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).
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.
patients who were discharged AMA from the ED between 1/1/2012 and 1/1/2013 was
retrospective chart review of all patients who were discharged AMA from the ED
between 1/1/2012 and 1/1/2013 was done.
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.
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).