ER nurses! Do you have this policy in your hospital?

chelynn · Dec 2, 2009

I'm very new at the ER here but the last one I worked at it WAS policy that anyone receiving narcs would need a driver to get them. We did like to tell our pts this BEFORE the injection so they had the option of refusing if they had no driver.

Boog'sCRRN246, RN · Dec 3, 2009

I'm not in the ER, but at my clinic we have a form the patient has to sign, acknowledging that unless a driver is present, they won't be given narcotics.

PAERRN20 · Dec 3, 2009

I don't know if there is a formal policy for my ED, but I always let the patient know upfront no driver= no narcs. I document that teaching was done, patient verbalizes understanding of no driving, and then give the medication. Then a discharge note that patient verbalizes understanding of no driving, patient discharged to waiting room to wait for ride or with driver.

SheaTab · Dec 3, 2009

No driver present? No meds until one is. I will be happy to give Motrin or Toradol until such time as a driver arrives. It isn't worth the risk. Tabitha

bobarb, BSN, RN · Dec 3, 2009

We do not give narcs if there is no driver...........and we make sure the pt. understands it. Some lie and say they have a driver, so we now have to see the driver in person. Makes for an intereting time sometimes!:redpinkhe

tiffanyleigh0212 · Dec 3, 2009

I don't work in the ER, still just a student, but from when I have been a patient before it has always be required. They ask before they would give if I had a driver to take me home. Unless of course I was admitted.

Riseupandnurse · Dec 3, 2009

I went to the ER with a horrible abcess under my arm. They gave me Kefzol and then the dr. asked if anyone was with me. When I said no, he said he'd have to clean out the abcess then without any pain medicine and dug right in. If he had just given me two minutes, I would have gotten my husband or my son in to take me home. It burned like fire; the pain was terrible. I think I should have been given the option to get someone in there; it wouldn't have taken 15 minutes. But then it would have thrown the ER behind schedule.... so of course we couldn't have that. And yes, I am a nurse but I really didn't go in expecting an I&D, just some antibiotics.

Emergency RN · Dec 3, 2009

Like Janhetherington alluded to; to withhold an analgesic based upon the outside chance that someone may drive, is technically withholding care. The same can be asked if you give someone a BENADRYL for an allergic reaction, KEPPRA for seizure disorders, or a whole host of other other agents or medications that can inhibit operation of a motor vehicle. The flip side of this is, that the onset of severe blinding pain may induce driver inattentiveness (or even recklessness) and can likely be just as hazardous. Further, there are plenty of pain management (ie cancer) patients out there driving around in receipt of daily doses that would probably kill half of us.

Granted, in some isolated or sporifice geographic areas, it can require just about any patient to drive to the ED. But in a large city, the patient can just call or take a taxi. The bottom line is, this is all about informed consent. As adults, we all have the choice to do as we wish so long as we know or are informed of the dangers. As professionals, we give our learned advice, and patients can do with it as they like. Keeping someone in pain while they're undergoing a procedure is actually medical malpractice, no matter how good the original intentions. There is such a thing as post op recovery, where a patient is kept in the institution under monitors while they recover from their sleep inducing agents (LOL... imagine if they did same day surgery without anesthesia because a pt may have to drive home?) If post treatment somnolence is a concern, then keep the pt there until they're awake enough to go.

In our institution (large city based) we give printed out and detailed discharge instructions; if the patient had received any sleep inducing agent, it is spelled out in the discharge papers that operation of a motor vehicle and or any machinery may result in severe injury or death as the medications may affect their alertness, judgment or reaction time. I myself purposely point to and circle this passage as I hand the discharge instructions to the patient. That said, if they don't look like they're ready for safe discharge (for any reason, including drowsiness) I just don't let them leave.

Mayday! · Dec 3, 2009

I'm not a nurse, but I did work in ER Registration, and I do know that our hospital DID have a policy on this. If a patient was determined to need pain medication, Registration staff had a form that we took to the patient and had them fill out and sign, within the presence of one nurse AND the doctor; the form had to be witnessed by all three of us, so four signatures in all. The form explaining the need for an alternative driver, and the patient was required to check the appropriate box, either consenting to pain medication or refusing. If the patient consented, there was a space on the form for the name and contact information of the alternate driver the patient was going to be relying on. Registration staff or the nurse would call that person and verify whether or not they would be providing transportation for the patient; if not, patient was provided with a taxi voucher.

I know it sounds like a bit of overkill, but right after I started that job, there was a patient who had said her husband had driven her to the ER but stayed in the parking lot, so she was heavily medicated then discharged. Turns out she drove herself and ended up right back in the ER via EMS for a major MVA. The medical staff decided we needed a new system, and that's what they came up with. Our hospital had worked out a deal with a local taxi service where we bought vouchers in bulk and provided them free of charge to patients who needed them, so even if the patient didn't have someone available to drive them home, they could still get their pain medication.

SummerGarden, BSN, MSN, RN · Dec 3, 2009

Yep... The ride must be by the bedside in order for the patient to leave after given narcs. If the ride is not by the bedside and the patient's ride does not show up in time, then they must remain the given amount of time for the drug to ware off (yep.. ouch). Usually the patients receiving narcs understand this policy (frequent fliers) and so they will have family waiting. The ones the docs do not trust (frequent fliers with bad reps for no rides) are given pain killers that is not a narcotics.

RhiaRN75, RN · Dec 3, 2009

we have a policy, but it's fairly generalized. basically it states that if staff feel a pt isn't safe to drive, then pt should be required to have a driver. the policy makes no suggestions as to the practical application of said policy.

i've read several articles recently concerning this topic. i cannot remember which particular journal at work had a story on this, but medscape has also had a couple recently. ::

legal obligations to the dangerous patient http://www.medscape.com/viewarticle/707580

[color=#5757a6]what is my legal obligation if i allow an intoxicated patient to drive home?http://www.medscape.com/viewarticle/578133

"legal obligations to the dangerous patient" covers the topic in depth, but the best quote is:

federal law
breach of confidentiality. the federal health insurance portability and accountability act (hippa) requires that healthcare providers ensure that an individual's health information is used only for purposes related to treatment, payment, or operations; that only the minimum amount of necessary information is disclosed; and that disclosure is made only to individuals who need to know the information in order to treat the patient, conduct the practice's operations, or obtain payment for services.
hipaa contains an exception that specifically applies to the dangerous patient. the law permits nurses and physicians to disclose protected health information, without the individual's written authorization, when consistent with applicable law and ethical standards, to a law enforcement official reasonably able to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public.[color=#004276][1]
the key to legal use of this exception is "serious and imminent." if a nurse assessed a patient as intoxicated or impaired, such that he or she was very likely to cause an accident shortly after getting into the driver's seat, then hipaa would allow the nurse to report the patient to a police officer or hospital security. if the intoxicated driver is not a patient (such as the parent who shows up to drive a child home from school), hipaa does not apply, so the nurse could report the individual to police.
of course, reporting an individual to law enforcement officials would not be the first step. the nurse would first communicate his or her assessment (of impairment) and recommendations (not to drive) to the patient or driver, and make reasonable efforts to assist with alternate arrangements. if the patient or driver still wants to drive, then a report may be in order.

even prior to reading this article, i warned pts that they must have a driver or i could not give certain medications unless a driver is present. one of my first triage questions is "who drove you to the er?" i don't allow any pt who receives a sedating medication to drive home. (of course, i cannot hold them against their will, and this is also covered in the article.) this includes the obvious, like narcotics and sedatives, but i also include meds like benadryl, phenergan, and even clonidine for pts who have never had it before.

i also strongly discourage pts too sick to drive safely from driving. for example, if someone comes in with afib, again, and is converted but subsequently refuses admission, i tell them they cannot drive home. same w/ n/v/d orthostatic pts or what have you.

i have had to go down the "if you leave, i'll have to call the police" road on occasion, and i've actually had to call the police only a handful of times- but i don't hesitate to do so. i'd rather not go to court, but if i do it will be because i was trying to keep as many people safe as possible, not because i 'let' someone drive home who then wrecked and killed/injured themselves or someone else.

i also document my 'pt safety' education- after all, knowledge deficit is a nursing diagnosis i include a standard "if you receive any medication that may impair your ability to drive or perform any activity safely.... yada yada" instruction on all my d/c forms, even if we didn't give such a medicine. if i have an allergic reaction pt, for example, who is instructed to take benadryl for itch q 6hrs for 24hrs and then prn, i give them a work note to cover that timeframe even if they tell me they don't need one. i don't want a construction worker to fall off a roof while taking benadry like we instructed w/out making sure that pt knows they don't need to be on a roof or even at work in the first place. it may seem to be overkill to someone who hasn't worked er, but you have to keep in mind that i see pts all the time who are apparently unable to make commen sense decisions. on my last shift, i had a parent bring in a kid well known to have febrile seizures w/ a c/o of..... fever. parent hadn't given tylenol or motrin because they felt the need to 'prove' the fever. the did have the valium suppository on hand though, just in case. :hdvwl:

in all honesty, if you're 'er sick' enough to have to have a medication that makes it dangerous for you to drive, you're most likely too sick/in pain/whatever to be safely driving anyhow.