Standards › Standard 6 › Policies
Policy · DAY-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.4
At a glance
- Every day-case patient leaves with an adult escort.
- The escort is confirmed before the day of surgery.
- Written discharge advice is given to the patient and the escort.
- The advice covers the warning signs and who to call.
- Stop and get help straight away if: a patient leaves day surgery with no escort, or with no written advice.
1. Purpose
To make sure no patient goes home after anaesthesia alone, and that they know what to watch for (6.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A patient who goes home alone after anaesthesia can collapse without anyone to help. An adult escort at discharge, and written advice, is the simplest protection.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead nurse | Confirms the escort and gives the advice | Nurse |
| Anaesthetist | Confirms the discharge criteria are met | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Confirm escort.
- Confirm the adult escort at booking and again on the day, and record the name.
Key point: Named, confirmed twice.
Step 2. Discharge.
- Check the discharge criteria are met (DAY-FRM-002) before the patient leaves.
Key point: Criteria before discharge.
Step 3. Advise.
- Give the written advice to the patient and escort, with the warning signs and a contact number.
Key point: In writing, to both.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Discharges with escort recorded | 100% | Monthly | Lead nurse | Escalate to clinical director |
| Discharges with written advice | 100% | Monthly | Lead nurse | Escalate to clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| DAY-FRM-002 | Discharge and escort record | Record |
| HOS-FRM-008 | Discharge aftercare plan | Aftercare |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Safe Surgery Saves Lives guidelines (2008). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)