Pediatric Discharge From the Emergency Department Against Medical Advice

PEDIATRICS ◽  
2021 ◽  
Author(s):  
Meaghann S. Weaver ◽  
Haavi Morreim ◽  
Lydia H. Pecker ◽  
Rachel O. Alade ◽  
David J. Alfandre
Keyword(s):  
Emergency Department ◽  
Discharge Planning ◽  
Medical Advice ◽  
Pediatric Resident ◽  
Best Interest ◽  
Against Medical Advice ◽  
Febrile Infant ◽  
Ethics Rounds ◽  
Safety Plan ◽  
Discharge Against Medical Advice

In this Ethics Rounds we present a conflict regarding discharge planning for a febrile infant in the emergency department. The physician believes discharge would be unsafe and would constitute a discharge against medical advice. The child’s mother believes her son has been through an already extensive and painful evaluation and would prefer to monitor her well-appearing son closely at home with a safety plan and a next-day outpatient visit. Commentators assess this case from the perspective of best interest, harm-benefit, conflict management, and nondiscriminatory care principles and prioritize a high-quality informed consent process. They characterize the formalization of discharge against medical advice as problematic. Pediatricians, a pediatric resident, ethicists, an attorney, and mediator provide a range of perspectives to inform ethically justifiable options and conflict resolution practices.

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

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.

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

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.

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

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.

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

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.

Discharge against medical advice from a Tehran emergency department

2016 ◽  
Vol 29 (1) ◽  
pp. 24-32 ◽  
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.

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

Healthcare ◽  
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.

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

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

<p class="abstract"><strong>Background:</strong> 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.</p><p class="abstract"><strong>Methods:</strong> 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.<strong></strong></p><p class="abstract"><strong>Results:</strong> 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.</p><p class="abstract"><strong>Conclusions:</strong> 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.</p>

scholarly journals Discharge against Medical Advice (DAMA) from an Emergency Department of a Tertiary Care Hospital in Saudi Arabia

2019 ◽  
Vol 2019 ◽  
pp. 1-6
Author(s):  
Ashraf El-Metwally ◽  
Nesreen Suliman Alwallan ◽  
Ali Amin Alnajjar ◽  
Nida Zahid ◽  
Khalid Alahmary ◽  
...  
Keyword(s):  
Emergency Department ◽  
Saudi Arabia ◽  
Tertiary Care ◽  
Medical Advice ◽  
Urgent Care ◽  
Categorical Variables ◽  
Care Hospital ◽  
Against Medical Advice ◽  
Discharge Against Medical Advice ◽  
Effect Of Age

Background. The discharge against medical advice (DAMA) in the Emergency Department (ED) is an issue of great concern because it may result in adverse consequences at a later stage. The reported worldwide prevalence of DAMA ranges from 0.07 to 20% for emergency admissions. The outcomes of DAMA can have significantly damaging effects, causing possible relapses of disease, readmission, and increases in medical costs for the patient. Therefore, it is imperative to identify the predictors of DAMA in ED. Methods. It was a cross-sectional study. The medical records used were those of all the patients (n = 11513) admitted to the Emergency Department (ED) of King Abdullah Bin Abdulaziz University Hospital (KAAUH) in Riyadh, Saudi Arabia, between 2017 and 2018. A thorough analysis was performed using IBM SPSS Statistics version 22. Descriptive statistics were reported for quantitative and categorical variables and assessed by independent t-test/chi-square/ANOVA (analysis of variance), where appropriate. Unadjusted and adjusted odds ratios with their 95% CI (confidence interval) were reported by performing logistic regression. A p value of ≤0.05 was considered statistically significant throughout the study. Results. The prevalence of DAMA in our study was 1%. In a multivariable analysis, after adjusting for the other covariates, we observed a significant interaction between age and gender. It was observed that the odds of DAMA for ≤40-year-old males were 3.12 times higher than those of a ≤40-year-old female (p value < 0.1). To further investigate this interaction, men and women were modeled separately in multivariable models using the same covariates. We found that, for men, the effect of age (≤40 years) was significant (OR = 3.94, 95% CI 1.31–11.80, p=0.014), while, for women, the effect of age (≤40 years) was not as pronounced (OR = 1.27, 95% CI = 0.66–2.42, p=0.27). Conclusions. Our study concluded that DAMA was more likely among younger male patients (≤40 years of age). Most of the patients with DAMA were presented to the urgent care of the Emergency Department. We recommend that patients be given some financial support to bear the expenses of the hospital stay from the healthcare facility or from the state. Future studies should assess the socioeconomic status of the patients and estimate the cost that is incurred by the patients.

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