Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return.

J Emerg Med. 2011 Oct;41(4):412-7

Authors: Jerrard DA, Chasm RM

Abstract
BACKGROUND: How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied.
OBJECTIVE: To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge.
METHODS: This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits.
RESULTS: A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6-71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9-91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7-82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6-33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5-64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9-25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8-8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician.
CONCLUSION: Patients who leave the ED AMA have significant pathology.

PMID: 20097503 [PubMed - indexed for MEDLINE]

Quantifying off-hour emergency physician coverage of in-hospital codes: a survey of community emergency departments.

J Emerg Med. 2011 Oct;41(4):381-5

Authors: Sherwin RL, Garcia AJ, Bilkovski R

Abstract
BACKGROUND: Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours.
OBJECTIVE: The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments.
METHODS: A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC.
RESULTS: Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60-242) and 11 (IQR 6-20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25K (IQR 14-40) and 5% (IQR 2-10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p<0.001), fewer ICU beds (12 vs. 27; p<0.001), and have a smaller ED annual volume (24 K vs. 39 K; p<0.001).
CONCLUSIONS: Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.

PMID: 21215553 [PubMed - indexed for MEDLINE]