Large numbers of patients attending accident and emergency (A&E) departments drive to and from the consultation. This audit set out to examine if patients attending A&E were advised about their fitness to drive.
The authors carried out a retrospective audit over a one month period. The Driver and Vehicle Licensing Authority (DVLA) booklet “At a glance guide to the current medical standards of fitness to drive” was used to derive a list of conditions that require driving restrictions. Any condition within these guidelines was audited. If the patient was discharged and diagnosed as having a condition requiring the patient to cease driving, the notes were scrutinised for any evidence that the doctor had given advice about driving.
A total of 337 patients were discharged with conditions which may have required some restrictions to driving; 332 sets of notes were available. Twenty two patients needed restrictions to be placed on their driving. Only one patient had any documented evidence of the examining doctor informing them of restrictions to be placed on driving.
The study provides clear evidence that patients were not being informed about their fitness to drive following consultation in the authors' A&E department. Previous studies have shown that doctors' knowledge on driving restrictions is poor. Further education is needed for A&E doctors and patient information leaflets should be provided to explain the restrictions placed on a driver's licence if they have certain illnesses.
accident and emergency; DVLA, driving; patients; restrictions
Patients who leave the hospital before clinician certification of fitness are referred to as discharge against medical advice (DAMA). This phenomenon of discharges against medical advice is an undesirable but relatively common occurrence worldwide. Professional liability and harmful effect of this practice to individual health are of concern.
The essence of this study is to determine the spectrum of patients who DAMA in a Nigerian teaching hospital.
Descriptive study over a two-year period in an urban teaching hospital in Nigeria.
Materials and methods
All consecutive patients who discharge against medical advice at the surgical emergency room of University Teaching Hospital, Ilorin from January 2004 to December 2005 were studied prospectively. The patients’ demographic details, diagnosis, reason for discharge, signatory to discharge and length of hospital stay were studied.
Analysis of the data was done using Statistical Package for Social Sciences (SPSS) version 11.
Prevalence rate of DAMA was 4.2%, comprising 110 of a total of 2,617 patients admitted during the study period. Male to female ratio was 3.8:1, the mean age was 30.0 years (range, 4–70 years). Trauma accounted for the highest number of patients 102(97.2%) out of whom 52 (51%) had long bones fracture. Patients who wish to seek alternate medical care accounted for 43.6%, while financial constraint contributed to 29.1% DAMA. Forty-five out of forty-eight (93.7%) of patients who DAMA to seek alternate medical care had fracture.
Trauma was the most common clinical condition for patients who DAMA. Most common reason for DAMA was to seek alternate treatment followed by financial constraint. Health education on potential benefit of orthodox treatment of fracture, treatment subsidy and full implementation of national health insurance scheme will reduce incidence of DAMA.
Discharge; Medical advice; Trauma; Health education
A summary of injuries sustained by 340 sportsmen over 9 successive weekends from 16 November 1991 to 12 January 1992 attending an accident and emergency (A&E) department is presented. Most injuries occurred in young males usually as a result of soccer or rugby. Sixty-seven per cent of patients were discharged with no further followed up in hospital. Seventy-two per cent of patients were X-rayed, 33% of X-rays showed a fracture or dislocation. A total of 193 attendees received minimal treatment, (defined as discharge with advice only, simple analgesia or strapping only with no hospital follow-up) and of these 152 were X-rayed. A total of 100 patients who received minimal treatment were selected randomly by computer to receive a follow-up letter asking about certain issues relating to their care in the A&E department. Most patients felt that the A&E Department was the most appropriate source of treatment for their sports injury, and over half attended specifically for an X-ray examination. Despite the doctors view that many of these minor injuries could have been self-treated, few patients felt able to treat future similar minor injuries themselves. They were, however, more likely to go elsewhere for treatment on subsequent occasions.
The outcome in 115 consecutive patients with mild self-poisoning seen by junior medical staff and discharged from the accident department was compared with that of 98 similar patients admitted to the medical wards. Psychiatrists saw only four patients in the accident department and 25 admissions. In making their assessments the junior medical staff considered psychosocial factors as well as the patients' physical condition. Most patients recommended for further care, and discharged from the accident department, subsequently received it. Repetition rates were similar in the two groups and there had been no suicides when patients were followed up at one year. It is feasible for junior staff in an accident department to decide whether patients with self-poisoning need admission or may be discharged with or without subsequent referral for psychiatric or social work help.
Background—Patients over the age of 75 years comprise an increasing proportion of accident and emergency (A&E) department attendances. Within this group there is a high incidence of comorbidity, which mandates effective discharge coordination from the A&E department.
Objectives—The aims of this study were to assess the needs of these patients the day after discharge, target patients for appropriate interventions and identify critical incidents.
Setting—The study was undertaken in a district general hospital A&E department that has 62 000 new patient attendances per year.
Inclusion criteria—Patients aged 75 years or over who were discharged from the A&E department.
Exclusion criteria—Nursing home patients. Patients without a telephone.
Study design—Pre-discharge information was collected from the medical notes. A community liaison nurse (CLN) then contacted patients by telephone. A semi-structured questionnaire was used to assess patients. Patients were risk stratified and appropriate interventions made. Interventions initiated by the CLN were scored from 1 to 6 based on the level of input required.
Results—551 patients or their carers were contacted by telephone. Existing home support was felt to be insufficient in 44 (8%) cases and in need of immediate intervention in a further 45 (8%) cases. Sixty five (11%) Category 1 patients required no intervention, 223 (42%) Category 2 patients required advice only, 107 (19%) Category 3 patients were referred to their GP, 127 (23%) Category 4 patients required a domicillary visit by a GP or a nurse, 26 (5%) Category 5 patients were at risk requiring urgent home assessment and three Category 6 patients had to re-attend A&E. Advice was given by the CLN on a broad range of issues and a wide range of health care services was accessed. Five hundred and fifty nine referrals were made by the CLN after telephone assessment.
Conclusions—Telephone follow up of patients over 75 attending our A&E department identified a number of areas where care could be improved before and after discharge. This low cost, high quality intervention has the potential for decreasing inappropriate return visits to the department by a vulnerable group of patients as well as improving overall quality of care.
Factitious disorder can present with a wide variety of symptomatology. We present a case of a young girl presenting with spontaneous extrusion of wires from her limbs. These metallic wires were present in both her upper and lower limbs in the muscle bulk and were visible on X-ray. She sought repeated surgical removal of these wires, but the wires would invariably reappear. The patient could not be engaged in a therapeutic relationship and the family took premature discharge against medical advice, as they believed in supernatural causation for the phenomenon and were afraid that medical intervention might bring further ill fortune. The case highlights the importance of belief systems of family members as a barrier in managing such cases.
Factitious disorder; India; rural background; wires; young female
Objective To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units.
Design Individual patient randomised controlled trial comparing intervention with usual care.
Setting Two hospitals in Nottingham and Leicester, UK.
Participants 433 patients aged 70 or over who were discharged within 72 hours of attending an acute medical assessment unit and at risk of decline as indicated by a score of at least 2 on the Identification of Seniors At Risk tool.
Intervention Assessment made on the acute medical assessment unit and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services.
Main outcome measures The primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use.
Results The two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days’ follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was −4.6 to 3.6 days (P=0.31). No significant differences were found for any of the secondary outcomes.
Conclusions This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from acute medical units had no effect on patients’ outcomes or subsequent use of secondary care or long term care.
Methods: A retrospective review of all case notes coded as "self discharge" for a three month period. A second cohort was reviewed following the introduction of a new self discharge proforma.
Results: Patients who self discharge represented 0.5% of the total number of attendances, and those who "did not wait" represented a further 11%. Fifty percent were under the influence of drugs or alcohol. Sixty three percent refused admission, 24% refused treatment, and 13% refused medical assessment. In the first audit, assessment of capacity was documented in 0%, 58% signed a self discharge form, 25% were reviewed by a doctor prior to leaving, and 31% left the department without the staff's knowledge. In the second audit, capacity was documented in 80%, 80% signed the new self discharge form, 41% were reviewed by a doctor prior to leaving, and 0% left the department without being reviewed.
Discussion: Self discharge may be a significant risk to both the patient and the hospital trust. Departments should review their own systems for assessing and managing this patient group. Further work looking at the consequences of self discharge is required.
OBJECTIVE--To examine the assessment of adolescent self harm patients attending an accident and emergency department. DESIGN--Retrospective assessment of case notes. SETTING--Accident and emergency department, Leicester Royal Infirmary. PATIENTS--210 adolescent patients (aged 9-19 years) attending the department during 1 January 1989-31 December 1989 after deliberate self poisoning; records were available for 200. MAIN OUTCOME MEASURES--Numbers of admissions, discharges from department without either a psychiatric consultation or some form of follow up, and discharges with either of these; scoring of adequacy of psychiatric and social assessment by accident and emergency doctor. RESULTS--89 patients were admitted (mean score 5.1, excluding 22 patients too drowsy or unforthcoming for proper assessment), 80 were discharged without specific psychiatric consultation or other follow up (mean score 5.4), and 31 were discharged with psychiatric consultation or other follow up (mean score 9.1). The percentage of patients in each group whose assessment by the accident and emergency doctor was considered to be adequate or better than adequate over 10 headings ranged from 0%-40% for admitted patients, 0%-50% for those discharged without psychiatric assessment, and 0%-61% in the remaining group. Overall, in almost half (49%, 54/111) of all of those discharged documentation of the suicidal state was inadequate. CONCLUSION--The assessment of many adolescent self harm patients in this clinic was unsatisfactory. IMPLICATIONS--Doctors working in accident and emergency departments should be encouraged to liaise with child psychiatrists before discharging such patients.
Approximately 500,000 patients are discharged from U.S. hospitals against medical advice annually, but the associated risks are unknown.
We examined 148,810 discharges from an urban, academic health system between 7/1/2002 and 6/30/2008. Of these, 3,544 (2.4%) were discharged against medical advice and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities, or discharges with home-care. Using adjusted and propensity score matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges.
Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (ORadj = 2.05, 95% CI: 1.48–2.86), and in propensity-matched analysis (ORmatched = 2.46, 95% CI: 1.29 – 4.68). Discharge against medical advice was also associated with higher 30-day readmission after adjustment (ORadj 1.84; 95% CI 1.69 – 2.01), and in propensity-matched analysis (ORmatched 1.65, 95% CI: 1.46 – 1.87). Finally, discharges against medical advice had shorter lengths-of-stay than matched planned discharges (3.37 vs. 4.16 days, p <0.001).
Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths-of-stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.
OBJECTIVE: To investigate demographic changes in attenders at an accident and emergency (A&E) department. METHODS: Patients attending Leeds General Infirmary A&E department in 1990 were compared with those attending in 1993 and 1994. Internal quality control suggested that 99% of patients were correctly registered for details of method of arrival, age, and departure (admission/discharge). RESULTS: By 1994 there had been a 6.9% increase in total numbers, including a disproportionate rise in elderly patient attendances. The overall number of patients admitted increased, as did the proportion of those attending the A&E department. There was a 28% increase in number of patients arriving by ambulance between 1990 and 1993, and this rose to 32% in 1994. CONCLUSIONS: The increasing number of new patients, especially elderly people, has implications for future planning of A&E departments. The expected demographic rise in the elderly population means that A&E departments must expect to receive more elderly patients. Our figures, if generally applicable, suggest that this is already occurring. Staffing requirements and the physical space necessary to care for these extra patients needs to take these figures into account. These factors are of relevance to both purchasers and providers.
A pilot study was undertaken in the Accident & Emergency (A & E) departments of two central London teaching hospitals to determine if patients who were abusing alcohol and had not received any prior medical treatment or counselling for their drinking problem were amenable to offers of help. During the 24-month study period 104 patients were identified as having a previously untreated alcohol problem, and of these 46% attended an appointment to discuss their drinking habits. The group identified was much smaller than would be expected from the number attending the A & E departments during the study period and the reasons for this are discussed. However, the important observation from the study is that almost half the patients identified as having an alcohol problem returned to the department the following day to seek advice. This suggests that A & E departments are an appropriate place to offer patients initial help about their drinking habits.
This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma.
Subjects and Methods:
Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed.
A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001).
Management of acute asthma in Malta requires optimization in order to compare with international guidelines.
Accident and emergency department; adults; asthma exacerbations
This study examines the relationship between race and discharge against medical advice from hospitals. Data were taken from the 1990 National Hospital Discharge Survey, which provides national estimates of hospitalizations in short-stay hospitals. Discharges against medical advice by white, African-American, and other race patients were examined. In 1990, there were an estimated 241,911 discharges against medical advice, accounting for 0.92% of all live discharges. In bivariable analyses, African-American patients were 1.78 times more likely then white patients to be discharged against medical advice. This may reflect greater dissatisfaction with inpatient care by African-American patients and may expose them to additional risk for adverse medical outcomes. Optimization of the delivery of inpatient services to patients of all races requires addressing this inequity.
Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality. This study looked at the use of the emergency services by people with diabetes, with particular reference to hypoglycaemia.
Data were collected on all attendances related to diabetes at accident and emergency departments at two district general hospitals in Surrey, UK, over a one year period.
Hypoglycaemia was the commonest reason for attendance at accident and emergency. The management of hypoglycaemia was variable, the most frequent method of treatment being intramuscular glucagon administered by the ambulance service. Ninety per cent of patients with hypoglycaemia were either discharged or self‐discharged from the accident and emergency department, and half of these patients had no follow up arranged.
Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal. Standardised protocols and better education of healthcare professionals and patients are required.
diabetes mellitus; hypoglycaemia; management
Nine pharmaceutical workers were exposed to hydrochloric acid (HCl) fumes. Four were discharged with no symptoms after a 4 h observation period in the accident and emergency (A&E) department. The remaining five were admitted to the medical unit because of severe symptoms, reduced peak expiratory flow rate (PEFR), or hypoxaemia. Treatment was symptomatic and discharge followed 24 h later. Only one patient, discharged from the medical unit, developed long term airway hyper-reactivity, superimposed on a background of chronic obstructive airways disease. Thus patients who are minimally symptomatic with normal PEFR and oxygen saturation values can be safely discharged from the A&E department after a short observation period of 4 h with advice to return if dyspnoea occurs. Caution should be employed in severely symptomatic patients, those with pre-existing lung pathology or reduced PEFR, and hypoxaemic patients, where observation for at least 24 h is recommended.
Objectives: To evaluate the impact of a severe acute respiratory syndrome (SARS) outbreak in the emergency department (ED).
Methods: Computerised records of all ED visits in January and May 2003 were analysed and compared, representing before and during the SARS epidemic respectively. Data were grouped into two categories. Group 1 was the indicators of impact on patients, including visitor's condition classification, number of patients that died on arrival (DOA), received cardiopulmonary resuscitation, underwent endotracheal intubation, needed mechanical ventilation, discharged against medical advice (AAD), died in the ED, and the admission rate to wards. Group 2 was the indicators of impact on the quality of medical care, including number of visits that returned within 72 hours (early returns), underwent chest radiography, upper abdomen sonography or computed tomography, and the length of stay.
Results: There were 6650 and 3901 consecutive encounters in January and May 2003 respectively. There were significant differences on condition classifications (p = 0.000), increased rate of patients that underwent endotracheal intubation (p = 0.003), needed mechanical ventilation (p = 0.020), and admission (p = 0.000). The rate of AAD decreased significantly (p = 0.024). There was no significant difference on early returns, although the length of stay in the ED increased (p = 0.043). The number of visits that underwent chest radiological examination increased (p = 0.000) and upper abdomen sonography (p = 0.007) decreased significantly in May.
Conclusions: SARS had an impact on the medical service system and decreased visits by 40% in the ED. Patients visiting the ED had more severe conditions than before. The impact of SARS on quality of medical care can be minimised when adequate infection control measures are applied.
Many older people presenting to Acute Medical Units (AMU) are discharged after only a short stay (< 72 hours), yet many re-present to hospital or die within 1 year. Comprehensive Geriatric Assessment may improve patient outcomes for this group.
Patients aged > 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.
Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.
Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.
Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.
Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.
Discharge against medical advice (DAMA) is a major problem in healthcare delivery as it can complicate the health problems from which patients are suffering. The aim of this study was to understand DAMA among children in a tertiary teaching hospital in Oman and to evaluate the documentation of the events in the medical records.
A retrospective survey of the medical records of patients discharged against medical advice over a two-year interval was performed (2004–2006).
Of the 11,802 admissions, there were 38 cases of DAMA, giving a prevalence rate of 0.32%. In 39.5% of the cases, the discharge happened within 24 hours of hospital admission. The majority of the cases were infants (n = 24; 63.25%). The diagnosis at discharge in some cases included life-threatening conditions. However, in 57.9% of the cases, the reasons for DAMA were neither reported nor documented in the patients’ medical records.
Although the results of this study yielded a low prevalence rate compared to the rates reported in other studies, the occurrence of DAMA for children in a tertiary hospital is a distressing phenomenon. It was evident that the documentation of the DAMA process was poor. More studies should be conducted to understand the details of the problem. Policies should be established and implemented in order to attempt to reduce DAMA among child patients and to protect them from the consequences of such discharges.
Children; Patient Discharge; Hospitals; Oman
OBJECTIVE: To investigate how often elderly patients are discharged from an accident and emergency (A&E) department with unrecognized but remediable problems. METHODS: Over a period of six months, 174 elderly patients fulfilling inclusion criteria for the study were discharged from A&E, and of these 97 (56%) agreed to be reviewed in the day hospital. They were assessed by a doctor, nurse, physiotherapist, occupational therapist, speech therapist, and social worker. A full blood count, urea and electrolytes, liver and thyroid function tests, a chest radiograph, and an electrocardiogram were performed. A Barthel activity of daily living index was performed on the first visit and before discharge. RESULTS: 28% had missed diagnoses which benefited from day hospital attendance and a further 13 patients had been admitted before they could attend day hospital. Those patients presenting with falls and living alone constituted a high risk group. CONCLUSIONS: Elderly patients attending A&E merit special consideration to detect underlying medical or social problems.
Previous research shows that surgeon-performed ultrasound for patients presenting with abdominal pain in the emergency department leads both to higher diagnostic accuracy and to other benefits. We have evaluated the level of patient satisfaction, health condition and further health care consumption after discharge from the emergency department.
A total of 800 patients who attended the emergency department for abdominal pain were randomized to surgeon-performed ultrasound or not as a complement to standard examination. All patients were interviewed by telephone six weeks after the visit to the emergency department using a structured questionnaire including information about health condition, satisfaction and medical examinations. A regional health register was used to check health care consumption over two years and mortality was checked for in the personal data register.
We found a higher self-rated patient satisfaction in the ultrasound group when leaving the emergency department. After six weeks the figures were equal. There were fewer patients in the ultrasound group with completed or planned complementary examinations after six weeks (31.1%) compared with the control group (41.4%), p = 0.004. There was no difference found in the two-year health care consumption or mortality between the groups.
For patients with acute abdominal pain, bedside ultrasound examination is related to higher satisfaction and decreased short-term health care consumption. No major effects were revealed when evaluating effects on a long-term basis, including mortality. The previously proven benefit together with the lack of adverse effects from the method makes ultrasound well worth considering for implementation in emergency departments.
The study has been registered in ClinicalTrials.gov ID NCT00550511.
All patients who presented to our Accident & Emergency Department over a 6-month period with an acute knee injury were randomly assigned to receive either immediate physiotherapy or not prior to further follow up at an out-patient clinic. Patients with trivial injuries not requiring follow up and patients with severe injuries requiring immediate admission were excluded from the study. Patients not immediately referred for physiotherapy could be referred if this was thought necessary at later follow up. There was no statistical difference in the number of outpatient follow up appointments or the length of time to discharge from the clinic between the groups. Those patients referred for physiotherapy immediately had a significantly greater number of total attendances at the physiotherapy department. However more patients in the 'no physiotherapy' group ultimately required arthroscopy for suspected meniscal injury. We conclude that a blanket referral of all acute knee injury patients is unjustified and wasteful of resources. However physiotherapy may be indicated in patients initially suspected of having meniscal injury.
In the UK, about 2% of the population attend the accident and emergency (A&E) department every year after a head injury. A majority of the patients have minor head injury and are discharged. Studies reveal that patients who reattend the A&E after a minor head injury represent a high‐risk group.
Concussion injuries are common and not all require treatment at the time of presentation. However, some may worsen after initial presentation and develop signs of serious head injury. A case of minor head injury as a result of head butt during a game of rugby, not associated with alteration in conscious state or focal neurological signs, and subsequent development of frontal lobe abscess a month later is reported. It is important that patients fit to be discharged at the time of consultation are discharged in the care of a responsible adult with clear head injury instruction sheets and are advised to return should their symptoms change. A high index of suspicion should be maintained and an early imaging technique, such as CT scan should be considered in patients reattending the A&E with persistent symptoms even after minor head injury.
Many studies have shown that a high proportion of patients attending accident and emergency (A&E) departments have only trivial or non-urgent complaints. A&E staff treat these inappropriate attenders while recognizing that this detracts from the care given to more serious cases. Dwindling resources and higher attendances make it a matter of necessity that inappropriate attenders be treated by general practitioners or equivalent primary care services. In this study, the authors examined the feasibility of methods of reducing inappropriate attendance. The authors investigated patients' ability to accurately assess the urgency of their condition and, hence, their need for A&E services. The authors concluded that there is probably no practical way of reducing inappropriate attendance that does not involve risk to a proportion of patients. The possibility of extending the role of the A&E department to provide more general primary care is discussed.
Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.