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UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Outpatient Discharge After Receiving Sedation (2.3.2)

Outpatient Discharge After Receiving Sedation (2.3.2) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Outpatient Discharge After Receiving Sedation
Policy Number: 2.3.2
Category: UW Health
Type: Ambulatory
Effective Date: January 21, 2016

I. PURPOSE

Provide direction to promote safe transportation after receiving sedation for outpatient procedures at UW
Health.

II. POLICY ELEMENTS

In order to provide a consistent standard for safe patient transportation that follow s sedated outpatient
procedures at UW Health, the follow ing procedures w ill apply to all adult patients w ho receive sedation, as
defined by UWHC policy #8.38 and 2.45 (Adult Sedation and Standards of Nursing Practice: Post
Anesthesia Care). These medications may impair judgment, memory, coordination and motor skills.
This policy is intended for safe patient transportation and home care from UW Health follow ing outpatient
sedation.

III. PROCEDURE

A. PLANNED OR NON-EMERGENT PROCEDURE
i. Pre-Procedure
a. At the time of scheduling an outpatient appointment for a procedure requiring sedation,
the scheduler w ill inform the patient of the requirement that he/she must have a
designated driver and/or responsible adult accompany.
b. If another transportation method is utilized (taxicab, bus, w alking, van service), the patient
receiving sedation must have an adult w ho accepts responsibility for the patient
accompany him/her upon discharge.
c. If there are challenges in f inding a suitable designated driver/responsible adult, staff
should reach out to the area manager for help w ith coordination.
ii. Day of Procedure
a. During the preparation for the procedure requiring sedation, the designated driver/adult
accepting responsibility for patient should be identif ied by the patient.
1. Care team w ill document in the patient’s chart the name and contact information
(such as phone number and location) for this person.
2. Care team w ill call the designated driver/adult accepting responsibility prior to
sedation administration to confirm him/her acceptance of the responsibility and
the discharge plan.
b. If a patient presents for a procedure and does not have an identif ied designated
driver/responsible adult, staff w ill notify the provider performing the procedure to
determine if the procedure can be done w ithout sedation.
1. If it is not possible to perform the procedure w ithout sedation, the procedure w ill
be cancelled and rescheduled w hen a designated driver/responsible adult is
available.
c. In the event that a patient receives sedation and the designated driver/responsible adult
cannot be located or contacted, staff w ill offer assistance to help the patient f ind another
designated driver, responsible adult, and/or alternative transportation options.
1. If there is not an alternative driver/responsible adult/or alternative transport the
patient w ill be required to remain in the care of UW Health until the performing
provider (or delegate) performs and documents an assessment of the patient to
determine if the patient can be safely discharged w ithout the company of an
individual w ho accepts responsibility for the patient.
2. If the provider deems that the patient is not safe for discharge the patient w ill
need to either be admitted to UW Health for observation or stay in the procedure
unit until a designated driver/responsible adult can be found or the provider
decides that he/she is safe to be discharged independently. If the patient insists
on leaving before they are deemed safe for discharge by the provider refer to
UWHC policy #4.19, Discharge Against Medical Advice/Elopement from Hospital



UW HEALTH CLINICAL POLICY 2
Policy Title: Outpatient Discharge After Receiving Sedation
Policy Number: 2.3.2

for further information.
3. Patients w ho are discharged w ithout the company of an individual w ho accepts
responsibility for the patient w ill be transported to their home by taxi. Payment for
this ride w ill be assumed w hen possible by the patient. If the patient does not
have the ability to pay for the taxi home, care team should contact UW Patient
Relations at (608) 263-8009.
B. EMERGENT PROCEDURE
i. In the event of an urgent or emergent procedure (as determined by the performing provider)
requiring sedation, if a patient does not have a designated driver/responsible adult or night
supervision set up, the procedure w ill not be cancelled. Instead, the care team w ill assist patient in
making calls and attempting to connect w ith emergency contacts obtained from the patient prior to
sedation administration.
ii. If the care team is unable to connect w ith a responsible adult/designated driver then patient w ill be
required to remain in the care of UW Health until the performing provider (or delegate) performs
and documents an assessment of the patient to determine if the patient can safely be discharged
w ithout the company of an individual w ho accepts responsibility for the patient. If the patient insists
on leaving before they are deemed safe for discharge by the provider refer to UWHC policy #4.19,
Discharge Against Medical Advice/Elopement from Hospital for further information.
iii. If the provider deems that the patient is not safe for discharge the patient w ill need to either be
admitted to UW Health or other local hospital for observation or stay in the procedure unit until a
designated driver/responsible adult can be found or the provider assesses and documents that the
patient is safe to be discharged w ithout the company of an individual w ho accepts responsibility for
the patient.
iv. Patients w ho are discharged w ithout the company of an individual w ho accepts responsibility for
the patient w ill be transported to their home by taxi or appropriate alternative. Payment for this ride
w ill be assumed w hen possible by the patient. If the patient does not have the ability to pay for the
taxi home, care team should contact UW Relations at (608) 263-8009.
C. PATIENTS DRIVING UNDER INFLUENCE AFTER RECEIVING SEDATION
i. If the patient insists on driving, staff members w ill contact UW Police((608)264-2677) or Madison
Police Department ((608)255-2345) depending on his/her clinic location and inform them of the
circumstances and any available information about the vehicle, such as color, make and license
plate number. Disclosure of confidential medical information should be minimized. Generally the
fact of incapacity w ill be suff icient.

IV. FORMS

Discharge Against Advice, UWH #335

V. COORDINATION

Author: Director, Nursing Quality and Safety; Co-Chair Sedation Steering Committee
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Director, Risk Management; Patient Relations Coordinator; Director, UWHC Security; Digestive
Health Center Leadership; UW Health Office of General Counsel
Approval committees: Sedation Steering Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Jeff Grossman, MD
UW Health CEO




UW HEALTH CLINICAL POLICY 3
Policy Title: Outpatient Discharge After Receiving Sedation
Policy Number: 2.3.2

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

The Joint Commission Standards, Moderate to Deep Sedation PC.03.01.07 Line 6
UWHC policy #8.38, Adult Sedation
UWHC Surgical Services Departmental policy #2.45, Standards of Nursing Practice: Post Anesthesia Care
UWHC policy #4.36, Reporting Patients Who May Be Unsafe Driver
UWHC Emergency Department Departmental policy #6.0, Safe Discharge from the ED
UWHC policy #4.19, Discharge Against Advice/Elopement from Hospital

VIII. REVIEW DETAILS
Version: Original
Next Revision Due: January 21, 2019