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The purpose of this project was to examine nurse anesthetists’ practice and encounters with ambulatory surgery patients experiencing transportation difficulties after the provision of anesthesia.
Design
A mixed method approach was used.
Methods
An eleven-item questionnaire was disseminated nationally to 2,827 Certified Registered Nurse Anesthetists (CRNAs) practicing in the outpatient setting. The survey consisted of multiple-choice questions and open text for qualitative assessment. Questions focused on frequency of encounters with patients experiencing transportation difficulties post-anesthesia and policies for rideshare options.
Findings
A total of 43% of responding CRNAs work in a clinical practice setting in which patients have the option of being discharged using rideshare (Uber/Lyft) but only if accompanied by an adult. Issues emerged around patient safety when using a rideshare service for discharge postanesthesia.
Conclusions
The proliferation of rideshare options may provide increased access to surgical services in the outpatient anesthesia care setting. Practice considerations associated with transportation policies for postanesthesia patients in the era of rideshare services are warranted.
Health care organizations and outpatient surgical facilities require transportation as an integral component of the discharge process and care coordination. Transportation is considered a key social determinant of health, impacting access to health services and health outcomes.
A lack of transportation for health services potentiates delays in medical interventions, reduces patient compliance, and can worsen health outcomes. Additionally, transportation directly impacts patient utilization of health care services, and if not reliable or available can lead to cancelled appointments, missed prescription adjustments and postponed changes in therapeutic regimens.
Currently, policies and guidelines within surgical facilities require patients to secure transportation and a responsible driver as part of the discharge plan following procedures requiring anesthesia. However, this mandate can present a significant burden on patients and impede or delay access and use of needed surgical services. Lack of a support system, the feeling of burdening others, economic impact of time-off from work, recent relocation to a new residence, long distance and extended travel time for patients residing in rural areas have been identified as barriers and challenges to meet the responsible driver criteria.
With new transportation options available, examining the feasibility of using such alternatives in an ambulatory surgical setting is warranted. Nearly one in three Americans readily access rideshare services.
While transportation hardships and inconveniences have been eased by the multifaceted world of ride sourcing companies in the United States, such as Uber and Lyft, many organizations have not addressed these transportation options in surgical discharge policies and guidelines. The purpose of this paper is to describe practices among CRNAs and transportation issues arising in the outpatient surgical setting along with implications for policy considerations of unaccompanied adults requiring rideshare postanesthesia care.
Background
Outpatient Surgery
The Centers for Disease Control and Prevention (CDC) indicate that 22.5 million surgical and nonsurgical procedures are performed in ambulatory surgery centers, representing 47% of all total outpatient surgical cases.
A surge in use of the ambulatory setting is attributed to favorable patient outcomes with reduced morbidity and mortality. Ambulatory Surgery Centers (ASCs) require a very selective patient-type. Patients characterized as having minimal health issues are likely well-suited for this type of environment.
Additional factors that contribute include decreased wait times for services, lowered overall costs and reduced risk of nosocomial infections when compared to inpatient admissions.
Operating room time, actual surgery time and postoperative care for patients in ASCs are significantly shorter in duration than hospital surgeries within the same specialties.
As the growth of outpatient surgical services increases, patient access to these ambulatory settings must be considered. It is estimated that 3.6 million Americans miss medical appointments each year due to transportation issues with a resultant of $150 billion-dollar cost to health care systems nationwide.
Much of the published literature focuses on transportation problems within primary care. Researchers found that Medicaid patients were 2.5 times more likely to attend their primary care appointment when offered a ride-share voucher
. Another study demonstrated a 30% reduction in average wait times, 32% decline in average per-ride costs, and increased patient satisfaction by 80% with a ride service.
This occurred when 479 independently funded, non-emergency medical transportation rides were provided by the study and compared to federally funded non-emergency transportation options, such as freelance ambulance services and medical care transport vans.
Current transportation and escort guidelines used in surgical settings derive from safety concerns related to the known cognitive and physiologic effects of anesthesia. Cognitive and psychomotor impairment are characteristic of patients after receiving general anesthesia (includes the use of a volatile inhaled anesthetics like sevoflurane, ± opioid, ± nitrous oxide, ± muscle relaxant), total intravenous anesthesia (TIVA-ie, propofol, ± opioid, ± nitrous oxide, ± muscle relaxant) or monitored anesthesia care (MAC).
Patients returning to their preoperative state depends on their personal physiologic ability to metabolize anesthetics. For this reason, it is customary for escorts to be secured with the intention of driving the patient home then monitoring mild side effects such as nausea, vomiting, and dizziness.
Traditional transportation requirements were instituted prior to the development of modern medications, such as propofol. The pharmacokinetics (PK) and pharmacodynamics (PD) of propofol, when administered by an anesthesia provider and using the necessary physiologic monitors, allow patients to have a more pleasant and safe anesthetic experience. The PK of propofol which includes ease of distribution across the blood-brain-barrier, efficient hepatic metabolism, and rapid elimination
affords patients the ability to quickly recover to baseline. Additionally, propofol's PD properties of hypnosis, amnesia, anxiolysis, and antiemetic effects
further enhance the patient's ability to rapidly return to independence.
The Pennsylvania Patient Safety Reporting System evaluated the need for escorts in the discharge process of outpatient surgery centers. The project's investigators referenced a small study of 20 patients that had an outpatient knee-arthroscopy under general anesthesia.
The patient's ability to drive was measured at 2 hours and 24 hours postanesthesia through a simulator-based assessment. At the 2 hour mark patients showed signs of considerable impairment in driving yet were found to be safe via simulation to drive at the 24 hour time.
Based on the findings of this study, driving is not a reasonable option for postanesthesia patients prior to the 24 hour time period after a procedure. Although more evidence is needed to determine if a patient can safely drive prior to the 24 hour postanesthesia mark, the simulation established that providers should advise patients to refrain from driving for at least 24 hours.
Maintaining Anesthesia Safety
In 2018, the American Association of Nurse Anesthetists (AANA) developed policy considerations for discharging rideshare patients to further address anesthesia patient safety. The AANA emphasized accreditation standards regarding patient transport after discharge from an outpatient or same-day surgical setting and includes these elements: (1) determine whether a responsible adult is required to accompany the patient home; (2) determine whether a responsible adult is required to remain with or be readily available to the patient for 12 to 24 hours; (3) if not, know the facility's requirements for discharge and transport home; (4) advise the patient and responsible adult that patients should not drive after sedation or anesthesia as mental alertness, coordination and physical dexterity may be impaired; (5) instruct patients in advance of the procedure to make arrangements for a responsible adult to accompany them to the health care facility, drive them home or accompany them in a ride-share service, taxi, or public transportation, and be present or readily available to assist them at home; (6) instructions may be provided in the surgeon's or proceduralist's office at the time the case is scheduled; (7) verify availability of responsible adult during discussions or health history acquisition prior to the patient's arrival at the facility.
The policy considerations flow chart in this document notes that if a patient qualifies as a candidate for unaccompanied discharge, the CRNA should: (1) review and adhere to facility policy; (2) consider type of procedure, type of anesthesia, and patient limitations and comorbidities; (3) the patient may not drive themselves home; (4) verify the patient's transportation plan; (5) determine if a longer recovery stay is required; (6) assess whether the patient has signed a discharge consent, acknowledging their awareness of the risks of unaccompanied discharge; (7) determine whether the patient has a responsible adult and/or individual at home; (8) decide based on this information whether the patient is a ride-share candidate. Note that if the decision to proceed with anesthesia and surgery is made for patients who will be unaccompanied after discharge, considerations include, but are not limited to, use of infiltration or field block, regional anesthesia, and techniques to minimize or eliminate anxiolytic, induction agent(s) [propofol is used for both the induction and maintenance of anesthesia], and/or opioids.
The AANA outlined practice considerations are established to also potentially reduce CRNAs risk of legal negligence. Krisza, an attorney, advises surgery centers that are caring for the unaccompanied patient the following guidance to help reduce liability concerns: (1) obtain patient's signature on an Against Medical Advice (AMA) document; (2) complete the facility's incident report form; and (3) assure copies of these documents are placed in the chart with notation from the surgeon.
Current transportation guidelines are based on dated literature and practices that are not reflective of present-day resources driven by advancements in technology. A new generation of communication has revolutionized the way people interface, access services and perform daily tasks. These technological advancements have transformed transportation and the way people connect, plan and increase the level of accessibility to other people, places, and to a great extent, broadens their independence.
Rather than obligate a personal network of people, Americans readily access rideshare services for general purposes.
As health care systems emphasize patient-centered care, providers are becoming increasingly sensitive to patient requests for rideshare options. In 2019, an outpatient surgery survey with 533 responders revealed to Outpatient Surgery Magazine that 30% of the provider participants have discharged patients without an escort through Uber, Lyft or taxi service.
The transportation networking company, Lyft, has capitalized on the opportunity of linking their service to health care. At the 2018 Health Information and Management Systems Society (HIMSS) annual meeting, Lyft announced a partnership with an electronic health records (EHR) business, Allscripts, which will allow a health provider to secure a Lyft ride on behalf of a patient directly from the EHR platform.
Some of the top health enterprises in the nation recently came together to invest $10.5 million dollars into a company by the name of Circulation, a digital platform that arranges NEMT rides, outsourced through entities such as Uber and Lyft, for over 1,000 health facility locations nationwide.
In 2018, the University of California San Diego piloted a program in which patients scheduled for a routine gastroenterology procedure under anesthesia were permitted to be discharged unaccompanied in a rideshare service inclusive of Uber and Lyft.
” Patients received only propofol sedation for their respective procedures and every patient made it safely home without claim of any adverse outcomes.
While the sample size was small (N = 12), the results indicate that, in this sample, rideshare services may offer a feasible option for patients receiving a modified anesthetic plan, with the use of only propofol, in this type of setting.
Current Practice
In 2012 at the Mayo clinic, a retrospective study was conducted to examine the “sedation dismissal process” that allows patients without a designated escort to proceed with their scheduled outpatient procedure.
The researchers found that the patients adhering to the dismissal protocol following surgical procedures requiring anesthesia resulted in a low postoperative risk for complications such as acute myocardial infarction, syncope, postprocedural nausea and vomiting, cerebral vascular accident, motor vehicle accident, respiratory failure, altered mental status, cardiac arrhythmia, or death.
. There was no difference in the occurrence of adverse events between groups of patients that were discharged home with a person they knew versus groups of patients that were unescorted and discharged home through alternative methods.
Moreover, in the period of 24 to 96 hours following discharge, the participants in the dismissal protocol group (n = 2,441) in comparison to the control group (n = 5,133) experienced similar low incidences of unplanned admissions related to the procedure. Neither the mode of transportation nor the presence or absence of a caregiver seemed to demonstrate any notable differences in outcomes.
For the patient using rideshare, relative costs such as caregivers taking time off of work to accompany patients, could potentially be minimized. It has been estimated that the average cost for a Lyft ride is $12.53.
DOI is instrumental when introducing new policies in health care like innovative practice ideas pertinent to post-anesthesia transportation guidelines. DOI theory embodies the dynamic of change that served as the framework in understanding how to effectively implement processes for sustained utility of rideshare in anesthesia practice. DOI's five phases, Awareness, Knowledge and Interest, Complexity, Trialability, and Observability, were incorporated in the CRNA survey.
In the awareness phase, individuals are innovative adopters of an idea and are inclined to test new options. An innovation is determined to be compatible for implementation if it aligns with the principles, experiences and needs of those considering the new idea. Early adopters are found in The Knowledge and Interest phase.
DOI categorizes this group based on their ability to quickly welcome change opportunities. The next group, termed the early majority, are action-based adopters of the complexity phase. Early majority requires proof that an idea is effective before giving it a try, at least once. For an innovation to gain acceptance, it must have trialability for the late majority adopters to determine if there is evidence that the idea will be successful in practice.
The final phase of the change process occurs when most adopters have already acclimated to the new idea. Laggards are the last group of adopters. These individuals are skeptical until they witness or observe others adopting the innovation for their work environment in a favorable manner.
Policy diffusion usually occurs in a shorter time frame because of a national public interest, willing individuals or organizations, and a modern solution that is regarded as impactful.
There are barriers and facilitators in any change process. CRNAs can be the change agents in this practice improvement process. Mandated transportation policies have been rooted in anesthesia care for a very long time. DOI substantiates the methods necessary to operationalize new “norms” in the anesthesia clinical specialty.
Methodology
Project Design
A mixed-method approach was used to examine CRNA encounters with ambulatory surgery patients experiencing transportation difficulties after the provision of anesthesia. An 11 item survey was constructed to assess prevalence of the issues, and CRNA's perceptions and professional practices in the workplace concerning transportation-challenged situations.
Prior to launching the survey nationally, a pilot survey was administered to twelve CRNAs in metro-Atlanta who served as subject-matter experts. Six surveys were completed and returned. The responses were used to ensure readability, estimate time of completion, and validate relevance of questions to CRNA practice.
Ethics and Participants
The survey was deemed as exempt from review for human subjects research criteria by the Emory University's Institutional Review Board. The AANA's Research and Quality Division disseminated the survey via email to 2,827 databank members who indicated the outpatient setting as the primary work environment on their 2018 annual profile assessment. The response rate was 17% (N = 491). Table 1 displays the respondents’ profile.
The survey was deployed over a 4 week period (October 21, 2019 to November 18, 2019). In receipt of the email invitation to complete the survey, CRNAs then had the option to proceed to the survey link for completion of the 11 item questionnaire. The survey consisted of multiple-choice questions and open text for qualitative assessment. All questions allowed participants to submit additional comments to expound on their selected response. Table 2 displays the survey format.
Table 2Survey to Assess CRNA Encounters with Transportation Issues Postanesthesia
1. How many years have you practiced as a CRNA?
2. Which best describes the practice model for CRNAs at your primary practice facility?
3. Which of the following best describes the location of your primary practice facility?
4. In the past 12 months, how often have you encountered patients who are scheduled to receive anesthesia care and do not have an approved discharge transportation plan?
5. At your primary practice facility, how often are patients rescheduled or cancelled if they do not have approved transportation arrangements?
6. When conducting the preanesthetic assessment with your patient, how often do you ask your patient about their discharge transportation plan?
7. According to your primary practice facility policy, which of the following are an option when discharging post-anesthesia patients?
8. Which of the following barriers prevents your practice or facility from implementing a policy specific for rideshare patients?
9. Please respond to the following statements within the below table:
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I am concerned for my patient's safety if discharged using a rideshare service.
I have no authority regarding a patient's choice of transportation at discharge.
After my patient recovers from anesthesia, their transportation needs are not my responsibility.
10. Are you aware that the AANA has a position statement and policy considerations for patients experiencing transportation challenges?
11. Based on your experience, please list one clinical consideration you would suggest adding to the flow chart from the AANA's 2018 position statement and policy considerations, titled Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Adult.
AANA, American Association of Nurse Anesthesiology; CRNA, Certified Registered Nurse Anesthetist.
SPSS version 24 was used for evaluation. Survey responses were coded in Likert scale categories. Descriptive statistics, correlation and paired sample t-tests were the statistical tests used for analysis. Partially completed surveys, in which some questions were skipped, were included in the analysis.
Findings
Most CRNAs had greater than 10 years of experience. The greatest number of CRNAs were employed by an anesthesia group that provides service for hospital settings. Overall, the majority of CRNAs surveyed provided anesthesia care in suburban areas followed by CRNAs working in urban based facilities, rural area providers, and finally CRNAs that serve in military and/or government or Veteran's sector.
Within the twelve months prior to the completion of the survey, 17% of the CRNAs indicated they encountered at least six patients who were scheduled to receive anesthesia care and did not have an approved discharge transportation plan. Nearly 56% of survey participants’ patients were rescheduled or cancelled for not having approved transportation arrangements.
Survey responses revealed, CRNAs (51%) primarily do not ask patients about their discharge transportation plan during the preanesthetic assessment (Figure 1). Most respondents (43%) work in a clinical practice in which patients, if accompanied by an adult, have the option of being discharged in rideshare. The majority of CRNAs (51%) were unsure of barriers in their primary practice that prevented the implementation of a discharge policy that incorporates rideshare. CRNAs (32%) expressed strong agreement about safety concerns when discharging patients using rideshare services. When asked if CRNAs lack authority regarding a patient's choice of transportation at discharge, 44% agreed and 43% disagreed.
Figure 1Relationship of CRNA's years of experience and frequency of preoperative discussion of discharge transportation plan. This figure is available in color online at www.jopan.org.
The survey helped to assess the landscape of transportation issues encountered by CRNAs in the ambulatory surgical care setting. Based on responses close to 75% of CRNAs encounter patients experiencing transportation issues. A large percentage of respondents also indicated that surgical procedures were cancelled or delayed until a facility approved transportation plan was established. These findings support that transportation is a critical determinant of health that has direct impact on access to surgical services. Additionally, last minute cancellations due to a lack of transportation have implications for clinical operations and an economic impact to facilities, providers, staff, and patients. Consequently, these issues have a ripple effect on patient accessibility to timely surgical care. A number of CRNAs indicated that their facility resorted to 24 hour observation admissions or extended stay in postanesthesia care units to address issues relative to transportation, patient safety, and homelessness. Unfortunately, extensive details were not provided by CRNA survey participants that indicated, through open-text, that their unaccompanied patients were admitted. However, because the majority of the CRNA sample work for anesthesia groups in the hospital setting (27%) it can likely be concluded that most unaccompanied admissions were to hospitals from ASCs.
Based on this survey, the vast majority of discharge transportation plans on the day of the surgical procedure is assessed and verified by the preoperative nursing staff. As issues arise, CRNAs are notified of transportation difficulties. These findings suggest that there are opportunities for quality practice improvement processes that ensures effective communication with the entire surgical care team for the transportation discharge plan. Transportation is a salient social determinant of health and surgical care and should be recognized as such when designing and delivering whole-person clinical care. Assessing and addressing social determinants of health is a key element in assuring health equity and improved health outcomes.
Facility policies addressing rideshare postanesthesia varied among respondents. The most common policy and standard of practice requires an adult to accompany the patient after surgery and anesthesia. Additional comments indicated use of a liability waiver or surgeon's orders to use a rideshare at discharge without an accompanied adult. The degree of transportation options was limited in rural settings as respondents indicated that Uber and Lyft were not available in their respective areas. Rural health disparities have been recognized as a major contributor to patient accessibility. According to the CDC, rural counties are challenged by fewer health care providers, specialists, facilities and transportation options.
Other transportation options cited by CRNAs were non-emergency, private medical, and Veterans Affair transport services.
Limitations
Although the response rate was significant with a sample of 491 respondents, this was a representation of less than 1% of the 55,653 CRNAs credentialed with the National Board of Certification and Recertification of Nurse Anesthetists (NBCRNA).26 While employment demographics were assessed, we were unable to ascertain personal demographics such age, race, ethnicity, and gender identity. The survey was deployed in year 2019, and as such may not reflect the current state of transportation needs of patients in the outpatient surgical area.
Conclusion
While on-demand transportation businesses are continuing to gain popularity, the convenience does not come without some inherent challenges in policies and implications for the ambulatory surgical setting. Development of an infographic featuring care model concepts as a resource for practicing CRNAs is included in Figure 2. As the modern social trend of ride-sharing increases, integrating the transportation industry with anesthesia health services seems necessary. This process could revolutionize ambulatory surgical care practices, offering patients a transportation modality that meets compliance guidelines and maintains personal independence. Establishing policies that addresses liability issues and provide clear guidance to providers that care for patients who struggle with transportation but require outpatient surgery, serves to standardize the care for rideshare participants, improve operations, patient safety and patient satisfaction, and obviate the need for last-minute discharge resolution plans. Transportation, as a social determinant of health, plays a significant role in accessing timely care in urban settings and particularly in rural areas where patients tend to be older, farther away from health services and from lower socioeconomic status. Assessing and addressing plans and needs for transportation cannot be overstated, it is an important step in achieving health equity and improved health outcomes. The findings from this project could ignite policy change for rideshare options that advance patient-centered care and improved access to outpatient surgical care services.
Acknowledgments
A sincere appreciation is extended to all contributors of this manuscript.
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