Irregular discharge against medical advice from the accident and emergency department--a cause for concern.

Introduction. The goals of health care provision include that it be accessible, acceptable, affordable and adequate. Discharge against medical advice (DAMA) is a failure of proper health care provision as there is disagreement arising from dissatisfaction with provided health care. DAMA is common in our sub-region because of many reasons; these includes ignorance, financial constraint of the patient, beliefs in unorthodox care and patients feeling that they are well when their caregivers do not think so. Aim. The objectives of this study are to determine the incidence, method of documentation of DAMA in the case notes and patients reasons for DAMA in our tertiary health institution. The A&E of any hospital in our environment attracts public criticism when there is dissatisfaction with services and DAMA when not handled well can lead to justifiable criticisms and/or litigations. Material and methods. This is a retrospective study. It was carried out at the adult accident and emergency department of Enugu state university of technology teaching hospital Enugu. Duration of the study was from January 2017 to December 2018. Results. A total of 8,152 patients were seen in the accident and emergency during this period. One hundred and seventy one (171) case notes were retrieved and reviewed for the study, DAMA rate of 2.1% was obtained. Fifty one folders (29.8%) did not have reason for the DAMA documented in them. The commonest reason for the DAMA was to seek traditional medical care with frequency of 17.5%. This was closely followed by financial constraint with 15.8%. Documentation for DAMA was done directly in the case notes. Conclusion. The incidence of DAMA from this study is similar to what is obtainable from other local studies, financial constraint on the patients and seeking alternative medical treatment were the commonest reasons for DAMA in our sub-region. Also, the documentation for the DAMA in this study was poorly done.

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Incidence and reasons for leave against medical advice among orthopedic and trauma patients at the university college hospital Ibadan

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20205555 ◽

2020 ◽

Vol 7 (1) ◽

pp. 1

Author(s):

Tolulope O. Ogunrewo ◽

Oluwadayo A. Magbagbeola ◽

Samuel T. Oladejo ◽

Adeoye Allen-Taylor

Keyword(s):

Emergency Department ◽

Medical Advice ◽

Clinical Event ◽

College Hospital ◽

Against Medical Advice ◽

Accident And Emergency ◽

University College ◽

Accident And Emergency Department ◽

The University ◽

Orthopedic Patients

Background: Leave against medical advice (LAMA) of hospitalized patients is an adverse clinical event in which a patient chooses to leave the hospital before it is medically advisable to do so and it negatively affects the treatment outcome. Because of this, the study was designed to determine the incidence of and indications for LAMA among orthopedic patients who presented at the accident and emergency department of the university college hospital, Ibadan.Methods: This was a prospective hospital-based study determining the incidence of LAMA among orthopedic patients who presented at the accident and emergency department of the university college hospital, Ibadan between September 2019 and March 2020.Results: A total of 289 patients with orthopedic conditions presented within the study period and about 12.46% of these LAMA. The male to female ratio observed in this study is 2:1. The age range was between 8 and 93 years. Trauma from motorbike and motor vehicle accidents accounted for over 80% of the etiology. The most important factor influencing LAMA is financial constraints (63.9%) and LAMA was signed mostly by the patients (25%).Conclusions: LAMA among orthopedic patients in Ibadan is mostly due to financial reasons, therefore, factors that will reduce the cost of management such as the accessibility to health insurance schemes will significantly reduce the incidence of LAMA among orthopedic patients in Nigeria.

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Rate and causes of discharge against medical advice from a university hospital emergency department in Iran: an ethical perspective

Journal of Medical Ethics and History of Medicine ◽

10.18502/jmehm.v13i15.4391 ◽

2020 ◽

Author(s):

Sanaz Rouhbakhsh Halvaei ◽

Hojat Sheikh Motahar Vahedi ◽

Ayat Ahmadi ◽

Maryam Sadat Mousavi ◽

Alireza Parsapoor ◽

...

Keyword(s):

Emergency Department ◽

Medical Staff ◽

Medical Advice ◽

University Hospital ◽

P Value ◽

Emergency Ward ◽

Ethical Perspective ◽

Against Medical Advice ◽

Discharge Against Medical Advice ◽

Clinical Records

Discharge against medical advice (DAMA) is a common problem in the health-care system. It imposes risks to both patients and medical staff and could be the subject of ethical deliberation. This cross-sectional study was conducted in 2017 on 400 patients who were discharged against medical advice from the emergency ward of Shariati Hospital, Tehran, Iran. Patients’ information was collected using clinical records and telephone calls. The collected data were analyzed using STATA software. DAMA rate was 12% in the emergency department of Shariati Hospital. Male gender was found to be a risk factor for DAMA (OR: 1.90; CI (95%): 1.44 - 2.52; P < 0.0001). In addition, younger patients were more likely to leave hospital against medical advice (p-value: 0.04). The more common reasons for DAMA were feeling better, long delay in diagnostic and therapeutic procedures and the hectic ambience of the emergency ward. Patients’ self-discharge is a multi-dimensional phenomenon that is affected by patients’ characteristics, medical conditions and hospital circumstances. It raises some ethical concerns, mainly due to a conflict between patients’ autonomy and beneficence. It is helpful for the medical staff to create an effective relationship with patients who are at higher risk of DAMA, in order to increase their compliance and prevent the consequences of leaving hospital against medical advice.

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Audit of documentation proficiency of emergency department patients who are discharged against medical advice before and after implementation of a checklist

Journal of Hospital Administration ◽

10.5430/jha.v5n4p28 ◽

2016 ◽

Vol 5 (4) ◽

pp. 28

Author(s):

Sze Joo Juan ◽

Ghee Hian Lim ◽

Beng Leong Lim

Keyword(s):

Emergency Department ◽

Primary Outcome ◽

Medical Advice ◽

Against Medical Advice ◽

Documentation Quality ◽

Before And After ◽

Discharge Against Medical Advice ◽

Emergency Department Patients ◽

A Prospective Study

Objective: Documentation of the discharge against medical advice (AMA) is poorly performed in the emergency department (ED). Little is known about the impacts of a checklist on this. Our study aimed to compare the quality of AMA documentation before and after implementation of a checklist.Methods: A retrospective review was conducted followed by a prospective study; each over three months of AMA interactions in our ED pre and post implementation of a checklist. An 11-point checklist was used to determine documentation quality during these two periods. Quality was assessed based on the number of points fulfilled on this tool. Documentation was classified as “good” (8-11), “average” (4-7) and “poor” (0-3). The primary outcome measured was the proportions of discharged AMA records that showed “good”, “average” and “poor” documentation. Secondary outcomes were compliance rates to each of the categories of the checklist before and after its use.Results: 339 and 309 complete records were retrieved from the retrospective and prospective arms respectively. The proportions of case records in the three grades before and after use of the checklist respectively were: poor, 199/339 (59%) vs. 7/313 (2%); fair, 133/339 (39%) vs. 66/313 (21%) and good 7/339 (2%) vs. 240/313 (77%); all p-values were statistically significant. There were also statistically significant differences in compliance rates to each of the categories of the checklist pre and post checklist implementation.Conclusions: This study shows improvement in quality and compliance rates in the audit categories after the implementation of an AMA checklist.

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Discharge against medical advice from emergency department: results from a tertiary care hospital in Tehran, Iran

European Journal of Emergency Medicine ◽

10.1097/mej.0b013e3283334ef1 ◽

2010 ◽

Vol 17 (6) ◽

pp. 318-321 ◽

Cited By ~ 13

Author(s):

Farzaneh Shirani ◽

Mohammad Jalili ◽

Hossein Asl-e-Soleimani

Keyword(s):

Emergency Department ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Medical Advice ◽

Care Hospital ◽

Against Medical Advice ◽

Discharge Against Medical Advice

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Discharge against medical advice and premature leave of neurological patients from an interdisciplinary emergency department: a retrospective observational study.

10.21203/rs.2.9965/v1 ◽

2019 ◽

Author(s):

Carolin Hoyer ◽

Patrick Stein ◽

Angelika Alonso ◽

Michael Platten ◽

Kristina Szabo

Keyword(s):

Emergency Department ◽

Observational Study ◽

Patient Flow ◽

Waiting Times ◽

Medical Advice ◽

Retrospective Observational Study ◽

Against Medical Advice ◽

Presenting Symptoms ◽

Neurological Patients ◽

Discharge Against Medical Advice

Abstract Background: Discharge against medical advice (DAMA) or premature leave (PL) from the emergency department represent relevant medical problems with impact on patient safety and potential medicolegal consequences. They may also indicate structural or procedural problems in the ED. To date, no dedicated analysis of DAMA/PL exists for neurological patients presenting to the ED. Methods: A retrospective observational study was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017. DAMA/PL patients were compared to the total of patients who were admitted or discharged regularly (non-DAMA/PL). Results: Of all neurological cases, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p<.001), and their presentation was more frequently self-motivated (p<0.001. Waiting times did not differ between DAMA/PL and non-DAMA/PL patients (p=.166) but treatment duration was significantly shorter in the former (p<.001) Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and in 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the length of waiting time. Conclusions: Both individual and structural/systemic reasons contribute to DAMA/PL in neurological patients. Optimization of pre-hospital assessment and the development of alternative models of care for patients with non-urgent conditions appear to be promising targets for future improvements regarding demand management and the direction of patient flow.

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Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults

Journal of Comparative Effectiveness Research ◽

10.2217/cer-2021-0024 ◽

2021 ◽

Author(s):

Eberechukwu Onukwugha ◽

Aakash Bipin Gandhi ◽

David Alfandre

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Healthcare Costs ◽

Retrospective Cohort ◽

Medical Advice ◽

Emergency Department Visits ◽

Against Medical Advice ◽

Prior Literature ◽

Discharge Against Medical Advice

Aim: Prior literature detailing the consequences of a discharge against medical advice (DAMA) has not focused on costs. We examine costs following a DAMA. Materials & methods: This retrospective cohort study utilized the IQVIA PharMetrics® Plus database to identify adults hospitalized during 2007–2015. We compared 30-day postdischarge healthcare costs between matched DAMA and routinely discharged groups. Results: Thirty-day healthcare costs for the DAMA group were US$1078 (95% CI: US$434–1730) higher, driven by inpatient readmissions (US$979; 95% CI: US$415–1543) and emergency department visits (US$79; 95% CI: US$56–102). Costs due to prescription drug fills were lower in the DAMA group. Conclusion: A DAMA was associated with higher 30-day postdischarge healthcare costs compared with routine discharges.

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Discharge against medical advice from a Tehran emergency department

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-03-2015-0030 ◽

2016 ◽

Vol 29 (1) ◽

pp. 24-32 ◽

Cited By ~ 2

Author(s):

Azar Hadadi ◽

Patricia Khashayar ◽

Mojgan Karbakhsh ◽

Ali Vasheghani Farahani

Keyword(s):

Emergency Department ◽

Teaching Hospital ◽

Cross Sectional Study ◽

Medical Advice ◽

Contributing Factors ◽

Cross Sectional ◽

Against Medical Advice ◽

Policy Makers ◽

Content Type ◽

Discharge Against Medical Advice

Purpose – The purpose of this paper is to identify the main reasons for discharge against medical advice (DAMA) in the emergency department (ED) of a teaching hospital in Tehran, Iran. Design/methodology/approach – This cross-sectional study was conducted on all the patients who left the ED of a referral teaching hospital against medical advice (AMA) in 2008. A questionnaire was filled out for each patient to determine the reasons behind patient leaving AMA. Findings – In total, 12.8 percent of the patients left the hospital AMA. Dissatisfaction with being observed in the ED, having a feeling of recovery and hospital personnel encouraging patients to leave the hospital were the main reasons for leaving the hospital AMA. Practical implications – Like many other centers, the results showed that poor communication skill and work overload were the main contributing factors to DAMA. The center managed to improve patient satisfaction and thus lowered DAMA rates following this study. Considering the similarities reported in the reports and that of other studies, it could be concluded that policy makers in other centers can also benefit from the results to adopt effective approaches to reduce DAMA rate. Originality/value – To the knowledge no study has evaluated the rate and the reasons behind DAMA in the Iranian EDs.

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Factors Influencing Early Readmission after Discharge against Medical Advice from the Emergency Department

Healthcare ◽

10.3390/healthcare9080986 ◽

2021 ◽

Vol 9 (8) ◽

pp. 986

Author(s):

Byeong-Keon Moon ◽

Ryeok Ahn ◽

Deulle Min ◽

JaeLan Shim

Keyword(s):

Emergency Department ◽

Healthcare Workers ◽

Medical Center ◽

Financial Burden ◽

Foreign Worker ◽

Medical Advice ◽

Against Medical Advice ◽

Factors Influencing ◽

Number Of Patients ◽

Discharge Against Medical Advice

Discharge against medical advice (DAMA) and readmissions are important issues worldwide and can lead to adverse clinical outcomes, financial burden, and exposure of healthcare workers to unintended medical disputes. This study aimed to identify factors that affect readmissions within 48 h after DAMA. This retrospective study utilized the medical records of patients who visited an emergency medical center in Korea for treatment and were readmitted during a 10-year period. Factors predicting readmission after being DAMA were identified using logistic regression analysis. The total number of patients who were DAMA during the study period was 5445, of which 351 were readmitted to the emergency department within 48 h (6.4%). Factors influencing readmission included medical aid (odds ratio (OR) = 2.02, 95% confidence interval (CI): 1.46–2.83) and foreign worker insurance (OR = 2.07, 95% CI: 1.04–4.09) as their health insurance, as well as presenting for readmission by car (OR = 1.41, 95% CI: 1.08–1.82). Healthcare workers should treat patients who are DAMA and those who are likely to return with a more careful and preventative management strategy so that potential clinical, legal, and economic impacts of DAMA can be mitigated.

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Characteristics and outcome of road traffic injured patients in the emergency department of a tertiary teaching hospital in Nigeria

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20211601 ◽

2021 ◽

Vol 7 (3) ◽

pp. 451

Author(s):

Oludolapo O. Afuwape ◽

Temitope O. Alonge ◽

Achiaka E. Irabor ◽

Mosi J. Balogun

Keyword(s):

Emergency Department ◽

Teaching Hospital ◽

Road Traffic ◽

Road Traffic Injury ◽

Medical Advice ◽

Against Medical Advice ◽

Traffic Injury ◽

Tertiary Teaching ◽

Tertiary Teaching Hospital ◽

Discharge Against Medical Advice

Background: The exit modes from the emergency department (ED) for road traffic injury patients are namely planned discharge; admission to the wards/intensive care unit or transfer to the operating theatre; discharge against medical advice (DAMA). The aim of this study was to assess the characteristics and outcomes of non-poly-traumatized road traffic injury (RTI) related ED admissions of a tertiary health care facility in a developing country and the exit pattern from the ED.Methods: This was a retrospective hospital data-based study of outcome of RTI patients seen in the ED of a tertiary teaching hospital in Nigeria from January to December 2017.Results: 1120 RTI patients were recruited consisting of 774 males and 346 females with a male: female ratio of 2.24:1. The age range was 1 to 94 years with a mean age of 37.5±17.5 years. Peak ages were in the fourth (24.2%) and third (20.4%) decades of life respectively. 85.5% of the patients were commercial vehicles passengers. Motorcycle accidents constituted 44% of the patients while 41.8% were in cars. The commonest injuries were head injuries (31% m:f 2.7) and fractures (21% m:f 3). There were 11.5% DAMA and 7.1% deaths. Motorcycles injuries had the highest mortality rate while the motorized tricycles injuries had the highest DAMA rates.Conclusions: Motorized tricycles may be considered as a safer means of commercial mode of transportation compared to motorcycles despite its own limitations. There is a need to educate patients against the common practice of discharge against medical advice.

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