Background
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Discharge against medical advice (DAMA), uncompleted emergency care and emergency department (ED) walk-outs, often without being seen by a medical professional (LWBS), occur in 1–3% of ED visits [1]. They present relevant and multi-faceted problems: With an increased risk for adverse health events, ED readmission and subsequent hospitalization [2‐4], DAMA and LWBS negatively impact patient safety, and also carry medicolegal and socioeconomic implications [5‐7]. Previous studies have identified a number of predictors for DAMA or LWBS. Besides male sex, younger age, low socioeconomic status, and substance abuse [8], other relevant factors include triage category, mode and time of arrival. Presentation during periods of high patient traffic has been found to increase the odds of patients leaving the ED prematurely, presumably due to longer waiting times [9‐11]. Door-to-doctor and other process times critically influence patient throughput, which is a major quality indicator for ED patient management [12]. Hence, a high prevalence may indicate that an institution’s ED patient flow and management requires review and improvement.
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Patients presenting with neurological complaints in the ED are often particularly challenging because signs or symptoms may be non-specific and the ensuing diagnostic and therapeutic implications may not be evident from the outset [13, 14]. For example, headache, the most common chief complaint among ED patients with neurological complaints [15], is frequently found among patients leaving against medical advice [1, 16]. While most headaches are of benign etiology, a small percentage of patients have a serious underlying cause warranting immediate medical attention [17]. In addition, neurological symptoms may manifest episodically in non-benign conditions, such as the waxing and waning course observable in patients with basilar artery thrombosis. This may theoretically lead patients to prematurely leave the ED due to intermittent symptom improvement and subsequent clinical deterioration may be brought to medical attention with relevant delay and potentially devastating consequences. To date, studies about DAMA and PL from the ED have not specifically focused on patients with neurological complaints, who have been identified to be at a high risk of leaving the ED prior to completion of care [1, 18]. In a retrospective analysis, we sought to investigate the characteristics of patients admitted to our interdisciplinary ED for neurological evaluation in order to identify factors associated with DAMA or uncompleted ED care in this group of patients compared to patients who were admitted or discharged.
Methods
Study design
Statistical analysis of neurological referrals to the interdisciplinary ED
Results
Disposition and demographics
Patients who signed to leave against medical advice (N = 161) or left before complete ED care without signing (N = 120); total N = 281 | Patients who were discharged or admitted (N = 5059) | p value* | |
---|---|---|---|
Demographics
| |||
age, mean (SD; IQR) | 44.1 (19.2; 28–57) | 56.9 (21.2; 39–76) |
< 0.001
|
< 30, N (%) | 84 (29.9%) | 825 16.3%) |
< 0.001
|
30–50, N (%) | 94 (33.5%) | 1104 (21.8%) |
< 0.001
|
50–70 N (%) | 71 (25.3%) | 1456 (28.8%) | 0.205 |
> 70, N (%) | 32 (11.4%) | 1674 (33.1%) |
< 0.001
|
sex, M, N (%) | 141 (50.2%) | 2442 (48.3%) | 0.535 |
living in local area, N (%) | 174 (61.9%) | 2986 (59.0%) | 0.336 |
living outside local area, N (%) | 93 (33.1%) | 1985 (39.2%) | 0.040 |
other, N (%) | 14 (5.0%) | 88 (1.7%) |
< 0.001
|
Time of ED presentation, N (%)
| |||
weekend | 73 (26.0%) | 1220 (24.1%) | 0.478 |
0 h–6 h | 22 (7.8%) | 475 (9.4%) | 0.381 |
6 h–12 h | 63 (22.4%) | 1425 (28.2%)) | 0.036 |
12 h–18 h | 129 (45.9%) | 1981 (38.9%) | 0.024 |
18 h–24 h | 67 (23.8%) | 1178 (23.3%) | 0.829 |
ED times in min, mean (SD; IQR)
| |||
door-to-doctor time | 43.0 (78.3; 8–36) | 38.7 (67.0; 6–40) | 0.32 |
ED length of stay | 264.6 (311.0; 140–320) | 260.4 (173.6; 132–347) | 0.69 |
Mode of presentation, N (%)
| |||
Self-presenting | 140/236 (59.3%) | 2055/5055 (40.7%) |
< 0.001
|
Emergency medical service (EMS) | 75/236 (31.8%) | 2481/5055 (49.1%) |
< 0.001
|
EMS with emergency physician | 21/236 (8.9%) | 518/5055 (10.2%) | 0.503 |
Presenting symptom according to Royl, 2010, N (%)
| |||
Ataxia/movement disorder | 2/221 (0.9%) | 60 (1.2%) | 1.000 |
Impaired consciousness | 7/221 (3.2%) | 238 (4.7%) | 0.288 |
Seizure | 41/221 (18.6%) | 560 (11.1%) |
0.001
|
Headache | 36/221 (16.3%) | 652 (12.9%) | 0.141 |
Other pain | 8/221 (3.6%) | 139 (2.7%) | 0.440 |
Motor deficit | 20/221 (9.0%) | 652 (12.9%) | 0.094 |
Confusion/amnesia | 7/221 (3.2%) | 279 (5.5%) | 0.131 |
Disturbed vision | 17/221 (7.7%) | 254 (5.0%) | 0.078 |
Sensory deficit | 34/221 (15.4%) | 426 (8.4%) |
< 0.001
|
Impaired language/speech/ swallowing | 12/221 (5.4%) | 491 (9.7%) | 0.034 |
Vertigo | 31/221 (14.0%) | 776 (15.3%) | 0.596 |
Other neurological complaint | 1/221 (0.5%) | 282 (5.5%) |
< 0.001
|
Non-neurological complaint | 5/221 (2.3%) | 250 (4.9%) | 0.076 |
Time and mode of presentation
Presenting symptoms
Detailed description of DAMA/PL patients
Patients who left the ED before the ED diagnostic work-up was complete (N = 156) | Patients who left the ED after complete ED diagnostic work-up (N = 125) | p value* | |
---|---|---|---|
Demographics
| |||
age, mean (SD; IQR) | 40.6 (17.1; 27–53) | 47.5 (20.2; 30–61) | 0.005 |
sex, M, N (%) | 72 (46%) | 70 (56%) | 0.12 |
ED times in mins, mean (SD; IQR)
| |||
door-to-doctor time | 81.5 (96.0; 15–122) | 41.8 (74.4; 8–40) |
< 0.001
|
ED length of stay | 116.8 (159.5; 0–199) | 275.2 (351.9; 147–321) |
< 0.001
|
Mode of presentation, N (%)
| |||
Self-presenting | 88/125 (73%) | 61 (49%) | 0.09 |
Emergency medical service (EMS) | 24/125 (20%) | 51 (41%) |
< 0.001
|
EMS with emergency physician | 8/125 (7%) | 13 (10%) | 0.18 |
Presenting symptom according to Royl, 2010, N (%)
| |||
Ataxia/movement disorder | 2/112 (1.8%) | 1 (0.8%) | 1.00 |
Impaired consciousness | 3/112 (2.7%) | 5 (4.0%) | 0.47 |
Seizure | 21/112 (18.8%) | 23 (18.4%) | 0.32 |
Headache | 32/112 (28.6%) | 10 (8.0%) | 0.004 |
Other pain | 6/112 (5.4%) | 2 (1.6%) | 0.31 |
Motor deficit | 4/112 (3.6%) | 17 (13.6%) |
0.001
|
Confusion/amnesia | 3/112 (2.7%) | 5 (4.0%) | 0.47 |
Disturbed vision | 8/112 (7.1%) | 10 (8.0%) | 0.46 |
Sensory deficit | 11/112 (9.8%) | 23 (18.4%) | 0.005 |
Impaired language/speech/swallowing | – | 12 (9.6%) |
< 0.001
|
Vertigo | 20/112 (17.9%) | 13 (10.4%) | 0.58 |
Other neurological complaint | – | 1 (0.8%) | 0.45 |
Non-neurological complaint | 2/112 (1.8%) | 3 (2.4%) | 0.66 |
Discharge diagnosis of DAMA/PL patients (in alphabetical order) | Frequency, N (%) |
---|---|
CNS demyelinating autoimmune disease | 6 (2.14) |
CNS tumour | 1 (0.36) |
Intracranial hemorrhage | 2 (0.71) |
Manifest ischemic stroke | 11 (3.91) |
Migraine and other headache | 40 (14.23) |
Movement disorder | 6 (2.14) |
Non-neurological disorder | 35 (12.46) |
Other neurological disorder | 28 (9.96) |
Peripheral nerve palsy | 6 (2.14) |
Seizure | 44 (15.66) |
Transient ischemic attack | 17 (6.05) |
Vertigo | 24 (8.54) |
Discussion
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We retrospectively studied records of patients discharged against medical advice or premature leave initially presenting with neurological complaints to an interdisciplinary ED, aiming to identify factors associated with irregular discharge in this group of patients. This issue has hitherto not been investigated in detail. We found a DAMA rate of 3% and a PL rate of 2%, which in addition to the observed predominance of younger age in the DAMA/PL subgroup is comparable to studies of unselected ED patient populations [1, 18, 19].
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Neurological conditions have been observed to carry a high risk of DAMA [18]. Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients in our investigation, and the latter two were significantly more prevalent in DAMA/PL compared to non-DAMA/PL patients. In our study population, more than half of DAMA/PL patients presenting with a seizure had a previously known epilepsy. Patients with known epilepsy and – in retrospect – typical seizures make up a considerable portion of ED admissions due to seizures [20]. Limited access to relevant information on scene regarding whether a seizure was typical or whether it may have been secondary to some condition requiring immediate medical attention as well as the lack of formal non-conveyance criteria often impact the decision of emergency medical service (EMS) staff to err on the side of safety and transport a patient to hospital [21, 22]. As a consequence, incongruencies regarding the perceived necessity for ED presentation between patients and EMS or ED personnel may be one factor contributing to DAMA/PL in this subgroup of patients. Such differences in perception and evaluation may also underlie the higher proportion of patients with sensory deficits leaving DAMA/PL. While they may indicate a serious underlying pathology, it can be hypothesized that sensory deficits are less functionally impeding or less noticeable to other people than neurological deficits such as dysarthria, motor deficits or gait ataxia. Accordingly, patients with sensory deficits may wish to leave the ED despite the need for further in-hospital work-up or monitoring. The large proportion of DAMA/PL patients presenting with headache, which also rated among the top ten DAMA diagnoses in a general population [1], presumably reflects – at least in part – the fact that headache, in most cases in the context of a primary headache disorder and thus of benign etiology [23], is the most prevalent neurological symptom in the ED [15].