Wait for D/C after narcs/benzos?

[Miss Mab]

Does your ED have a written rule or P/P about how long one must wait to be discharged after receiving a mind altering substance? Does it address whether they are driving themselves or not?

If it's not in writing anywhere, do you have some unwritten standard that you all adhere to?

We are in the midst of a situation--take a guess---and could very much use some perspective from other facilities across the US.

Thanks guys--the more opinions the better!!

[ZippyGBR, BSN, RN]

the other thing is what sorts of opates and benzos ?

Benzos for procedural sedation or for fitting you are going to want to keep them until they are upright coherent etc ....

same with parenterla opiates assuming you aren't keeping them ... but often it's case of see above ref procedural sedation ( dislocated shoulders, patella ...)

mild opiates eg, codeine as long as they aren't adversely effected by it - and cocodamol 30/500 is a bugger for this - i'm a healthy sized and i can take 2 ( so gram of paracetamol and 60 of codiene phos and carry on pretty much as normal yet some peopel seem to be hugely senstiv and 1 sends them light headed , and suffering 'proper' opiate side effects ... but then again i'm a pretty solidly built chap having trained relatively seriously in my teens as a small boat sailor and still havingthe lower body that this develops ( big muscualr thighs and glutes reasonable abdo muscle mass ...)

[PANurseRN1]

The reasons that you all have given for waiting for discharge after med administration, or waiting until the pt.'s ride arrives, are valid.

My experience in the ER where I work is totally different.

I'm just asking - how do you know how someone arrives or leaves? Can you see the parking area from triage or the waiting room? Do you not really not give narcs/benzos to anyone who has driven themselves and intends to drive themselves home? Wow.

Other than pts. who arrive via EMS, I don't have the slightest idea how many of my pts. arrive. My ER is smack in the middle of the city. They may have driven, they may have been dropped off, they may have walked, taken the bus, gotten a jitney or cab ride ...

No one would discharge a pt. who was unsteady, lethargic, etc. ... but as long as they're steady on their feet, alert, and not nauseated ... out the door they go. I'm not saying that's the best practice, but I am saying that in this particular setting I don't see how it could be any other way. The ER is the primary or only health care for probably 1/3 of our patients. To not treat complaints because a patient arrived alone ... it just wouldn't fly.

Also, a majority of our patients are not, lets say, *opiate naive*.

On the other hand, it's not unheard of for a pt. whose address is within several blocks of the hospital to come in w/a vague, bogus complaint and then make a big deal of demanding a bus ticket ... they have places to go, doncha know. And they need a sandwich too ... but I digress.

In my state, that would be a DUI. If the pt drove and then got in an accident, there could be huge liability issues.

If a pt doesn't have a driver, then we give him/her a taxi voucher. They don't leave the dept. until the taxi gets there.

As far as how long to hold someone after medicating, if it's the first time the pt has had that med, I usually hold the pt for about a half hour just to make sure they're getting some relief. If it's a pt who is in frequently, then I ususally just medicate and let him/her go.

[Jennifer, RN]

If a pt does not have a ride, we still medicate, just with toradol and zofran. The other day, we had a women with abd pain demanding narcs, she was taking a cab home and had her 5 year old daughter with her (came in by ems). No narcs for her!!! The cab driver can't be responsible for her daughter well being if she is doped up. We will usually give narcs if people are catching a cab. Just as long as the pt has sobered up before they walk out of the building. If they have little kids with them, no, they have to be able to care for their children.

[NicoleRN07, RN]

We make sure the patient has someone to drive them home before administering narcs/benzos, and after giving IV/IM meds, we observe the patient for 30 minutes and then d/c. The observation time is on all meds, not just narcs.

[canuck_nurse]

You never can be sure they aren't driving can you? In a perfect world, patients do what's good for them and listen to the nice nurses..LOL. In our department, anyone receiving narcotics has to sign a document that says they have received the Narc, and that they have been advised not to drive for 24 hours or whatever....that solves the issue of nurse/dr liability, but truth be told...I don't know if anybody ever listens to me..LOL

[caroladybelle, BSN, RN]

What is wrong with taking a taxi home under the influence?

I had a bronchoscopy with MS 20mg and valium 5mg IV (don't ask how traumatic - I had a small pneumothorax a day later). I was on assignment in Manhattan, and knew no one with a car. Thus a friend signed me out, and escorted me to the cab line.

I also had minor surgery (required general anesthesia and pain meds) and was taken home by the car service. The surgeon did call after to make sure that I was fine. I do have to say that I remember little of the trip. My doorman did have to help me get my keys in the door though.

[Kay Ciel, RN]

If the pt is getting a script for narcotics, they see the rx when I see the whites of the driver's eyes. Sounds too cynical, doesn't it?

Not cynical, just practical. The way I see it: if I sent a patient like this home, the guilt I'd suffer if they got into an accident far outweighs any sort of inconveniece I'm causing them to wait until they sober up.

Most times, I give the written DC instructions but hold the scripts hostage until I see the driver. It's not like they won't have the time to review it. *giggles* It's tough when the ER stresses rapid bed turnover though: the times I've been chastised by the charge nurse by holding a pt. who just got a shot... *sighs* No wonder others look the other way.

[bidimom]

I work in a couple ERs and they are the same regarding this. No D/C unless driver in the flesh, and able to sign that they are going to take care of this person. We always ask, are you driving before any type of narc is given. Also they are not D/C'd to care of cab for liability purposes. If something happens to them in the cab, the driver is not responsible, so it's a ride or no narc.