Transportation barriers and endoscopic procedures: barriers, legal challenges, and strategies for GI endoscopy units

With significant advancements in the field of gastroenterology, the diagnosis and treatment of GI disease often involve the performance of GI endoscopy. For example, in 2019 an estimated 7.4 million upper GI endoscopies and 13.8 million colonoscopies were performed in the United States.1Peery A. Crockett S. Murphy C. et al.Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021.Gastroenterology. 2022; 162: 621-644Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Many of these procedures are performed in the outpatient setting, often with moderate sedation or deep sedation with propofol. Because of concerns about delayed psychomotor recovery after sedation, especially as it pertains to neurocognitive abilities (eg, driving a car or using public transportation), the current standard of practice is to require a responsible adult to escort patients home and review discharge instructions and request the patient delay driving until the following morning. However, data in outpatient endoscopy are essentially nonexistent and are historically extrapolated from patients undergoing ambulatory surgery.2Chung F. Assmann N. Car accidents after ambulatory surgery in patients without an escort.Anesth Analg. 2008; 106: 817-820Crossref PubMed Scopus (34) Google Scholar,3Ip H. Chung F. Escort accompanying discharge after ambulatory surgery: a necessity or luxury?.Curr Opin Anaesthesiol. 2009; 22: 748-754Crossref PubMed Scopus (32) Google Scholar Additionally, despite formal discharge instructions, patient noncompliance with such instructions is common. For instance, in a British survey of 240 postoperative patients, 4% drove a vehicle despite postoperative instructions to the contrary.4Cheng C. Smith I. Watson B. A multicentre telephone survey of compliance with postoperative instructions.Anaesthesia. 2002; 57: 805-811Crossref PubMed Google Scholar Transportation requirements are recognized to represent a barrier to timely health care for many individuals, with up to 62% of patients being negatively impacted.5Syed S. Gerber B. Sharp L. Traveling towards disease: transportation barriers to health care access.J Community Health. 2014; 38: 976-993Crossref Scopus (879) Google Scholar Although there is no known systematic analysis on the frequency of patients arriving unescorted to outpatient GI endoscopies, anecdotally this is a recurrent problem in practices across the United States. This white paper has 5 objectives. First, it aims to describe the patterns of recovery from commonly used sedatives for GI endoscopy. Second, it explores the psychosocial factors related to patients arriving for their endoscopy unescorted. Third, it offers a compendium of current regulatory, accreditation, and legal opinions, particularly in situations of clinical dilemma. Fourth, it describes various solutions that have been tried in diverse GI practice settings across the United States. Finally, it offers a set of practical recommendations that, in conjunction with local risk management, may be considered for risk mitigation in this increasingly encountered clinical problem. Multiple studies have demonstrated that propofol-based sedation in endoscopy has significantly faster postprocedural recovery compared with sedation with midazolam-based regimens.6McQuaid K. Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures.Gastrointest Endosc. 2008; 67: 910-923Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar Studies have also demonstrated rapid recovery of psychomotor function as early as 1 hour after propofol sedation, including recovery of driving skills.7Riphaus A. Gstettenbauer T. Frenz M. et al.Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study.Endoscopy. 2006; 38: 677-683Crossref PubMed Scopus (93) Google Scholar However, to date, most psychomotor recovery evidence after endoscopic sedation has come from studies that use driving simulators, which are known to not fully reflect real-world driving scenarios.7Riphaus A. Gstettenbauer T. Frenz M. et al.Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study.Endoscopy. 2006; 38: 677-683Crossref PubMed Scopus (93) Google Scholar,8Horiuchi A. Nakayama Y. Fujii H. et al.Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation.Gastrointest Endosc. 2012; 75: 506-512Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Thus, common practice continues to suggest it is best to instruct patients not to perform cognitively challenging tasks such as driving or signing legal documents until the following day. A patient may come unescorted for a colonoscopy appointment for many reasons. Certainly, patient personality or misunderstanding of discharge instructions is one cause of noncompliance with endoscopy unit postsedation policies. However, societal forces, such as reduced intergenerational living, greater social mobility, delayed marriage, dual-career families, and increased single-residence households, are also associated with increased social isolation,9Holt-Lunstad J. Smith T. Layton J. Social relationships and mortality risk: a meta-analytic review.PLoS Med. 2010; 7e1000316Crossref PubMed Scopus (4211) Google Scholar often resulting in difficulty securing a ride home. Also, if a patient chooses to keep health information private from family and friends, this may affect the ability to secure a driver. In a recent safety net hospital study on barriers to a colonoscopy, nearly 1 in 4 participants listed transportation as an important barrier to completing a colonoscopy.10Issaka R. Bell-Brown A. Snyder C. et al.Perceptions on barriers and facilitators to colonoscopy completion after abnormal fecal immunochemical test results in a safety net system.JAMA Netw Open. 2021; 4e2120159Crossref Scopus (6) Google Scholar It is therefore important for endoscopy unit leadership not only to emphasize the existing policies on rides, but also to proactively mitigate transportation issues as soon as they are identified. Ambulatory surgical centers that are Medicare certified must follow the Centers for Medicare & Medicaid Services (CMS) Conditions for Coverage Standard on Discharge §416.52(c). Specifically, the language states, “§416.52(c) Standard: Discharge. The ASC [ambulatory surgical center] must … ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.”11Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 416, Subpart C, § 416.52.https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-416/subpart-C/section-416.52Date accessed: October 25, 2022Google Scholar Accrediting organizations, such as The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), and others assess this standard during a deeming survey (a mechanism that deems an accredited facility as meeting Medicare/Medicaid certification requirements). If a facility is not deemed, then the state department of health typically assesses for the same standard on behalf of the CMS.12Centers for Medicare & Medicaid ServicesState operations manual, appendix L—guidance for surveyors: ambulatory surgical centers.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdfDate accessed: October 25, 2022Google Scholar Additionally, for a nondeemed status AAAHC survey, the organization is required to meet the AAAHC standard 9.M.3: “Evidence is present that patients must be discharged in the company of a responsible adult.”13Accreditation Association for Ambulatory Health Care (AAAHC). Accreditation handbook for ambulatory health care. 2022. p. 82.Google Scholar Although well meaning, this requirement potentially leads to a clinical dilemma when patients are in need of endoscopy with sedation but lack the social support to have an escort accompany them home after the procedure. Historically, this requirement has been applied to patients undergoing deeper levels of sedation for surgery as opposed to moderate sedation for GI endoscopy. Although the CMS standard allows for the attending physician to grant an exemption, some may not feel comfortable granting such an exemption because of perceived medicolegal risk. Various medical professional societies that administer sedation have offered slightly varied positions regarding postsedation discharge (Table 1). For instance, the American Society of Anesthesiologists practice guidelines for ambulatory anesthesia simply states that “[p]atients who receive other than un-supplemented local anesthesia must be discharged with a responsible adult,”14Care, CoASGuidelines for ambulatory anesthesia and surgery.https://www.asahq.org/standards-and-guidelines/guidelines-for-ambulatory-anesthesia-and-surgeryDate accessed: January 16, 2022Google Scholar as does the Veterans Administration.15VHA National Center for Patient SafetyModerate sedation toolkit for non-anesthesiologists.https://www.patientsafety.va.gov/professionals/onthejob/sedation.aspDate accessed: January 16, 2022Google Scholar However, the Veterans Administration allows the use of approved Veterans Administration–funded services to transport the veteran to his or her home when another individual cannot be identified.16Halter J. Dominitz J. Pawlikowski S. et al.Post Sedation & Anesthesia Care Workgroup. Post sedation anesthesia care and discharge toolkit. Department of Veterans Affairs, Washington, DC2019Google Scholar The Joint Commission and the American College of Radiology/Society of Interventional Radiology similarly advise that patients who received sedation or anesthesia should be discharged to a responsible adult.17The Joint Commission. Comprehensive ambulatory care accreditation manual. 2022. Available at: https://www.jcrinc.com/. Accessed June 25, 2023.Google Scholar,18American College of Radiology/Society of Interventional RadiologyACR-SIR practice parameter for minimal and/or moderate sedation/analgesia.https://www.acr.org/-/media/acr/files/practice-parameters/sed-analgesia.pdfDate: 2020Date accessed: June 25, 2023Google ScholarTable 1Escort guidelines across various professional societies or regulatory bodies in the United StatesSociety or regulatory bodyResponsible adult escort required after sedationNotesAmerican Society of AnesthesiologyYesResponsible adult is not explicitly definedAmerican Association of Nurse AnesthesiologyYes, although algorithm provided to address scenarios if no responsible adult is availableSee reference 19Centers for Medicare & Medicaid ServicesYes, unless exempted by attending physicianThe Joint CommissionYesSee reference 17The Accreditation Association for Ambulatory Health CareYesSee reference 13American College of Emergency PhysiciansNot explicit“If the patient is being discharged post-recovery, appropriate written care instructions should be given to the patient and their family or caregivers.”21Green S. Roback M. Krauss B. et al.Unscheduled procedural sedation: a multidisciplinary consensus practice guideline.Ann Emerg Med. 2019; 73: e51-e65Abstract Full Text Full Text PDF PubMed Google ScholarAmerican College of CardiologyNo commentSee reference 22American College of Radiology/Society of Interventional RadiologyYesSee reference 18Veterans AdministrationYes, although various alternative solutions proposed in situations in which no responsible adult is availableSee references 15 and 16American College of SurgeonsNot explicitSee reference 20 Open table in a new tab Conversely, the American Association of Nurse Anesthesiology recognizes the real-world challenges patients may face in securing a responsible adult escort after procedures and discusses various possible shared decision-making alternatives, including an unescorted ride home.19American Association of Nurse AnesthesiologyDischarge after sedation or anesthesia on the day of the procedure: patient transportation with or without a responsible adult.https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/discharge-after-sedation-or-anesthesia-on-the-day-of-the-procedure.pdf?sfvrsn=ed4a5bb1_4Date accessed: January 16, 2022Google Scholar Finally, the American College of Surgeons, American College of Emergency Physicians, and American College of Cardiology simply advise meeting discharge criteria without explicitly requiring an adult escort after procedures, especially because such patients may receive unscheduled procedural sedation.20American College of SurgeonsStatement on patient safety principles for office-based surgery utilizing moderate sedation/analgesia.https://www.facs.org/about-acs/statements/118-office-based-surgeryDate: 2019Date accessed: January 16, 2022Google Scholar, 21Green S. Roback M. Krauss B. et al.Unscheduled procedural sedation: a multidisciplinary consensus practice guideline.Ann Emerg Med. 2019; 73: e51-e65Abstract Full Text Full Text PDF PubMed Google Scholar, 22Fisher J. Welt F Villines T. et al.Impact of new guidelines of unscheduled and scheduled sedation for cardiologists: JACC council perspectives.J Am Coll Cardiol. 2019; 74: 1505-1511Crossref PubMed Scopus (2) Google Scholar Despite a paucity of legal claims against gastroenterologists from postsedation transportation decisions, such lawsuits are understandably concerning. We approached postsedation transportation through a health equity lens and weighed the potential risks of various alternative transportation scenarios, presenting the current legal positions on potential lawsuit risks. Importantly, the readership is reminded of 2 points: there is a paucity of scientific or legal literature on the topic, and this legal section is for discussion only and is not intended to constitute legal advice. Readers are encouraged to consult with an attorney for legal advice. There is little formal legislation and guidance regarding discharge after GI endoscopy with sedation. Thus, we looked primarily to common law, peer-reviewed literature, clinical research, and professional guidelines to frame our analysis of the risks associated with postsedation transportation. Most common policies and procedures for postsedation in gastroenterology practices are derived from the requirements detailed in the U.S. CMS Conditions for Coverage for Ambulatory Surgical Centers, which require “[that] patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.”16Halter J. Dominitz J. Pawlikowski S. et al.Post Sedation & Anesthesia Care Workgroup. Post sedation anesthesia care and discharge toolkit. Department of Veterans Affairs, Washington, DC2019Google Scholar A “responsible adult” is also not defined.16Halter J. Dominitz J. Pawlikowski S. et al.Post Sedation & Anesthesia Care Workgroup. Post sedation anesthesia care and discharge toolkit. Department of Veterans Affairs, Washington, DC2019Google Scholar The leading case law on postsedation litigation is Young v Gastro-Intestinal Care, Inc, in which a patient who had undergone colonoscopy lied to the staff that a responsible adult would be picking him up after the procedure.23Court document 205 S.W.3d 741. Young v Gastro-Intestinal Center, Inc. (Arkansas 2005).Google Scholar Instead, the patient went against clearly communicated medical advice not to drive himself and chose to drive himself home, and then crashed his car and died. The patient’s wife later brought a negligence suit against the gastroenterology department. The court found that the physician had no duty to protect the patient beyond what was reasonably foreseeable. The court determined the “warning not to drive, especially where it is reinforced by having the patient sign a paper affirming he or she will not drive, is proportionate to the danger” and thus falls within proper performance of their legally obligated duty to their patient.23Court document 205 S.W.3d 741. Young v Gastro-Intestinal Center, Inc. (Arkansas 2005).Google Scholar It seems reasonable that the holding in Young v Gastro-Intestinal Care, Inc would likely be the precedent for any similar future litigation, particularly when the patient goes against medical advice and understands the risks of doing so. Although under normal circumstances the endoscopy unit is not required to notify officials that a patient has left the unit against medical advice, it may be reasonable to contact risk management and/or law enforcement if the unit suspects the patient may try to drive him- or herself home. This is based on the precedent of Tarasoff v Regents of University of California and the duty to warn to protect innocent bystanders from the actions of the patient who insists on driving after undergoing sedation.24Court document 13 Cal 3d 177, 118 Cal. Rptr. 129, 529 P. 2d 553. Tarasoff v Regents of University of California (California 1974).Google Scholar Most potential legal challenges around discharge after sedation are believed to be centered around problems related to patients driving, which could harm themselves or others. However, other options may seem to be safe and reasonable and may be considered in extenuating circumstances (Table 2). Again, the following is meant only for discussion, not formal recommendations. It is critical to work closely with risk management if one wishes to incorporate the following ideas into a formal unit policy.Table 2Alternative transportation optionsAlternativeConsiderationsProConSolo dischargeNo family or friends in the area, has already met discharge criteria (eg, postanesthesia scoring system score), or highly reliable patientEnsures access to health care“Reliable” is a subjective assessment and medicolegal concernsNurse’s aideResponsible adult caretaker at home but is not available to accompany patient homeEnsures access to health care when responsible adult cannot drive or escort patient homeUncertain qualifications for this role, significant time commitment per patient, and medicolegal considerationsTaxiPatient who needs no obvious assistance during transportation home or highly reliable patientEnsures access to health care when patients are unable to secure a responsible adult to escort them home“Reliable” is a subjective assessment and medicolegal considerationsRide sharePatient who needs no obvious assistance during transportation home, technologically savvy, and highly reliable patientEnsures access to health care when a responsible adult is unable to escort patient home“Reliable” is a subjective assessment, contracting requirements, Health Insurance Portability and Accountability Act of 1996 requirements, and medicolegal considerationsHotel or short-stay admissionPatients who live very far away and need to drive themselves home (the next day)May be acceptable from a medicolegal considerationCost and resource utilizationProlonged stay in postanesthesia care unitPatients who did not make appropriate provisions beforehandMay be acceptable from a medicolegal considerationResource utilization (eg, does nurse watch them the entire time?) vs vicarious liability (eg, if unattended, who takes responsibility for adverse outcomes?) Open table in a new tab A retrospective case-control study from the Mayo Clinic did not find that discharging patients without escort by a responsible adult (ie, solo dismissal) after endoscopic and other procedures requiring sedation resulted in an increased number of adverse outcomes requiring unexpected admissions.25Martin D. Warner M. Johnson R. et al.Outpatient dismissal with a responsible adult compared with structured solo dismissal: a retrospective case-control comparison of safety outcomes.Mayo Clin Proc Inn Qual Outc. 2018; 2: 234-240Abstract Full Text Full Text PDF PubMed Google Scholar In this study, 2441 solo dismissal process patients undergoing 2703 procedures were compared with 4923 unique control patients who underwent 5133 procedures between June 1, 2012 and March 31, 2017. The rate of unplanned readmissions related to the procedure was .11% (n = 9), with no difference between the solo dismissal process patients (.07%) and control subjects (.14%). Similarly, there was no difference in adverse event rates between solo dismissal process patients and the control group, suggesting the presence of a responsible adult escort is not associated with reduced risk after discharge for procedures using ambulatory anesthesia.25Martin D. Warner M. Johnson R. et al.Outpatient dismissal with a responsible adult compared with structured solo dismissal: a retrospective case-control comparison of safety outcomes.Mayo Clin Proc Inn Qual Outc. 2018; 2: 234-240Abstract Full Text Full Text PDF PubMed Google Scholar Additional research is warranted to validate these findings. A certified nurse’s aide can theoretically accompany the patient and hand over the care to the family member at home, ensuring patient safety,25Martin D. Warner M. Johnson R. et al.Outpatient dismissal with a responsible adult compared with structured solo dismissal: a retrospective case-control comparison of safety outcomes.Mayo Clin Proc Inn Qual Outc. 2018; 2: 234-240Abstract Full Text Full Text PDF PubMed Google Scholar in essence “curb to curb.” The advantage of this option is that the aide can be trained to notice signs of distress and can help clarify postsedation instructions to family at home. However, for patients who have fully met discharge criteria and have strong support networks, this level of service may not be necessary. Also, this may be cost prohibitive depending on the practice environment. Most ambulatory surgical centers historically do not use taxis or ride-sharing (such as Uber or Lyft) because the driver is not considered a responsible adult in relation to a patient who has undergone sedation or anesthesia.26Flowers L. Ambulatory surgery centers: tips for enforcing patient escort policies.OR Manager. 2006; 22: 25-27Google Scholar However, when no other alternative exists, this option may need to be explored.27Trapani G. Altomare C. Liso G. et al.Propofol in anesthesia. Mechanism of action, structure-activity relationships, and drug delivery.Curr Med Chem. 2000; 7: 249-271Crossref PubMed Google Scholar Of note, Lyft28Lyft Healthcare.https://www.lyft.com/healthcareDate accessed: October 25, 2022Google Scholar and Uber29Uber Health.https://www.uberhealth.comDate accessed: October 25, 2022Google Scholar now offer patient appointment transportation, although the issue regarding postsedation responsibility remains unanswered. Intriguingly, the Uber option is touted to be compliant with the Health Insurance Portability and Accountability Act of 1996. A recent study by researchers in Seattle, Washington offered practical commentary on how to implement nonemergency medical transport to improve access to colorectal cancer screening in a safety net hospital population.30Bell-Brown A. Chew L. Weiner B. et al.Operationalizing a rideshare intervention for colonoscopy completion: barriers, facilitators, and process recommendations.Front Health Serv. 2022; 1: 799816Crossref PubMed Google Scholar On a case-by-case basis, patients may sometimes benefit from a prolonged stay in the postanesthesia care unit (eg, if a driver is planning to pick up the patient after work), provided this does not require ongoing nurse observation for patients who have otherwise met discharge criteria. Similarly, an overnight stay at a local hotel or perhaps admitting the patient to the hospital under observation status may be considered, although issues surrounding financial and logistical hurdles (eg, hospital bed availability) remain unresolved. Additionally, in the United States, Medicare is prohibited from paying for services that are not “reasonable and necessary,” as per section 1862(a)(1)(A) of the Social Security Act, meaning that purely custodial care is excluded from Medicare coverage.31Administration, NAaR Federal Register, CfMM Services. 2013, Office of the Federal Register: Washington, DC. p. 50494-1040.Google Scholar Not unlike inpatient discharge planning, the best time to initiate outpatient discharge planning may be at the time of appointment booking. This is helpful on 2 levels. First, by knowing in advance which patients require special planning, the endoscopy unit may offer viable alternatives that may not require sedation. Second, by having defined policies and procedures regarding patient discharge, the endoscopy unit’s charge nurse or attending physician are not compelled to make ad-hoc discharge decisions but instead can make safe discharge decisions (or offer acceptable, preapproved alternatives) that are compliant with current regulatory policy and maximize beneficence. First, as part of a comprehensive risk-mitigation strategy, the responsible adult escort policy should have been communicated and documented on multiple occasions before the endoscopy appointment. That way, even if a form for “against medical advice” discharge is required on the day of the procedure, there is still a clear indication that the endoscopy unit communicated the risk to the patient beforehand. Additionally, as a condition of patient participation in endoscopy, it may be worthwhile to have patients sign an attestation form during the initial check-in that explicitly highlights their understanding of having an adult escort, of the risk of driving after sedation, and that they personally accept the risk of such behaviors should they go against medical advice. This is important to reduce risk shifting in which some patients may feel emboldened to drive after sedation because they believe (erroneously) that the liability falls on the endoscopy unit. Three scenarios may arise in clinical practice (Table 3). In the first scenario, the GI endoscopy unit staff are aware before the procedure that the patient is not able to or does not intend to secure a responsible adult escort home. Here, it is important to consider various options that do not require sedation, such as unsedated colonoscopy, transnasal upper endoscopy, unsedated flexible sigmoidoscopy, or nonendoscopic tests (eg, barium radiography, fecal immunochemical testing). Depending on the outcome of discussions between a local group’s leadership and risk management department, it may be worth evaluating the appropriateness of propofol sedation for the unaccompanied patient based on studies demonstrating more rapid recovery with propofol than with sedation with benzodiazepines and opioids.32Fujisawa T. Takuma S. Koseki H. et al.Study on the usefulness of precise and simple dynamic balance tests for the evaluation of recovery from intravenous sedation with midazolam and propofol.Eur J Anaesthesiol. 2007; 24: 425-430Crossref PubMed Scopus (10) Google ScholarTable 3Discharge planning considerationsWhen does unit become aware of no responsible adult escort for patient’s discharge?First possible solutionAlternative possible solutionsBefore initiation of procedure (days or weeks)Consider options from Table 2, after review and approval by local leadership or risk managementNonendoscopic testing alternativesUnsedated endoscopyDay of procedure, but sedation has not been givenConsider options from Table 2, after review and approval by local leadership or risk managementNonendoscopic testing alternativesUnsedated endoscopyPropofol sedationAfter procedure with sedationConsider options from Table 2, after review and approval by local leadership or risk managementDischarge against medical advice as a continuation of pre-appointment planning (see text for further details) Open table in a new tab In the second scenario, a patient is believed to have a responsible adult escort after the procedure, but it is determined during the admission process that the patient does not have an adult to escort him or her home. In this situation, it may be worthwhile to have the endoscopy unit manager review with the patient the various options of unsedated endoscopy. Not infrequently, when patients recognize the gravity of the situation, they may be able to secure a responsible adult escort, and the procedure can proceed as planned. The alternative would be to contemplate the previously discussed alternative methods of transport, but each option must be carefully weighed with a local GI endoscopy unit’s risk management department. In the final scenario, the patient is believed to have a responsible adult escort after the procedure, the procedure proceeds as planned, but in the recovery area it becomes apparent that no escort is available. This is the most vexing situation. In this situation, it may be necessary to resort to the alternative transport methods that were vetted and approved by a local GI group’s risk management department. These patients may also need to sign out against medical advice, although the documentation trail leading up to the appointment date should help demonstrate the endoscopy unit’s due diligence regarding the unit requirements and reaffirm the patient’s assignment of risk should they engage in unadvisable activity such as driving after a procedure. With the increasing demand for GI endoscopy, particularly with the latest clinical guidelines recommending starting colorectal cancer screening at 45 years of age,33Shaukat A. Kahi C. Burke C. et al.ACG clinical guidelines: colorectal cancer screening 2021.Am J Gastroenterol. 2021; 116: 458-479Crossref PubMed Scopus (230) Google Scholar it is likely that the risk of unaccompanied patients will rise. It is also known that endoscopy can be life-saving, such as the demonstrated halving in the risk of death from colorectal cancer in patients undergoing colonoscopy for an abnormal fecal immunochemical testing.34Zorzi M. Battagello J. Selby K. et al.Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer.Gut. 2022; 71: 561-567Crossref PubMed Scopus (22) Google Scholar As such, there is increasing awareness of the transportation barriers to endoscopy. Additional research into an ideal, validated test that documents a patient’s recovery to baseline psychomotor and/or neurocognitive function is needed.35Walsh M.T. Discharging select patients without an escort after ambulatory anesthesia: identifying return to baseline function.Curr Opin Anaesthesiol. 2021; 34: 703-708Crossref PubMed Scopus (5) Google Scholar Until then, it may be reasonable and prudent for GI endoscopy units to develop policies that maximize access to care by addressing social determinants of health, such as lack of a driver after procedures.