ABSTRACT
BACKGROUND: Discharge against medical advice (AMA) increases the risk of 30-day readmission and 90-day mortality. The percentage of patients leaving AMA ranges between 1-2% and varies by hospital location with rural and community-based hospitals reporting lower rates (0.6%) than urban centers (13%). Factors associated with leaving AMA include substance use disorders, mental health illness, male sex, younger age, low socioeconomic status, mental illnesses, and having Medicaid or no health insurance. Fewer studies report on the association between hospital characteristics such as nurse: patient staffing ratios and communication practices of healthcare providers that may also impact AMA discharges. To investigate hospital level variables that may relate to AMA discharges, we first sought to describe AMA discharges over time at a large health care system and over the course of the COVID-19 pandemic. METHODS: This is a retrospective description of all patients who left AMA from seventeen hospitals belonging to a single Midwestern healthcare organization between January 2016 and November 2021. Rates of AMA discharges are described as the number of discharges that were AMA divided by all discharges. The protocol was reviewed and approved by the local IRB. RESULTS: All seventeen hospitals showed an increase in the proportion of AMA discharges over the study period. Overall, the percentage of AMA discharges increased from 0.81% in 2016 reaching a peak of 1.9 % in April 2020 . Urban, academic sites showed larger increases than community sites. Among females, we noted a bimodal age distribution in those who left AMA with a first peak in patients between 25 and 30 years and a second peak from 65 to 70 years. In males, the percentage of AMA discharges peaked at age 60-65 years. The percentage of AMA discharges was highest among Black patients. CONCLUSIONS: This preliminary analysis shows that rates of AMA discharges have progressively increased in the last five years with different patterns between urban and rural sites, age distribution between sexes and with higher rates among Black patients. The current analysis does not allow us to explain these findings, but we hypothesize that increased inpatient census, decreased RN to patient ratios and additionally increased work stress especially since the onset of COVID-19 pandemic may have played a role. We plan further detailed review to understand these trends and find solutions.
ABSTRACT
Purpose/Aims Healthcare workers internationally continue to look for innovative ways to improve patient outcomes and optimize resource utilization during the coronavirus disease 2019 (COVID-19) pandemic. Proning awake, nonintubated patients has been suggested as a potential intervention in critical care. The aim of this study is to provide a multidisciplinary approach to safely perform awake self-prone positioning in the acute care setting. Design This is a prospective, descriptive study. Method Patients with COVID-19 were screened and enrolled within 48 hours of a positive test. After approval from the primary team, patients were provided education materials by a multidisciplinary team on the self-prone intervention. Visual cues were placed in the room. Patients were requested to maintain a diary of hours of prone positioning. Patients' baseline characteristics, admission vitals, daily oxygen requirements, and level of care were collected. Results Of 203 patients screened, 31 were enrolled. No pressure-related injury or catheter (intravenous or urinary) displacement was identified. Eighty-one percent of patients spent less than 8 hours a day in prone positioning. Among patients enrolled, none required invasive ventilation or died. Conclusions Awake self-proning can be performed safely in patients given a diagnosis of COVID-19 in the acute care setting with a multidisciplinary team.