Demographic Factors Influencing Discharge Against Medical Advice (AMA) in Patients with Upper Gastrointestinal Bleeding and Abdominal Pain: A Study of 170 Emergency Department Discharges 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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Haemobilia in a previously stented hilar cholangiocarcinoma: successful haemostasis after the insertion of fcSEMS

Oxford Medical Case Reports ◽

10.1093/omcr/omaa010 ◽

2020 ◽

Vol 2020 (2) ◽

Author(s):

T Tien ◽

Y C Tan ◽

P Baptiste ◽

S Tanwar

Keyword(s):

Abdominal Pain ◽

Blood Loss ◽

Gastrointestinal Bleeding ◽

Hilar Cholangiocarcinoma ◽

Upper Gastrointestinal Bleeding ◽

Metal Stent ◽

Distal Stomach ◽

Periampullary Region ◽

Altered Blood ◽

Upper Gastrointestinal

Abstract Haemobilia describes blood loss from the biliary tract and classically presents as Quincke’s triad: upper gastrointestinal bleeding (UGIB), jaundice and right upper quadrant abdominal pain. We discuss the case of a 70-year-old male with a previously stented Bismuth 1 hilar cholangiocarcinoma who presented with haematemesis. He had a similar presentation a month ago where a forward viewing gastroscope identified fresh and altered blood in the distal stomach but no clear source of bleeding. During this admission, a side-viewing duodenoscope identified bleeding from the periampullary region, which was managed by inserting a fully covered self-expanding metal stent (fcSEMS) within his pre-existing uncovered SEMS to tamponade the haemorrhage. This case highlights the importance of using a side-viewing duodenoscope for patients with UGIB on a background of a stented cholangiocarcinoma and inserting a fcSEMS within an uncovered SEMS is feasible and effective in managing these patients.

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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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Clinical profile of patients presenting to emergency with upper gastrointestinal bleeding in a tertiary hospital of Nepal

Journal of Patan Academy of Health Sciences ◽

10.3126/jpahs.v8i2.28839 ◽

2021 ◽

Vol 8 (2) ◽

pp. 105-111

Author(s):

Sunil Adhikari ◽

Suraj Rijal ◽

Darlene Rose House

Keyword(s):

Emergency Department ◽

Gastrointestinal Bleeding ◽

Variceal Bleeding ◽

Clinical Presentation ◽

Upper Gastrointestinal Bleeding ◽

Tertiary Hospital ◽

Clinical Profile ◽

Ulcer Bleeding ◽

Cross Sectional ◽

Upper Gastrointestinal

Introduction: Upper gastrointestinal bleeding is an acute emergency condition. It is an important cause for the hospital admission. This study descriptively analyses the clinical profile of upper gastrointestinal bleeding presenting to a tertiary hospital in Nepal. Method: This is a cross-sectional study of patients presenting with upper gastrointestinal bleeding from 01 Oct 2018 to 30 Sep 2019 at Patan Hospital Emergency Department, Patan Academy of Health Sciences, Nepal. Patient’s demographics, clinical presentation, duration of illness before presenting to Emergency, vitals, and laboratory parameters were descriptively analyzed. Ethical approval was obtained. Result: There were 121 patients, male 82(67.8%) and female 38(31.4%) aging 14 to 90 years. Fifty-three patients (43.8 %) presented with hematemesis, 38(31.4%) with melena, and 27(22.3%) with both hematemesis and melena. Variceal bleeding was the main cause of upper gastrointestinal bleeding found in 73(60.33%) followed by ulcer bleeding in 48(39.66%). Conclusion: Variceal bleeding was the main cause of upper gastrointestinal bleeding and hematemesis was the most common clinical presentation in patients presenting to the Emergency Department.

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Prediction model of emergency mortality risk in patients with acute upper gastrointestinal bleeding: a retrospective study

PeerJ ◽

10.7717/peerj.11656 ◽

2021 ◽

Vol 9 ◽

pp. e11656

Author(s):

Lan Chen ◽

Han Zheng ◽

Saibin Wang

Keyword(s):

Emergency Department ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Area Under The Curve ◽

Decision Curve Analysis ◽

Acute Upper Gastrointestinal Bleeding ◽

Bleeding Score ◽

Selection Operator ◽

Upper Gastrointestinal ◽

D Dimer

Background Upper gastrointestinal bleeding is a common presentation in emergency departments and carries significant morbidity worldwide. It is paramount that treating physicians have access to tools that can effectively evaluate the patient risk, allowing quick and effective treatments to ultimately improve their prognosis. This study aims to establish a mortality risk assessment model for patients with acute upper gastrointestinal bleeding at an emergency department. Methods A total of 991 patients presenting with acute upper gastrointestinal bleeding between July 2016 and June 2019 were enrolled in this retrospective single-center cohort study. Patient demographics, parameters assessed at admission, laboratory test, and clinical interventions were extracted. We used the least absolute shrinkage and selection operator regression to identify predictors for establishing a nomogram for death in the emergency department or within 24 h after leaving the emergency department and a corresponding nomogram. The area under the curve of the model was calculated. A bootstrap resampling method was used to internal validation, and decision curve analysis was applied for evaluate the clinical utility of the model. We also compared our predictive model with other prognostic models, such as AIMS65, Glasgow-Blatchford bleeding score, modified Glasgow-Blatchford bleeding score, and Pre-Endoscopic Rockall Score. Results Among 991 patients, 41 (4.14%) died in the emergency department or within 24 h after leaving the emergency department. Five non-zero coefficient variables (transfusion of plasma, D-dimer, albumin, potassium, age) were filtered by the least absolute shrinkage and selection operator regression analysis and used to establish a predictive model. The area under the curve for the model was 0.847 (95% confidence interval [0.794–0.900]), which is higher than that of previous models for mortality of patients with acute upper gastrointestinal bleeding. The decision curve analysis indicated the clinical usefulness of the model. Conclusions The nomogram based on transfusion of plasma, D-dimer, albumin, potassium, and age effectively assessed the prognosis of patients with acute upper gastrointestinal bleeding presenting at the emergency department.

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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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Modification of Glasgow-Blatchford scoring with lactate in predicting the mortality of patients with upper gastrointestinal bleeding in emergency department

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918783159 ◽

2018 ◽

Vol 26 (1) ◽

pp. 31-38

Author(s):

Zeynep Konyar ◽

Ozlem Guneysel ◽

Fatma Sari Dogan ◽

Eren Gokdag

Keyword(s):

Emergency Department ◽

Blood Transfusion ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Venous Blood ◽

Erythrocyte Suspension ◽

Laboratory Findings ◽

Significant Difference ◽

Lactate Levels ◽

Upper Gastrointestinal

Background: Gastrointestinal bleeding is a commonly seen multidisciplinary clinical condition in emergency departments which has high treatment cost and mortality in company with hospital admission. Risk evaluation before endoscopy is based on clinical and laboratory findings at patient’s emergency visit. Objective: The purpose of this study is to investigate the efficacy of “Glasgow-Blatchford scale + lactate levels” to predict the mortality of patients detected with gastrointestinal bleeding in the emergency department. Methods: A total of 107 patients with preliminary diagnosis of upper gastrointestinal bleeding included in the study after approval of the ethics committee were prospectively evaluated. Glasgow-Blatchford scale scores were calculated and venous blood lactate levels were assessed. Need for blood transfusion in the follow-up, the amount of transfusion, and mortality in the next 6 months were evaluated. Results: A statistically significant difference was found in mortality rates between the lactate and Glasgow-Blatchford scale cohorts in our study (p = 0.001 and p < 0.01, respectively). The mortality rate was significantly higher in the lactate(+) GBS(+) cases compared to the lactate(–) GBS(+), lactate(+) GBS(–), and lactate(–) GBS(–) cases compared to the bilateral comparisons (p = 0.004, p = 0.001, p = 0.001, and p < 0.01, respectively). There was a statistically significant relationship between the rate of erythrocyte suspension replacement in the cases according to Glasgow-Blatchford scale levels (p = 0.001 and p < 0.01, respectively). The incidence of erythrocyte suspension replacement was 7.393 times greater in patients with Glasgow-Blatchford scale score of 12 and above. Conclusion: Glasgow-Blatchford scale is highly sensitive to the determination of mortality risk and the need for blood transfusion in upper gastrointestinal bleeding. Glasgow-Blatchford scale with lactate evaluation is more sensitive and more significant than Glasgow-Blatchford scale alone. This significance provides us to establish “modified Glasgow-Blatchford scale.” In the future, studies which will use Glasgow-Blatchford scale supported by lactate could be increased and the results should be supported more.

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