Retrospective Evaluation of Patients Leaving Against Medical Advice from Intensive Care Unit (ICU) in Tertiary Care Teaching Hospital

Introduction: Leaving Against Medical Advice (LAMA) can cause a state of dilemma among the treating physician whether to continue the treatment or to de-escalate from the treatment. It can deteriorate the primary disease of the patient, leading to an increase rate of re-admission to the hospital, increased morbidity and mortality. This is a worldwide phenomenon and the prevalence of LAMA varies between various countries and between different region, religion, and the socioeconomic status of the patient in the same country.Methods: The hospital records from 1st December 2018 to 30th November 2019 of a tertiary care teaching hospital were studied. Patient demography, disease characteristics and length of ICU stay and the factors leading to LAMA were noted and statistically analysed.Results: During the study period, 14.5% of patients asked for LAMA. The mean age was 51.22 ± 22.39 years (range 8 months to 97 years) with Male predominance (n= 288, 62.60%) over Female (n= 172, 37.39%). Patients residing in rural areas were 56.08% (n=258) and 63.91% were financially dependent on others for their living. The mean length of stay in hospital was 3.02 ± 3.50 days while 30.86% of patients required mechanical ventilation. About 51.73% of patients taking LAMA were admitted from the Internal medicine department. Around 79.56% were Hindus, with 54.34% opting for LAMA due to financial restrain followed by poor prognosis (22.60 %).Conclusion: The large number of patients admitted in ICU opts out for LAMA. This necessitates formulation and implementation of strategies to reduce the prevalence of LAMA discharge so that patient gets the optimum level of care and the burden in the health care system is reduced

Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions

Background: A patient decides to leave the hospital against medical advice. Is this an erratic eccentric behavior of the patient, or a gap in the quality of care provided by the hospital? With a significant and increasing prevalence of up to 1–2% of all hospital admissions, leaving against medical advice affects both the patient and the healthcare provider. We hereby explore this persistent problem in the healthcare system. We searched Medline and PubMed within the last 10 years, using the keywords “discharge against medical advice,” “DAMA,” “leave against medical advice,” and “AMA.” We retrospectively reviewed 49 articles in our project. Ishikawa fishbone root cause analysis (RCA) was employed to explore reasons for leaving against medical advice (AMA). This report presents the results of the RCA and highlights the consequences of discharge against medical advice (DAMA). In addition, the article explores preventive strategies, as well as interventions to ameliorate leaving AMA.

Impact of a Plan of Care Protocol on Patient Outcomes in People Who Inject Drugs With Infective Endocarditis

Background People who inject drugs (PWID) are at increased risk of deleterious sequelae due to infective endocarditis (IE). A standardized, hospital-wide drug use–associated infection protocol targeting medication safety, pain management, and limiting external risk factors was implemented at an academic medical center to improve outcomes in PWID with IE. Methods A quasi-experimental study included patients with active injection drug use and definite IE from January 2013 to July 2017 (preintervention group) and from September 2017 to January 2019 (intervention group). The primary outcome of interest was the 90-day all-cause readmission rate. Secondary outcomes included infection-related readmission rates, in-hospital and all-cause mortality rates, and the frequency of patients leaving against medical advice. Results A total of 168 patients were included, in the 100 preintervention and 68 in the intervention group. Patients in the intervention group had reduced odds of 90-day all-cause readmission (adjusted odds ratio, 0.2; 95% confidence interval, 0.08–0.6) after adjustment for confounding variables. The 12-month all-cause mortality rate was also significantly reduced in the intervention group (adjusted odds ratio, 0.25; 95% confidence interval, .07–.89). The intervention group had a higher proportion of patients leaving against medical advice (6% for the preintervention group vs 35% for the intervention group, P < .001). Conclusions A drug use–associated infection protocol demonstrated reduced 90-day all-cause readmission and 12-month all-cause mortality rates in PWID with IE. This study highlights the importance of standardized care processes for improving care in this specialized patient population.

Factors Affecting Discharges against Medical Advice in an Emergency Department of a Tertiary Care Center

Introduction: Patients leaving against the advice of the treating team before being certified as fit is a major concern and challenge for the treating professionals as it possesses adverse medical outcomes. This study hence aimed at identifying the prevalence and major factors affecting such discharges so that advocacy can be done to help prevent it. Methods: A descriptive cross-sectional study was conducted at emergency department of a tertiary center in Lalitpur from 15th May 2019 to 15th August 2019. All the patients visiting the emergency department were included in the study and a non-probability purposive sampling method was used excluding the patients who denied giving reasons for them leaving against medical advice. Data was collected using pre-structured questionnaire and analyzed using SPSS-v21 software. Results: A hundred and fifteen patients (4.08%) left against medical advice out of 2812 patients who presented to emergency department. There were 63 male patients (54.8%), 75 patients of the total patients in the age group of 15-44 years (65.2%) and those living within a distance of 1km from the hospital (53%). The most common reason for the patients leaving against medical advice was found to be due to financial constraint (38.3%) followed by preference to other hospitals (16.5%). Conclusion: Patients leaving against medical advice possesses a small percentage of actual hospital admissions but is still a major health concern as it drastically increases the morbidity, re-admission rates and total health-care costs. Hence, understanding the general characteristics and predictors of such discharges is of utmost importance to help improve the patient outcome and reduce the health-care costs.