randomized control trial in 2006, which looked at and compared propofol versus moderate sedation, where individuals that received propofol actually had psychomotor testing and driving skills that actually returned to baseline functionality within two hours post-sedation. In contrast, those individuals that received moderate sedation with the combination of a sedative and a hypnotic were found to have significantly more issues with lane deviations, basically a driving test. They essentially started having issues with their psychomotor driving exam. There was no difference between the two arms in terms of number connection test for what it's worth. So a bit busy. Our societies, you know, we actually wanted to take this opportunity to, you know, get a survey of the landscape, of the current landscape. And, you know, the preeminent society, the American Society of Anesthesiology, is actually, you know, quite firm in the request, almost demand, if you will, of an adult escort being present after sedation. As you can see, similarly, there are other societies and governmental regulatory bodies, Center for Medicare and Medicaid Services, that believe similarly. And even the, interestingly enough, the, oh, I'm sorry, I take that back, the American College of Radiology, Society of Interventional Radiology, believes similarly. There, of course, is a lot of nuance to this. And as you can see, for example, in the American College of Emergency Physicians, even American College of Cardiology, there is no explicit requirement to have responsible adult escort take a patient home after sedation. Because in their professions, if you will, they may not necessarily be able to predict with 100% certainty, which individuals may need moderate sedation, for example, for a time-sensitive procedure. Similarly, again, we're extremely honored to have Dr. Dominance with us in the Veterans Administration. He can sort of expound on that a little bit later in this webinar. There is a strong recommendation to have a responsible adult escort take a patient home after sedation, although they recognize that, you know, we live in a real world, there are real world challenges, and there are various other alternative solutions proposed in the VA toolkit. Now, the preeminent case that I think is worth highlighting and mentioning is actually this one from the state of Alabama. This is young versus gastrointestinal care. And essentially what happened in this case was an individual underwent moderate sedation, as you can see, on January 20th for an upper endoscopy, actually signed a form that stated he would not drive and that his wife would pick him up after the procedure. It turns out after the fact, upon investigation, that the patient actually lied and drove himself home on the very first day. He returned to the same ASC nine days later for an outpatient colonoscopy, again with moderate sedation. This time, again, stated that someone would pick him up, but it was finally discovered on the second procedure that nobody was available and ready to pick this patient up. So this individual signed an AMA form that he would not drive and of course proceeded to lie and did drive. As if that wasn't enough, this individual drove actually to another medical appointment where he received more sedation, ultimately attempted to drive home to his home in El Dorado, Arkansas, which is about 120 miles away. Unfortunately, this individual succumbed to a single car collision and he expired. So this resulted in a lawsuit by his estate, his wife, against the ambulatory surgery center. Initially, the wife won. This was appealed successfully to the Court of Appeals and then escalated to the Supreme Court of Arkansas. And what the Supreme Court of Arkansas found, they found several things, but their opinion was that number one, they believed very strongly that the unit leadership must be allowed to depend on information provided to the patient. Number two, similarly, they are not given necessarily the right nor the duty to hold someone for multiple hours on end. For example, after the second procedure, when it was apparent nobody was immediately available to pick this patient up. Thirdly, the Supreme Court found that the unit did not actually discharge the patient. In fact, it was very clear the patient left against medical advice. And lastly, I think the point that bears repeating is that, you know, in this case, the Supreme Court felt very strongly that, you know, patients must bear the responsibility for the consequences of following and more importantly, not following such advice that is rendered to them. Now, this is the preeminent case that I think is worth highlighting. Now, of course, this is only one case, but hence this was actually, you know, one of the interesting factors that led us as a committee to discuss this topic further and ultimately a result of the generation of the White Paper. And so what do we do in situations like this? There are potential various solutions, each of which carries its own pros and cons. So there are alternatives to having a responsible adult. One potential option, believe it or not, may be potentially a solo discharge. This was actually studied in Mayo, Arizona, where they looked at a one-year survey of individuals that were obviously very highly selected individuals that were selected to be able to be discharged without a responsible adult escort. And there was the conclusion of this study was that there was no increased incidence of ER visits or adverse events to those individuals upon discharge. In some practices across the country, there has been discussion of having a nurse's aide accompany the patient home, although that, you know, has many, many cons, you know, in terms of this so-called, you know, curb to curb type of policy. Number one is, of course, the logistics, you know, the financial implications, you know, potential medical legal considerations. But it has been used in some practices that, you know, during our informal survey across the country during a previous ASGE event. There are now options such as, you know, commercial rideshare options, such as, not to name names, I know this is meant to be commercial free, but I apologize, there's no real alternative. There are two major rideshare companies that tout having, you know, patient appointment transportation as part of their service offerings. And in fact, one company in particular touts that its medical ride option is HIPAA compliant. In fact, we had a very interesting observation discussion prior to the tonight's webinar where actually one of the study authors in our paper cited is actually actively looking into this option now as we speak in terms of having a systematic protocol of, of course, you know, properly selecting patients that may be eligible for solo discharge with this type of a rideshare arrangement. Other practice environments across the country have explored the idea of using, for example, a short stay unit, or even a potential nearby hotel. There are, again, of course, many potential considerations and issues in terms of, you know, who's financially responsible for this. And furthermore, I will note that it is not necessarily advisable to keep patients in the hospital, you know, post sedation, because, you know, Center for CMS explicitly states that purely custodial care is not allowed in terms of a, you know, patient care reimbursement perspective. So, you know, if there's a medical reason to keep an individual, you know, after a procedure with sedation, that's one thing, but if it's purely custodial care, this may not be covered under the evidence of coverage and their benefits. Prolonged PACU stay has also been tried in some units across the country, although, again, it raises a lot of issues in terms of, you know, is which nurse is responsible for watching this individual? What if this individual elopes while they're supposedly purportedly under PACU observation, and not to mention logistical and workflow throughput concerns? This is a summary of the various alternative options in terms of their pros and cons. This is actually the, you know, an expanded version of the previous slide. So I think the strategy here is, you know, there's, you know, the right thing, you know, a lot of times in medicine is it depends, right? And this is no different. I think the most important first step for the audience members is to consider engaging your local risk management and legal team to essentially come up with a solution that is guided in principles of beneficence, but also allows for one to sort of, you know, have a contingency plan in place, right? You know, potentially, arguably, one of the worst times to decide what to do with a patient that has no ride is when you're caught off guard after the procedure is complete, after the sedation has been administered. And so in this vein, you know, it's important to sort of understand and appreciate the concept that defense is really the best offense. Documentation during the entire patient booking process for their endoscopy procedure is critical. For example, making explicitly clear during the entire journey that, you know, an adult escort home is required. Please let us know immediately if that is not available so that we can undertake certain various risk mitigating strategies. Again, the whole premise is to not get caught off guard, you know, on the day of, after sedation has already been administered. And again, the concept here is to use a customized strategy depending on when the problem is first detected. And so if during the whole process, you're able to identify with a reasonable degree of certainty that an individual patient may have difficulty securing right afterwards, let's say days or weeks beforehand, you have multiple options. You can either choose to, for example, choose one of the options in table two, as long as it's properly vetted and discussed with your local risk and legal team, or you can potentially consider non-endoscopic testing or even unsedated endoscopy as one option, okay? A fourth option, actually, this is a minor typo, is to consider potentially full sedation, sorry, monitored anesthesia care, because the science appears to support a faster psychomotor recovery time. On the day of the procedure, if your admission team identifies that a patient will not have arrived home, you can essentially consider the same similar options. Again, it's important to actually emphasize to the patients that there is a possibility of, in the worst case scenario, canceling and rescheduling the procedure. At least on more than one occasion, in my own practice, for example, once we've emphasized to the patient the gravity of the situation, you know, within 15, 20 minutes, they're able to secure another responsible adult to take them home. So sometimes, you know, there is a little bit of nudging that is required on the part of the patient, but as long as we know a priori in advance. Those individuals that, you know, tell you after the sedation's been administered, the procedure's completed, they, ah, well, I guess I don't have a ride home, you're gonna have to let me go, this is the most vexing, you know, category of patients. Again, you can, you know, carefully consider your various options in table two. These individuals, out of necessity, do need to be let out of the unit against medical advice. You're not, you know, medically, legally discharging them. You're actually, in fact, telling them, look, we told you that you needed a ride. You don't have a ride. You're leaving against medical advice. And one last piece of advice, or consideration, I should say, is that, you know, in some environments, for example, as a condition of participation in endoscopy, you may want to consider, you know, working with your local risk and legal to have patients sign all necessary paperwork before they get admitted to the procedure. And the reason why this is important is, you know, there is a potential concern that, you know, if you make a patient sign papers after the fact, after they've received sedation, there is a potential concern that they could say, well, I was potentially under the influence, and essentially, you know, avoid responsibility. Although, again, this is another point worth making, that if you document, you know, systematically throughout the entire journey, from, you know, appointment initiation all the way to the day of the procedure, you know, you can show, you know, a due diligence and, you know, appropriate standard of care by making it very clear on several occasions that the patient was informed that they needed a responsible adult escort home, they needed a ride home. And then, of course, if they, even if they have to sign the AMA form on the day of the procedure, you can, you know, point to the entire chain of documentation during the entire journey process that, look, we informed the patient that they needed this, they chose not to bring one, you know, here we are. And with that, I want to thank every single audience member for coming to this webinar this evening, and I think now is a good time to open up for questions. So thank you, Dr. Kwok. Co-authors of the white paper will now join Dr. Kwok for Q&A and discussion. It's my pleasure to introduce Dr. Jason Dominitz. Dr. Dominitz is the Executive Program Director for Gastroenterology and Hepatology for the U.S. Department of Veteran of Health Affairs and a University of Washington Professor of Medicine. He has served as a member of the ASG Quality Assurance and Endoscopy Committee and currently serves as a member of the GI-QUIC Bolinoscopy Measures Subcommittee. Dr. TR Levin is a Research Scientist at the Kaiser Permanente Northern California Division of Research and Interim Associate Director for the Cancer Section. Dr. Levin is a Professor of Health Systems Science at the Kaiser Permanente School of Medicine and a Staff Gastroenterologist at the Kaiser Permanente Walnut Creek Medical Center. He is the Clinical Lead for Colorectal Cancer Screening and Assistant Chair of Gastroenterology for the Permanente Medical Group. Dr. Levin currently serves as a member of the ASG Quality Assurance and Endoscopy Committee. Kara Newberry serves as Director, Government Affairs and Regulatory Counsel for the Ambulatory Surgery Center Association. Through this role, Kara spearheads ASCA's regulatory efforts and serves as the association's primary contact with federal regulators. Prior to this role, Kara coordinated state legislative, regulatory and public affairs for the association. Kara received her law degree from the Ohio State University. So I see Dr. Dominance, you added a paper to the chat for everyone. Did you want to kind of let them know what that is? Yeah, sure. Thank you, Eden. Welcome everyone. Thanks for joining this webinar. One of my colleagues at the University of Washington, Dr. Rachel Asaka has been studying this issue. We have a safety net hospital, Harborview is our County Hospital in Seattle and they have these challenges that we all share with transportation for patients. And so they offered a ride share and I put the link or the PMID in there so you can pull it up. It's a very brief paper, but they offered it to individuals. They had 31 patients who took part in this. The average cost was $25 for the ride share. And I remember she spoke about this at the Colon Cancer Roundtable meeting last month. And what's nice is that they're able to track the patients. You know, you can see if you're the person ordering the ride share for a patient, you can actually follow that patient's journey home and you could check to make sure that they get home okay. So there's, you know, differences between that and a taxi service. And they felt that it was quite successful. It's a pilot study. It's only 31 individuals. But a lot of the patients said that were it not for this program, they wouldn't have been able to get their colonoscopy just reinforcing some of the points that Dr. Kwok made earlier today. So I think this is very encouraging. You know, who's gonna pay the money for the ride share? You know, I work in the VA setting, you know, so we, you know, really do worry about getting our patients their transportation. We have what's called the Veteran Transportation Service, which many veterans are eligible for, but not all. And we use that to send people home, but we're exploring the use of ride shares as well. We're using it in the non-procedural setting, you know, non-sedated setting now in many VAs. Using it with sedation is something that we wanna explore. That is really wonderful. And for the Kaiser Permanente group, Dr. Kwok or Dr. Levin, would you want to, have you all changed? Are you handling patients without a responsible adult in there to provide transport? How have you gone about making any changes in your practice, if you have? Yeah, I can speak first. You know, we are utilizing more our monitoring anesthesia care rooms. It's a work in progress, right? In terms of trying to identify these patients in advance. And we want to make this, ultimately the ideal state is to make it a, you know, what's the good term for this? No judgment type of a statement, right? We want to encourage patients in the future ideal state to let us know well in advance so we can map out, you know, their scheduling, you know, well in advance of their procedure date. But currently we are doing the, you know, the monitoring anesthesia care, you know, schedule switching into that room for those individuals that identify on the day of that they don't have a ride. You know, currently in discussions with our regional legal group here in Southern California to streamline the process even further, sort of as we alluded to earlier in terms of making sure that, you know, we follow a chain of events, if you will, so that it's systematic. Everybody is on the same page in terms of knowing that they need a ride and having them sign all the appropriate paperwork as a condition of participation in the endoscopy. And I'll hand the floor over to Dr. Levin. Yeah, you know, just this week, I was handed a policy that came from KP Southern California and we are sort of in discussion about launching here in Northern California. We haven't launched it yet. And we've just been having conversations with physicians getting their take on how comfortable they are with importing the Southern California policy into the Northern California practice. And it's been kind of interesting. I think some people are, you know, we've all been raised through our GI training to sort of feel like patients need to have a responsible adult. And many times, but I think what Carl did was actually really a nice exploration of what is the actual evidence and what is actually recommended by various groups. And it seems like there's more wiggle room than we initially, than many of us initially thought. I think it's important to bear in mind that not doing colonoscopy on people who absolutely need it, whether it's people with positive stool-based test or have an abnormal imaging test and where there's a mass, you're gonna end up delaying the diagnosis of cancer and they'll have its own set of mid-legal exposure, I think by failing to diagnose the cancer as well as the risk you might undertake by letting people drive or figuring out some way that they could safely get their way home using my chair or any other alternatives. So maybe that's a chance to kind of hand it off to Karen Newberry and see what she thinks from a mid-legal perspective. Sure, just to add a couple of things in response to some of the comments that have already been made. So CMS does, as noted, provide a little wiggle room but in the state operations manual for ambulatory surgery centers, which is kind of, we call it the Bible, the guidance that the surveyors really using when they go into the facility. It doesn't mandate this, but it does say that ASCs would be well-advised to develop policies that address what criteria a physician should consider when deciding a patient does not need to be discharged in the company of a responsible adult. And then it also goes on to say that exemptions have to be for specific patients. You can't have a blanket exemption for some population of your patients. So you couldn't just say, any patient under the age of 60, or I'm just making things up, but you can't make it a generalization. It has to be for specific patients and really need to have specific criteria. One other point that I just wanted to make, there was mention of who pays. And of course I know in an ambulatory surgery center, already they're very lean and efficient. And so there's not a ton of extra money to go around, but maybe you might've had some concerns about even if you're allowed to pay, even if you had that funding to do so. And it sounds like maybe the medical world and the legal world have the same sayings, but it's the typical, it depends. But there is some flexibility there from, there was an OIG opinion in 2016, and then it was also updated in 2020, indicating that there are circumstances in which a facility can pay for transportation. So if your clinicians and leadership at the facility have come to the conclusion that this individual is eligible to leave the facility without maybe a family member, there are, you could pay for that. There are certain restrictions on that. You're not allowed to market that service as something that you provide. So that might be a bigger barrier than one would want to start establishing this as something you're doing your facility. And there are other, you can't fly a person in, it's really supposed to be local travel that you can pay for. So I'm guessing with most endoscopic procedures, the reimbursement isn't high enough to fly a patient in any way, but just, and I'm happy to share some more guidance on what those limitations are for paying for that service if anyone's interested in that. So Cara, if I could just ask, if they pay, does that mean that they take on liability in a different way than if the patient were to pay? That's a whole, I mean, that's a whole nother, you know, question and issue that you would want to address with your legal team for sure. I think I was just addressing it from the perspective of it's not prohibited. In the VA, you know, if we have a patient who doesn't have a ride home and we, you know, lodge them in the hospital, for example, they take up a bed, the cost of that, you know, people may say, well, the VA, you don't really have costs the same way the private sector does, but that's not entirely true. If we have a patient tying up a bed for us in the hospital, it means we can't transfer a patient from the private hospital into our bed, which means we're paying many thousands of dollars a day with your taxpayer money to support them in that private hospital. I wonder if we have, I think we had a question from Dr. Savides, Eden, did you? Yes, and let's see. So Dr. Savides, I've opened your mic if you would like to share what you put in writing or any additional thoughts that you have from your facility. Okay, sure. No, thanks. Can you hear me okay? We sure can. Thank you so much. Okay, great. Thanks. Yeah, I was going to say, for the last at least five years, we created a UC San Diego Medical Center policy together with our chairman of anesthesia, in which we have a propofol policy where patients can go home using rideshare. And the requirements for it is they need to let us know ahead of time that they're going to be going home by themselves and this is for people who, for access reasons, can't otherwise get procedures because they don't have anyone to take them home. We do require, once we know they get pure propofol, so there's no other drugs associated with that, then what we do is we have to document in the chart that the physician says that they can go home via the propofol policy. We built into Epic a box for the nurses to check, so we're documenting who's going home via rideshare. And then after the patients get discharged, two hours later, the nurses call the patient and the patient has to answer their phone, and they have to say they're doing okay and got home okay. If they don't, the police get called for a courtesy check just to make sure everything's okay at home. And we've done this for easily over 100 people. Some patients actually get this every six weeks doing it this way because it's the only way they can get in for repeated procedures. And it's done well so far, no complications. And so we're putting this together in terms of publication. I'm just wondering, what am I missing? And I guess this is maybe for Kara mostly, it's like, are we medical legally putting ourselves at big risk here? We think we're providing services for patients who would otherwise wouldn't be able to get procedures. But is there anything in that protocol that we've done you think that we should be doing differently? So first question would be, when you say no complications, how many of the patients over the past five years, how many times was a safety check? Do you know how many times a safety check was required? I'm double checking that now, but it's above 80%. By our policy, it should be 100%. But like anything, this is where I need to see how compliant the nurses have been in documenting it. A big step in this was getting this hardwired into Epic so we could actually document and make sure that happens. And Tom, related to that, how many times did you think you had to call the police? That's what I meant, sorry. Oh, I think it's zero. Zero? Yeah, because I've not heard. They would have let me know if anything happened. Now, the one thing that I will say is that I know what goes on in the GI world with this. The same policy is being used in orthopedic surgery and ENT and other surgical services. So it's possible that other things are going on that I don't know about. And that's why we need to put it together, mostly through the Epic, tracking it. Because initially, we started doing this without Epic, and I'm not sure. There, I have no way to document what was happening. But this is what we're going to put together, and once we have that, we'll get it out there for publication. Because we've been doing it, and we need to get the data out there. That's really interesting, Tom. I look forward to seeing the data. You know, I understand you're restricting it to propofol, but there are new drugs. They're not that new, I guess, but remifenil, remibidazolam. I have no experience with it personally. One of my anesthesia colleagues says that this will be a big game changer for us. These are very short-acting drugs. So I wonder if that might be an opportunity to expand this kind of program. And pure propofol is not for everyone, so this might be an option. I don't know if anybody on the panel has any experience with those drugs. Maybe not. I have another question for Cara. Sorry, go ahead. No, go ahead. You know, the issue of, like, we had a patient who had a ride arranged, everything seemed good, then the procedure was done, and there was no ride to be found. And it turned out that the ride had suffered a myocardial infarction while in the VA lobby, and they were hospitalized, and we ended up hospitalizing that patient to lodge them. But sometimes the patients, you know, are insisting to go home, drive themselves. And we heard Dr. Kwok spoke about that prior case. And I wondered, do I have any ability to restrain the patient? Are the patients sedated? Are they competent to make a decision? Or do I have any legal right to restrain them? And do I have a legal right to call the police if I feel that they're at a duty? I know this was touched on by Carl. I'd love to hear your comments. Yeah, Carl, I don't know if you want to address it first. I mean, I can't, you know, provide legal advice with these different situations, like even the one that we were talking about earlier. But I know that in the hospital conditions of participation, there's a lot more language around, like, disruptive patients. So if it's a situation where they're causing, you know, problems, and they're disrupting the rest of the facility, I know that hospitals have a lot more to go by in their, you know, Code of Federal Regulations guidance than ASCs do. But you raise a good point about, you know, you know, holding someone against their will. We get sneaky people all the time who, you know, oh, yeah, my ride's going to stay here. And then the rides always leave. And then you're trying to track them down. And it takes a lot longer. And where are you keeping that patient, to your point? But I think that would be definitely something good to discuss with an attorney as you're developing a policy. Because, you know, like when the person comes in, I mean, the case of somebody else getting hospitalized, who was supposed to be the adult aside, you know, like in your facility, do you make the person, the responsible adult, like, come in and sign in at the same time? Do you know what time the patient is? Or how are you? Yeah, we typically did that, of course, during the pandemic, when there was limits of who could come in, everything changed. Right? They would often, you know, have them, we'd call them and talk to them. Some places use the rule of, you know, don't sedate the patient until you see the whites of their eyes of their driver, you know, and I think it's variable. Yeah, well, and some, a lot of our facilities have a policy that the driver is not allowed to leave. Like if they see the driver leave, though, I mean, I don't know what you do, if the patient's already gone back. And, you know, then the driver leaves, it's a it's a very tricky situation. But a lot of, especially our a lot of our GI facilities are smaller, and the waiting rooms just really aren't equipped to, you know, handle everybody either. So it's both. But yeah, that's a, that's an interesting scenario. And I think that there are, you know, there could be legal issues either way. So, you know, the question about who is a responsible adult is also a good one. And I appreciated that exploration as well, because Yes, question. All right. Oh, no, I was just gonna piggyback on what you said. Excellent points. You know, so in terms of, you know, do you call the police? I mean, you know, we've had in my own experience, you know, we've had a handful of times, maybe two or three that I can recall very vividly. You know, you always remember, you know, you never want to be the interesting patient, right. But in these cases, they were definitely the interesting patient. For long story short, you know, individual, you know, came in for an outpatient, actually, it was an EUS procedure. So a little bit deeper, you know, with football, fortunately. You know, at the time, you know, while we were still formulating, as Dr. Levin mentioned, we didn't yet have the formal region wide policy in place. We were trying to essentially figure out a way to have them do ride share. And long story short, you know, the individual said, Oh, the ride share is downstairs. And my charge nurse had a sneaking suspicion that they were not going to get in the ride share. And so sure enough, the individual bolted for the parking garage, you know, because they drove here themselves. So my question actually to Cara and actually to the whole group is, you know, there are other facets of life where we, you know, for lack of a better term, you know, we sign essentially, a lot of rights away, you know, as a condition of participation. This came up, you know, in fact, when we went to a car event, you know, with with my two boys, and, you know, before you can even set foot on campus, you know, the track, basically, you had to sign, you know, certain documents, which, you know, you do waive substantial rights. And I'm not saying it necessarily needs to be that draconian for outpatient elective endoscopy. But, you know, to this, at least the theme is, you know, what is the legal sort of protection or lack thereof, if you if you have an individual sign these forms, that, you know, I will be personally responsible if I drive home afterwards, if I, you know, do not have secure ride, etc, etc, etc. Before they even get started with a procedure as part of the checking process. I'm generally very curious to hear your thoughts on that. Well, I mean, there's, you know, when you were telling the story of the person who left the facility, and then went to another healthcare facility, and then died, you know, I was thinking, I mean, when you're signing those documents, are you a competent? Are you competent at that point to sign that? That's a question that, you know, a judge or a judge might ask. And, yeah, a lot of the liability to, you know, obviously, the facility has liability, but then, you know, it's also whoever's signing off on the discharge. And it's interesting, because it used to be that and not everybody followed this, but it was in the state operations manual that it had to be the basically the anesthesiologist or the I'm sorry, the operating physician who was discharging the patient and the discharge had to occur, like, basically, the patient had to be leaving within 15 minutes of that. And we were able to get that to be a little more flexible now. But I do worry, I guess, or wonder as we're having this discussion, if that flexibility could, you know, there could be more liability because of that. Because basically, now you can, like, whether it's the anesthesiologist or the operating surgeon, they could, or, you know, the, you know, procedural, whoever's doing a procedure, they could just sign that the patient can leave when stable. And if they've already signed that they're leaving when stable, then, you know, if it comes out later that the patient really was not stable or something, you know, that's what I think you bring into the discussion a lot more if the person's not leaving with a responsible adult. But I don't know if that answered your question at all. But I think, I think that there's a lot of, there's a lot of things to work through. I think it's, you know, as you've all said, there are access issues. And there are a lot of people who do not have the support system that they need. And how do we serve them? So thanks for taking the lead on this. I mean, I think Carl's really done a service for us by kind of either pulling back the curtain or shining a light on this issue. Because so many, so much of the time, you know, at least through my career, you know, multiple decades now, we just kind of like pretend that it doesn't exist. And then you find yourself in these situations, it's sort of like you're in, you're in the real bind, because now the patient's leaving, and you never had a chance to have that conversation before. So I think figuring out how to make this transparent to patients that these, as these options get created, and the Southern California policy that I saw was very rigorous. There's quite a lot of disclaimers that they're signing off on before they get sedated. And then after, before you can allow them to leave, they have to be able to write their phone number down and write a bunch of other information about how they're going to be, how they can be contacted. So they have to be somewhat cognitively intact to be able to carry out these tasks. But also, we wonder, if we make this too visible to patients, are too many of them going to opt for this? And then we've written, you know, it's one thing if it's like a one-off once a month or once every few months kind of thing. But if it happens regularly, you know, it would create a problem. Because now everyone gets one, oh, if you say the magic words, you know, the words, the patients talk to each other, say the magic words, you don't have to have a driver, despite, you know, all these policies that say that you do. So I don't know if Jason or Carl, any thoughts about that? Yeah, no, that's an excellent point. I think you're absolutely right. This is, this is like threading the eye of the needle, right? You absolutely want to develop systems, policies and procedures such that, you know, essentially, you're not, you know, calling an audible on the day of the procedure after they've received sedation. But also, precisely, you know, spot on, you don't want to advertise this, because, you know, even though, you know, risk is an independent probability, you know, if you keep having multiple events like this, inevitably, you know, there is going to be an absolute small, but increased, you know, absolute incidence of adverse events, right? So, I don't know, I don't know what the right answer is. I think that, again, and this may be a, you know, avenue of future research and discussion, right? Maybe it could very well be that, you know, maybe not the best, most palatable option, but you have to sign away substantial rights as a condition of participation of endoscopy. But similarly, make it very clear, you know, at the time of booking that, you know, you have options, right? I mean, we strongly encourage X, but, you know, if you absolutely cannot do X, please let us know well in advance. Again, I don't pretend to know what the right answer is. I'm sure there's a lot of ramifications and unintended consequences of any policy. But, you know, thank you for the kind words. I mean, this was exactly it. You know, we found out, you know, several years ago, we were having much more often increasing numbers of individuals that we were literally surprised and everybody gets stressed, right? I get stressed, the charge nurse gets stressed, the anesthesiologist gets stressed, the chief of service gets stressed, everybody gets stressed when we have to make on-the-fly decisions, you know, with regards to an individual that says, ha-ha, well, I don't have a right and I have to let me go. And that's why I was asking about, you know, the police wellness check or safety checks and the hospital outpatient departments and the ASCs. I can't speak to other sites of service. I'm not as familiar, but the quality reporting programs for those settings do have measures that track seven-day follow-up. So if there were to be some complication or, you know, tragic event happen even day of, you know, if the person's driving to the earlier case study, that would show up in our quality reporting. Now, right now, our quality reporting program is just pay for participation, not pay for performance. But if that were to ever change, obviously, that would be something to consider. And it is publicly available data. So if you had a ton of patients, you know, who were presenting at the hospital within seven days of procedures, you know, that could raise some red flags as well. This has been a tremendous conversation. I want to thank all of our presenters and panelists tonight. We've come to the close of this presentation. As a reminder, a recording of this session will populate your GI LEAP account when it's available. This concludes the presentation on transportation barriers and endoscopic procedure. We hope this information is useful to you and your practice.

transportation barriers

endoscopic procedures

adult patients

responsible escort

accessing medical care

alternative solutions

legal challenges

clear communication

managing legal risks