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Discharge against medical advice among pediatric patients: A retrospective study from a Saudi tertiary emergency
Bedoor H Al Qadrah1, Elaf A AlShammari1, Atheer M AlJeraibah1
1From the Department of Pediatrics (Al Qadrah, AlShammari, AlJeraibah, AlDabas, AlQahtani, AlMojali, Alsharif, AlYahya) and From Department of Nursing, Pediatric Emergency Department (AlGhamdi), King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City; and from the King Abdullah International Medical Research Center (Al Qadrah, AlShammari, AlJeraibah, AlDabas, AlQahtani, AlMojali, Alsharif, AlYahya, AlGhamdi), Ministry of the National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.
Insights
Discharge against medical advice (DAMA) in pediatric emergency rooms affects 0.52% of visits, with long waits being a key reason. Infants and children with infections are at higher risk for ER revisits after DAMA.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Management
- Patient Safety
Background:
- Discharge against medical advice (DAMA) represents a significant challenge in pediatric emergency care settings.
- Understanding the factors contributing to DAMA and subsequent revisits is crucial for improving patient outcomes and healthcare system efficiency.
Purpose of the Study:
- To determine the incidence of DAMA in a Saudi Arabian pediatric emergency department.
- To identify parental reasons for DAMA and predictors of emergency room revisits following DAMA.
- To inform targeted interventions for reducing DAMA rates and associated risks.
Main Methods:
- A retrospective cohort study was conducted at a tertiary care hospital from January 2020 to December 2024.
- Included were pediatric patients aged 0-14 years who signed DAMA during ER visits.
- Data collected included demographics, diagnoses, reasons for DAMA, and 30-day ER revisit outcomes.
Main Results:
- DAMA occurred in 0.52% of 446,251 ER visits, with caregiver availability and long waiting times cited as primary reasons.
- Over 24% of DAMA patients revisited the ER within 30 days, with 33.9% requiring hospitalization.
- Higher revisit risk was observed in children under 2 years and those with infectious conditions.
Conclusions:
- DAMA is a notable issue in pediatric emergency care, necessitating focused strategies for reduction.
- Interventions should target high-risk populations, such as infants and children with infections.
- Enhancing hospital efficiency, caregiver education, and discharge policies can mitigate DAMA rates and improve patient safety.
Objectives:
To investigate the incidence, parental reasons, and predictors of emergency room (ER) revisits following discharge against medical advice (DAMA) in a pediatric center in Saudi Arabia.
Methods:
This retrospective cohort study was conducted between January 2020 and December 2024 at a tertiary care hospital. Pediatric patients aged 0-14 years who signed the DAMA during ER visits were included. Medical records of patients with DAMA were reviewed to collect demographic data, diagnoses, reasons for DAMA, and outcomes.
Results:
Among 446,251 ER visits, 2,336 (0.52%, 95% CI: 0.50%-0.55%) involved caregiver-signed DAMA. These rates ranged from 0.45% (2020) to 0.69% (2023). The majority were Saudi (98.8%), male (55.3%), and under the age of 2 (43.5%). Most patients were triaged three/urgent (63.9%), with infections being the most frequent presenting complaint (52.8%). The documented reasons for DAMA included long waiting times (41.6%) and issues with caregiver availability (18.9%). Within 30 days, 567 patients (24.3%, 95% CI: 22.3%-26.3%) revisited the ER; of these, 33.9% required hospitalization. DAMA was associated with higher revisit risk in children <2 years (OR=1.23, 95% CI: 1.01-1.50) and those presenting with infectious symptoms (OR=1.43, 95% CI: 1.17-1.75).
Conclusion:
DAMA is a significant challenge in pediatric emergency care. Targeted interventions are crucial for reducing DAMA rates, particularly among high-risk infants and children with infections. Hospitals can improve outcomes by enhancing efficiency, caregiver education, and policies to prevent premature discharge.
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