Mean age of patients with neurological complaints was One-hundred and twenty-five patients Other reasons given were: symptom improvement either spontaneously two patients or because of analgesia administered in the ED one patient , need to care for family members six patients , preferred treatment in a different hospital closer to home four patients , need to go to work and other urgent appointment one patient each. While in 61 cases In 23 of 41 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. Neurological conditions have been observed to carry a high risk of DAMA [ 18 ]. 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 ].
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. First, there are individual reasons such as personal or professional commitments perceived as conflicting with a hospital admission or preference of a different hospital.
The recognition of these factors and proactive communication guided by principles of shared decision-making between patients and physicians are among the strategies suggested to reduce or prevent premature and irregular patient discharges [ 8 , 24 ]. Moreover, interventions such as increased rounding frequency of ED nurses and doctors [ 25 , 26 ] or establishing patient advocates in the ED [ 27 ] improve patient satisfaction in the emergency room, which in turn has been shown to reduce rates of patients who leave without being seen or against medical advice [ 26 ].
Long waiting times represent a main reason to prematurely leave the ED [ 11 ] that certainly contains a patient-related aspect, but they also indicate structural insufficiencies in prehospital assessment in particular: in recent years, EDs have been dealing with increasing numbers of patients with neurological complaints [ 31 ], many of whom present with non-urgent complaints but nonetheless consider themselves in need of urgent medical evaluation [ 32 ].
Inappropriate utilization of ED resources promotes overcrowding and negatively impacts on both door-to-doctor times as well as ED length of stay. Consequently, a structured evaluation for treatment urgency for patients with neurological complaints is needed, all the more so because neurological symptoms are not adequately represented in current triage systems.
Interdisciplinary EDs may benefit from a dedicated emergency neurology nurse overseeing patient management in co-operation with the neurologist on-call, and may, in particular, redirect patients with non-urgent complaints towards alternative care providers before they actually enter the ED. Moreover, limited health literacy poses a relevant challenge for health practices and policies [ 34 ], maybe even more so in light of the complexities of many neurological disorders [ 35 ].
Among others, campaigns directed to patients and families to increase knowledge about alternative care providers from the ED may aid in improving demand management. Our study has several limitations. To begin with, as a retrospective chart review, it critically rests on the completeness and accuracy of medical records.
Particularly in PL patients, documentation is often incomplete. In DAMA patients, a more complete and detailed investigation into motivations for leaving would be informative. DAMA patients left after an informed consent discussion but PL patients did not, so this may have an impact on the likelihood of readmission and risks associated with leaving the hospital. Hence, it was not always clear whether a complete evaluation would have resulted in admission or discharge.
Moreover, discharge diagnoses will certainly be imprecise or tentative in those cases where patients left before ED work-up was complete. Finally, information regarding ED visits and admissions to other hospitals or treatments in outpatient settings and other outcome information is lacking.
Accordingly, prospective investigations including follow-up assessment, e. We identified younger age and self-presenting mode of presentation as well as presentation with headache, seizures — in the majority of cases in a known history of epilepsy — or sensory deficits as being associated with irregular discharge of patients with neurological complaints from the ED.
ED staff should be aware of these factors in order to apply adequate communicative and procedural strategies for the prevention of ED premature or against-medical-advice discharge. Long waiting times as the main reason for irregular leave from the ED point towards systemic insufficiencies in the pre-hospital assessment of patients with neurological complaints as well as a lack of alternative care providers. Uncompleted emergency department care: patients who leave against medical advice.
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