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BMC Emergency Medicine

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Open Access 01-12-2019 | Care | Research article

Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review

Authors: Carolin Hoyer, Patrick Stein, Angelika Alonso, Michael Platten, Kristina Szabo

Published in: BMC Emergency Medicine | Issue 1/2019

Abstract

Background

Uncompleted emergency department care and against-medical-advice discharge represent relevant medical problems with impact on patient safety and potential medicolegal and socioeconomic consequences. They may also indicate structural or procedural problems in the emergency department (ED) relating to patient management and flow. While patients with neurological complaints frequently leave the ED against medical advice or without being seen, no dedicated analysis of this group of patients aiming at the identification of characteristics associated with irregular ED discharge has been performed so far.

Methods

A chart review was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017 for neurological evaluation. Demographics, mode of presentation, process times, presenting symptoms and diagnosis were recorded. Patients leaving against medical advice after an informed consent discussion and signing of documentation (DAMA) or leaving prematurely without notifying ED staff (PL) were compared to the total of patients who were admitted or discharged (non-DAMA/PL).

Results

Of all patients presenting with neurological symptoms or complaints, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p < .001), and they were more frequently self-presenting (p < 0.001). Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the duration of door-to-doctor time.

Conclusions

Younger age, self-presenting mode of presentation and presentation with headache, seizures or sensory deficits are associated with premature leave or against-medical-advice discharge of patients with neurological complaints from the ED, and long waiting times were given as the major reason for leaving the ED. Increasing ED staff’s awareness of these factors and the optimization of pre-hospital assessment and demand management, thereby positively impacting on patient flow and ED process times, may help to prevent irregular discharges from the ED.

Ding R, Jung JJ, Kirsch TD, et al. Uncompleted emergency department care: patients who leave against medical advice. Acad Emerg Med. 2007;14:870–6. https://doi.org/10.1197/j.aem.2007.06.027.CrossRefPubMed

Dubow D, Propp D, Narasimhan K. Emergency department discharges against medical advice. J Emerg Med. 1992;10:513–6.CrossRef

Garland A, Ramsey CD, Fransoo R, et al. Rates of readmission and death associated with leaving hospital against medical advice: a population-based study. CMAJ. 2013;185:1207–14. https://doi.org/10.1503/cmaj.130029.CrossRefPubMedPubMedCentral

Geirsson OP, Gunnarsdottir OS, Baldursson J, et al. Risk of repeat visits, hospitalisation and death after uncompleted and completed visits to the emergency department: a prospective observation study. Emerg Med J. 2013;30:662–8. https://doi.org/10.1136/emermed-2012-201129.CrossRefPubMed

Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56:325–7.PubMed

Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899–902. https://doi.org/10.1176/appi.ps.51.7.899.CrossRefPubMed

Yong TY, Fok JS, Hakendorf P, et al. Characteristics and outcomes of discharges against medical advice among hospitalised patients. Intern Med J. 2013;43:798–802. https://doi.org/10.1111/imj.12109.CrossRefPubMed

Alfandre DJ. ‘I'm going home’: discharges against medical advice. Mayo Clin Proc. 2009;84:255–60. https://doi.org/10.1016/S0025-6196(11)61143-9.CrossRefPubMedPubMedCentral

Ashrafi E, Nobakht S, Keykaleh MS, et al. Discharge against medical advice (DAMA): Causes and predictors. Electron Physician. 2017;9:4563–70. https://doi.org/10.19082/4563.CrossRefPubMedPubMedCentral

10.

Crilly J, Bost N, Thalib L, et al. Patients who present to the emergency department and leave without being seen: prevalence, predictors and outcomes. Eur J Emerg Med. 2013;20:248–55. https://doi.org/10.1097/MEJ.0b013e328356fa0e.CrossRefPubMed

11.

van der Linden MC, Lindeboom R, van der Linden N, et al. Walkouts from the emergency department. Eur J Emerg Med. 2014;21:354–9. https://doi.org/10.1097/MEJ.0000000000000086.CrossRefPubMed

12.

Casalino E, Choquet C, Bernard J, et al. Predictive variables of an emergency department quality and performance indicator: a 1-year prospective, observational, cohort study evaluating hospital and emergency census variables and emergency department time interval measurements. Emerg Med J. 2013;30:638–45. https://doi.org/10.1136/emermed-2012-201404.CrossRefPubMed

13.

Moeller JJ, Kurniawan J, Gubitz GJ, et al. Diagnostic accuracy of neurological problems in the emergency department. Can J Neurol Sci. 2008;35:335–41. https://doi.org/10.1017/S0317167100008921.CrossRefPubMed

14.

Newman-Toker DE, Perry JJ. Acute diagnostic neurology: challenges and opportunities. Acad Emerg Med. 2015;22:357–61. https://doi.org/10.1111/acem.12614.CrossRefPubMed

15.

Royl G, Ploner CJ, Möckel M, et al. Neurological chief complaints in an emergency room. Nervenarzt. 2010;81:1226–30. https://doi.org/10.1007/s00115-010-3020-x.CrossRefPubMed

16.

Shirani F, Jalili M, Asl-E-Soleimani H. Discharge against medical advice from emergency department: results from a tertiary care hospital in Tehran, Iran. Eur J Emerg Med. 2010;17:318–21. https://doi.org/10.1097/MEJ.0b013e3283334ef1.CrossRefPubMed

17.

Goldstein JN, Camargo CA, Pelletier AJ, et al. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26:684–90. https://doi.org/10.1111/j.1468-2982.2006.01093.x.CrossRefPubMed

18.

Lee CA, Cho JP, Choi SC, et al. Patients who leave the emergency department against medical advice. Clin Exp Emerg Med. 2016;3:88–94. https://doi.org/10.15441/ceem.15.015.CrossRefPubMedPubMedCentral

19.

Blake DF, Dissanayake DB, Hay RM, et al. ‘Did not waits’: a regional Australian emergency department experience. Emerg Med Australas. 2014;26:145–52. https://doi.org/10.1111/1742-6723.12223.CrossRefPubMed

20.

Girot M, Hubert H, Richard F, et al. Use of emergency departments by known epileptic patients: an underestimated problem? Epilepsy Res. 2015;113:1–4. https://doi.org/10.1016/j.eplepsyres.2015.02.017.CrossRefPubMed

21.

Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emerg Med J. 2013;30:236–40. https://doi.org/10.1136/emermed-2011-200388.CrossRefPubMed

22.

Noble AJ, Snape D, Goodacre S, et al. Qualitative study of paramedics' experiences of managing seizures: a national perspective from England. BMJ Open. 2016;6:e014022. https://doi.org/10.1136/bmjopen-2016-014022.CrossRefPubMedPubMedCentral

23.

Locker T, Mason S, Rigby A. Headache management--are we doing enough? An observational study of patients presenting with headache to the emergency department. Emerg Med J. 2004;21:327–32. https://doi.org/10.1136/emj.2003.012351.CrossRefPubMedPubMedCentral

24.

Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28:1657–62. https://doi.org/10.1007/s11606-013-2540-z.CrossRefPubMedPubMedCentral

25.

Karagun O, Yesilagac H, Gulalp B, et al. What Can We Do to Improve Patient Satisfactıon in the Emergency Department? A Prospective Study in a Turkish University Hospital. Adv J Emerg Med. 2018;2:e41. https://doi.org/10.22114/AJEM.v0i0.94.CrossRefPubMedPubMedCentral

26.

Meade CM, Kennedy J, Kaplan J. The effects of emergency department staff rounding on patient safety and satisfaction. J Emerg Med. 2010;38:666–74. https://doi.org/10.1016/j.jemermed.2008.03.042.CrossRefPubMed

27.

Feuerwerker S, Rankin N, Wohler B, et al. Improving patient satisfaction by using design thinking: patient advocate role in the emergency department. Cureus. 2019;11:e3872. https://doi.org/10.7759/cureus.3872.CrossRefPubMedPubMedCentral

28.

Howard LM, Wessely S. Reappraising reassurance—the role of investigations. J Psychosom Res. 1996;41:307–11. https://doi.org/10.1016/S0022-3999(96)00164-X.CrossRefPubMed

29.

Howard L, Wessely S, Leese M, et al. Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry. 2005;76:1558–64. https://doi.org/10.1136/jnnp.2004.057851.CrossRefPubMedPubMedCentral

30.

Ridsdale L, Noble AJ, Nadeem F, et al. Headache: the patient's view. J Neurol Neurosurg;1. doi:https://doi.org/10.19104/jnn.2014.94

31.

Topka H, Pfefferkorn T, Andres F, et al. Online survey of the organizational structures of emergency neurology in Germany. Nervenarzt. 2017;88:625–34. https://doi.org/10.1007/s00115-017-0343-x.CrossRefPubMed

32.

Harenberg L, Oßwald HM, Jaschonek H, et al. Self-assessment of treatment urgency on presentation to a neurological emergency department : results of a patient survey. Nervenarzt. 2018;01:126–8. https://doi.org/10.1007/s00115-018-0623-0.CrossRef

33.

Peterson CL, Walker C, Coleman H. I hate wasting the hospital“s time”: experiences of emergency department admissions of Australian people with epilepsy. Epilepsy Behav. 2019;90:228–32. https://doi.org/10.1016/j.yebeh.2018.11.018.CrossRefPubMed

34.

Sørensen K, Pelikan JM, Röthlin F, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Pub Health. 2015;25:1053–8. https://doi.org/10.1093/eurpub/ckv043.CrossRef

35.

Fleisher J, Bhatia R, Margus C, et al. Health literacy and medication awareness in outpatient neurology. Neurology. 2014;4:71–81. https://doi.org/10.1212/01.CPJ.0000436211.73013.ab.CrossRefPubMed

Title: Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review
Authors: Carolin Hoyer
Patrick Stein
Angelika Alonso
Michael Platten
Kristina Szabo
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Care
Headache
Published in: BMC Emergency Medicine / Issue 1/2019
Electronic ISSN: 1471-227X
DOI: https://doi.org/10.1186/s12873-019-0273-y

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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