Background: Patient who leave the emergency
department against medical advice are at high risk for complications. AMA
discharges are also considered high-risk events potentially leading to
malpractice litigation.
Objectives: Our aim was to characterize
patients who leave AMA in a payment prior to service ED model and to identify
predictors for return visits to ED after leaving AMA.
Methods: We conducted a retrospective
review study of charts of ED patients who were discharged AMA between 1/1/2012
and 1/1/2013 at a tertiary care center in Beirut Lebanon. We carried out a
descriptive analysis and a bivariate analysis comparing the first visit and the
return visit within 72 hours. This was followed by a Logistic regression to
identify predictors of return visits after leaving AMA.
Results: A total of 1213 ED patients were
discharged AMA during the study period. Mean age was 46.9 years (± 20.9). There
were 654 males (53.9%), 737 married (60.8%). The majority (1059 patients (87.3 %))
had an emergency severity index of 3 or less (1 or 2). ED average length of
stay was 3.8 hours (±6.8). Self payers accounted for 53.9%. Reasons for leaving AMA were: no reason
mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%),
financial reasons (7.9%), long wait times (2.9%) and others (2.2%). Discharge
diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious
(10.1%) and trauma (9.8%).
One
hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning
to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01-1.03)), private
insurance status (OR 4.64 95% (CI 2.89-7.47) within network insurance status
(OR 7.20 95% CI (3.86-13.44), longer ED LOS during the first visit (OR 1.03
95%CI (1.01-1.05).
Conclusions:
In
our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons
for leaving AMA, high-risk discharge diagnoses and predictors of return visit
were identified. Financial status was a strong predictor of return to ED after
leaving AMA.
All
patients who were discharged AMA from the ED between 1/1/2012 and 1/1/2013 was
done.
A
retrospective chart review of all patients who were discharged AMA from the ED
between 1/1/2012 and 1/1/2013 was done.
AMA
is a separate category that is assigned electronically to patients by the
discharging provider when they leave the ED in our system. A list of all
patients discharged AMA during the study period was generated and their charts
were included for review (initial visit). All patients who left AMA had a
signed AMA form completed in their chart. Patients who returned to the ED
within 72 hours of AMA discharge (return visit) were flagged and reviewed for
additional data collection.
A list
of 1256 patients was identified with 43 patients excluded because of admission
to hospital within the same visit (signed AMA for refusing a treatment with
proven benefits or additional work up needed to reach a clear diagnosis), or
missing ED charts (ED records consist of paper charting then scanning combined
with electronic tracking).