Unexpected Admissions and Patient-Directed Discharges - Understanding Trauma Patients: Scoping Review

Few studies have explored patient-directed discharges (PDDs), previously referred to as leaving against medical advice, in trauma patients, a unique patient population given the unanticipated nature of their injury and suddenness of hospital admission. This scoping review focuses on PDDs in trauma patients and aims to explore who may be at risk and what factors influence this decision.

A literature search was performed using five databases for publications between 1956 and 2023. Articles were included if they discussed admitted trauma patients who underwent a PDD and/or if they proposed why trauma patients choose to undergo a PDD. Articles that solely discussed PDDs from the emergency department were excluded as were PDDs for patients presenting with traumatic brain injuries. Studies were screened by two blinded independent reviewers with a third, tiebreaker reviewer if needed.

7931 articles were screened. Eleven (0.1%) articles were included. Demographic information associated with increased odds of PDD were as follows: younger age, lower socioeconomic status, and undomiciled. Those with substance use disorders and pre-existing psychiatric history had a higher rate of PDD. Stab and gunshot wounds, injuries to the upper and lower extremities and face were associated with increased odds of PDD. Hypotheses for PDDs were distrust in the health-care system, injury characteristics and workup (e.g., diagnostic testing versus direct therapeutic care), and impulsive decision-making secondary to substance intoxication or withdrawal.

Further research is required to better understand what interventions are successful for patients at risk of discharging themselves and implementation of these interventions.