Patients in a private hospital in India leave the emergency department against medical advice for financial reasons

The Role of Triple Rule-out CT in an Indian Emergency Setting

Background

Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way.

Materials and methods

Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings.

Results

Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv).

Conclusion

Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases.

How to cite this article

Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

Stakeholder engagement as a strategy to enhance palliative care involvement in intensive care units: A theory of change approach

BACKGROUND

Adult patients admitted to intensive care units in the terminal phase experience high symptom burden, increased costs, and diminished quality of dying. There is limited literature on palliative care engagement in ICU, especially in lower-middle-income countries. This study explores a strategy to enhance palliative care engagement in ICU through a stakeholder participatory approach.

METHODS

Theory of Change approach was used to develop a hypothetical causal pathway for palliative care integration into ICUs in India. Four facilitated workshops and fifteen research team meetings were conducted virtually over three months. Thirteen stakeholders were purposively chosen, and three facilitators conducted the workshops. Data included workshop discussion transcripts, online chat box comments, and team meeting minutes. These were collected, analysed and represented as theory of change map.

RESULTS

The desired impact of palliative care integration was good death. Potential long-term outcomes identified were fewer deaths in ICUs, discharge against medical advice, and inappropriate admissions; increased referrals to palliative care; and improved patient and family satisfaction. Twelve preconditions were identified, and eleven key interventions were developed. Five overarching assumptions related to contextual factors influencing the outcomes of interventions.

CONCLUSION

Theory of change framework facilitated the identification of proposed mechanisms and interventions underpinning palliative care integration in ICUs.

Analysis of Reasons for Orthopaedic Walkouts from the Emergency Department in a Private Tertiary Care Centre

Introduction:

A small proportion of patients presenting to the Emergency department (ED) of any hospital tend to take discharge against medical advice (DAMA) due to several patient related or hospital/service related reasons. Amongst these, orthopaedic patients are a special group due to their inability to mobilise independently due to injuries and have treatment needs which involve higher costs. The aim of the current study was to ascertain and analyse the reasons for orthopaedic walkouts at a tertiary care new private hospital.

Materials and Methods:

This retrospective telephonic structured interview-based study was carried out on all orthopaedic patients taking DAMA during a one-year period from July 2016 to June 2017. They were telephonically interviewed with a structured questionnaire. Hospital and ED records were analysed for demographic as well as temporal characteristics.

Results:

A total of 68 orthopaedic patients walked out of casualty against medical advice out of a total 775 (8.77%) orthopaedic patients presenting during the period as against 6.4% overall rate of DAMA for all specialties. The main reasons for DAMA were financial unaffordability of treatment (36.7%), preference for another orthopaedic surgeon (22%) and on advice of the patient’s General Practitioner (16.1%).

Conclusion:

Unaffordability of treatment is a significant cause for walkouts amongst orthopaedic patients. Private hospitals need to recognise and implement processes by which these patients can be treated at affordable costs and with coverage either by medical insurance or robust charity programs. Patient education and awareness are important to encourage them to have insurance coverage.

Cases of Left Against Medical Advice from the Emergency Department of a Tertiary Care Hospital in Kathmandu: A Descriptive Cross-Sectional Study

Introduction:

Left against medical advice is a worldwide phenomenon. Patients leaving against Left against medical advice does not provide the health professionals from legal impunity. A well-informed consent should be present with surety that they are well understood by the patient before they leave. The study was undertaken to study the prevalence of patients that leave against medical advice in a tertiary care center.

Methods:

This is a descriptive cross-sectional study done in the emergency department of a tertiary care hospital from 1^st February 2020 to 31^st July 2020. Ethical approval was taken from the Institutional Review Committee (ref. no. 130120205). The sample size was calculated and the convenient sampling method was used. Data were analyzed in the Statistical Package of the Social Sciences version 22. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Out of 5834 visits, 332 (5.96%) (4.70-7.22 at 95% Confidence Interval) patients left against medical advice. The mean age was 36.48 years (3 days-91 years) and males 173 (52.3%) were prone to leave than females. Only 50 (15.1%) cases had well-informed consent with complications documented. Hundred (30.5%) patients had wanted to come on follow up the next day in the out-patient department while 41 (12.4%) had to leave because of financial reasons. Only seven (2.9%) of well-oriented patients gave their consent and the remaining 233 (97.1%) was by the kin present. Only 76 (23%) patients were sent home with a well-documented medicine prescription.

Conclusions:

The proportion of patients who left against medical advice was more than the studies done in the similar setting.

Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study

Background:

In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country.

Methods:

This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019.

Results:

There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20–29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001).

Conclusion:

The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.

The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India

INTRODUCTION

Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS.

METHODS

We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents.

RESULTS

Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful.

CONCLUSIONS

Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India's ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.

Presenting complaints and mortality in a cohort of 22 000 adult emergency patients at a local hospital in Nepal

Background

There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal.

Methods

Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days.

Results

In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%).

Conclusions

Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.

Contra Consilium Medicinae: A Strange Malady Affecting Indian Healthcare!!

How to cite this article: Pandit RA, Kulkarni AP. Contra Consilium Medicinae: A Strange Malady Affecting Indian Healthcare!!. Indian J Crit Care Med 2019;23(3):113-114.

Retrospective Evaluation of Patients Leaving against Medical Advice in aTertiary Care Teaching Hospital

Background

Leaving against medical advice (LAMA) is a worldwide healthcare problem, occurring due to various contributing factors, seen more commonly indeveloping countries like ours.

Aim

To retrospectively study the prevalence of LAMA along with its affectingfactors.

Methods

We screened the hospital record of a tertiary care teaching hospital forone year, after obtaining approval from the institutional ethicalcommittee. Patient demography, disease characteristics and status at thetime of LAMA were noted and statistically analysed.

Results

During the study period, 4.95% patients took LAMA. The mean age was 47.2±21years (range newborn to 103 years) with 2:1 Male: Female ratio. Forty ninepercent of patients resided in rural areas and around 1/3rd were dependenton others for their living. The mean length of stay in hospital was 6.1±9.3days. Around 60% patients required mechanical ventilation and 51% patientshad been explained guarded prognosis. About 53% of patients taking LAMAwere admitted in medical wards, trauma being the most common diagnosis(17.2%). History of alcohol abuse and poisoning with suicidal intent wasseen in 11.47% and 3.9%, respectively.

Conclusion

The number of patients taking LAMA from our country is quite high. This necessitates formulation and implementation of strategies to reduce the prevalence of LAMA discharges like further investigations to look into the causes contributing to patients taking LAMA, attending to substance abuseissues, recognizing psychological factors and strengthening the socialsystems, encouraging insurance cover, helping patients’ treatment expensesthrough charity care and optimizing healthcare delivery and patient centredpolicies.

Key messages

LAMA is a global health issue precipitated by unemployment and alcohol abuse, commonly taken due to financial reasons. This necessitates a strong social system and national health insurance schemes to reduce the cost of treatment.

How to cite this article

Mahajan RK, Gautam PL, et al. Retrospective Evaluation of Patients Leaving against Medical Advice in a Tertiary Care Teaching Hospital. IndianJ Crit Care Med 2019;23(3):139-142.

Patients Leaving Against Medical Advice-A National Survey

Background

Leaving against medical advice (LAMA) is a common health concern seen worldwide. It has variable incidence and reasons depending upon disease, geographical region and type of health care system.

Materials and methods

We approached anesthesiologists and intensivists for their opinion through ISA and ISCCM contact database using Monkey Survey of 22 questions covering geographical area, type of healthcare system, incidence, reasons, type of disease, expected outcome of LAMA patients etc.

Results

We received only 1154 responses. Only 584 answered all questions. Out of 1154, only 313 respondents were from government medical colleges or hospitals while remaining responses were from private and corporate sector. Most hospitals had >100 beds. ICUs were semi-closed and supervised by critical-care physicians. LAMA incidence was maximum from ICU (45%) followed by ward (32%) and emergency (25%). Most patients of LAMA had ICU stay for >1 week (60%). Eighty percent of the respondents opined that financial constraints are the most common reason of LAMA. Unsatisfactory care was rarely considered as a factor for LAMA. Approximately 40% patients had advanced malignancy or disease. Nearly 2/3rd strongly believed that insurance cover may reduce the LAMA rate.

Conclusion

Most patients get LAMA from the ICU after a stay of week. Financial constraints, terminal medical illness, malignancy and sepsis are major causes of LAMA. Remedial methods suggested to decrease the incidence include a good national health policy by the state; improved communication between the patient, caregivers and heathcare team; practice of palliative and end-of-life care support; and lastly, awareness among the people about advance directives.

How to cite this article

Paul G, Gautam PL et al. Patients Leaving Against Medical Advice-A National Survey. Indian J Crit Care Med 2019;23(3):143-148.

Pattern and outcomes of paediatric medical admissions at the Living Word Mission Hospital, Aba, South East Nigeria

INTRODUCTION

There is a decline in child mortality rate globally, courtesy of the erstwhile Millennium Development Goals. However, under-five mortality is still high in the African sub-regions. The need to review the morbidity and mortality pattern among children admitted into private health settings, where 60% of the medical conditions of the masses are being attended to in the sub-regions, cannot be overemphasized. This study aimed at documenting the morbidity pattern and outcomes of admissions among children admitted into the Living Word Mission Hospital (LWMH), Aba, Nigeria.

METHODS

This was a retrospective descriptive study over a 3 year period. The study population comprised of all children aged 1 month to 15 years that were admitted into the pediatric wards of the Living Word Mission Hospital, Aba, Nigeria. The age, gender, diagnoses and disease outcome of these patients, were all retrieved from the pediatric ward registers and hospital medical records. The data were analyzed using SPSS, version 20.0.

RESULTS

There were 2278 pediatric medical cases admitted over the study period. Males were 1364 and females were 914, giving a male: female ratio of 1.5:1. More than 90% of these patients were aged < less than 5 years. Severe malaria (31.1%), septicaemia (16.6%), bronchopneumonia (15.4%), uncomplicated malaria (11.9%), acute watery diarrhea (10.5%) and meningitis (3.7%) were the leading causes of admission. Mortality rate was 5.7%, with 87.5% of these deaths occurring in under-fives. Septicaemia (34.6%) and Severe malaria (23.2%) were the leading causes of death.

CONCLUSION

There is a high rate of paediatric admissions at Living Word Hospital, Aba. The under-five population remains a vulnerable group to both childhood morbidity and mortality. Septicaemia, malaria, bronchopnuemonia and acute watery diarrhoea were the leading causes of morbidity and mortality. Childhood mortality at LWMH is lower than observed in most government hospitals in Nigeria.

What Happens to Patients Discharged Against Medical Advice?

Introduction

Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days.

Methods

This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up.

Results

Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were - wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%).

Conclusion

A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.

Retrospective Evaluation of Patients Who Leave against Medical Advice in a Tertiary Teaching Care Institute

Context:

Discharge against medical advice or leave against medical advice (DAMA or LAMA) is a global phenomenon. The magnitude of LAMA phenomenon has a wide geographical variation. LAMA reasons are an area of concern for all involved in health-care delivery system.

Aims and Objectives:

The study aimed to evaluate cases of LAMA retrospectively in a tertiary teaching care institute (1) to find the magnitude of LAMA cases (2) to evaluate demographic and patient characteristics of these cases.

Subjects and Methods:

We screened hospital record of a referral institute over 1 year after approval from IEC and ICMR, New Delhi. Patient demographics and disease characteristics were noted and statistically analyzed after compilation.

Results:

A total of 47,583 patients were admitted in the year 2015 through emergency and outpatient department. One thousand five hundred and fifty-six (3.3%) patients got DAMA. The mean age of patient excluding infants was 46.64 ± 20.55 years. There were 62.9% of males. Average hospital stay of these cases was 4.09 ± 4.39 days. Most of the patients (70%) belonged to medical specialties and had longer stay as compared to surgical specialties. Most of LAMA patients were suffering from infections, trauma, and malignancies. Most of the patients had LAMA from ward (62%) followed by Intensive Care Unit (ICU) (28.8%) and emergency (9.2%). In 592 (38%) of LAMA patients, the reason for leaving was not clear. The common cited reasons for LAMA were financial (27.6%) and poor prognosis (20.5%).

Conclusions:

About 3.3% of patients left hospital against medical advice in our retrospective analysis. Most of these cases did so from ward followed by ICU. Financial reasons and expected poor outcome played a significant role.

Discharge against medical advice (DAMA): Causes and predictors

Background and aim

DAMA is a result of patient dissatisfaction, which increases the rate of readmission, mortality, and complications. In this study, the causes and predictors of DAMA in Shahid Labbafinejad Hospital of Tehran were determined.

Methods

The descriptive and analytical study was conducted in 2016 from the information of 1,168 hospitalized patients in the period of 2015 and the first half of 2016. Patients’ information was collected using checklists and through clinical records, nursing unit reports, and telephone calls. The collected data were analyzed using SPSS-v18 software and by employing chi-square test and logistic regression modeling.

Results

The DAMA rate was estimated at 3.27%. Among the causes of DAMA, the high rates were related to personal problems (39.04%) and going to other centers (34.93%), and the lowest level was related to dissatisfaction with the physician (3.08%). Age groups (19–37, OR=2.17), (38–56 years, OR=1.70), and (57–75, OR=1.62), gender (male, OR=1.47), locations (Tehran city, OR=0.61) and (Tehran Province, OR=0.63) were predictors of DAMA (p<0.05).

Conclusions

The importance of DAMA requires practical measures such as creating a suitable environment for patients, providing consulting services for youth, improving staff relations, providing assistance for patients in need, and removing accommodation problems of patients and their companions to reduce the DAMA.