Association of Emergency Department and Medical-Surgical Nurse Staffing on Patient Departures Against Medical Advice

A patient departure against medical advice is an adverse event driven by patient care dissatisfaction and is associated with higher odds of hospital readmissions and death. Given evidence that better hospital nursing resources are associated with improved patient satisfaction, we evaluated whether nurse staffing ratios are associated with rates of emergency department patient departures against medical advice.

Cross-sectional design using data from 3 sources: 2023 Penn Nurses4All survey, the 2023 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Emergency Department Database of patient emergency department visits in New Jersey and Oregon, and the American Hospital Association Annual Survey. Patient-to-nurse staffing ratios were measured among direct care nurses in emergency departments and medical-surgical units. Logistic regression models were constructed with nurses and patients clustered within hospitals, with adjusted models accounting for patient and hospital characteristics.

The sample included 2,211,244 emergency department patient visits in 74 hospitals. After adjusting for patient and hospital characteristics, each additional patient added to an emergency department and a medical-surgical nurse's workload was associated with 19% and 55% higher odds of an against medical advice departure, respectively (emergency department, adjusted odds ratio, 1.19; 95% CI, 1.09-1.31; P < .001; medical-surgical, adjusted odds ratio, 1.55; 95% CI, 1.33-1.81; P < .001).

Increases in nurses' workloads, both in the emergency department and inpatient setting, were associated with more emergency department patients leaving against medical advice. When nurses care for more patients at a time, patients are attended to less frequently, which can result in more self-directed patient departures. Insufficient staffing in medical-surgical units contributes to longer length of stay and lower inpatient bed turnover. Hospital investments in safer staffing may reduce against medical advice departures.