Reasons of discharge against medical advice among children in Oman. SQUH experience Muna Al Saadoon, Hanan Al Mahrouqi, Nasra Al Jaafari, Hooriya Al Maawali College of Medicine and Health Sciences, Department of Child Health Introduction: Discharge against medical advice (DAMA) occurs when patient (adult and children) leave the hospital before the treating physician recommends that. This serious decision could affect the healthcare delivery as it can complicate the health problems that patients are suffering from. In Oman, the prevalence rate of pediatric DAMA was reported to be 0.38 (1). Studies conducted worldwide reported prevalence of 1%-25.85% (2–6). The reasons for DAMA among children include parent's perception of improvement, financial problems, dissatisfaction with hospitals’ services, not trusting the physician, and believes in natural and traditional medicine (7, 8). Many of the studies on this topic are retrospective and few form Arabian Gulf region. The aims of this study is to identify reasons for discharge against medical advice and the outcome of DAMA in Oman through a study with a prospective design. Method: A prospective study on pediatric patients with DAMA from Sultan Qaboos University Hospital (SQUH), during one year (Nov 2013-Nov 2014). Data was collected by telephone interview using a structured questionnaire developed by the research team based on literature review (face validity was done and a pilot study was conducted on 6 mothers before using it). Ethical approval was obtained from the College of Medicine and Health Sciences Research Ethical Committee. The study sample was identified from the ward registry book. All mothers of identified children were contacted by telephone within 48 hours of discharge. After obtaining consent to participate in the study they were interviewed to collect information about the child and family and the event of DAMA. The mothers were contacted again through a telephone call after 2 weeks of discharge to evaluate the child health condition. More information about the children medical problem were obtained by reviewing the electronic medical records. Descriptive analysis was done, using the Statistical Package for the Social Sciences (SPSS), Version 21. Results: During the study period, 58 cases of DAMA were identified, giving a prevalence of 1%. The DAMA happened within 24 hours of hospital admission in 63.8% of the cases. High percentage of patients were neonates (36.2%), compared with other age groups (table 1). In some cases, the diagnoses at time of discharge were life threatening diseases such as Central Nervous system Infections and Septicemia. Interviewed mothers reported improvement of their child's condition, based on clinical and laboratory findings (40.4%) to be the most common reason to sign DAMA for their children, Followed by social problems (29.8) mainly taking care of other children at home (table 2). Only 32 mothers (68.1%) reported that the doctors explored with them, the reasons of signing DAMA. Table 3 illustrate the attempts of the doctors to prevent DAMA and advices given to improve the outcome of such discharges. However, in 42.6% of the cases, the reasons for DAMA and efforts of doctors to prevent such early discharges were not documented in the children electronic files. The outcome of DAMA was reported to be favorable by 57.4% of the mothers as the child improved. However, this parents judgement of the child condition might not reflect accurately the child health state. In 10.6% of the cases the child was reported to be Readmitted in a health facility for further management (figure 1). Discussion Despite the small prevalence rate of DAMA in this study, DAMA is a worrying problem. The slight increase in the rate compared to the study conducted in 2013 (1) could be due to the implementation of the child law in May 2014 with more reporting of cases of DAMA rather than actual increase in number of cases. Neonates were the most victimized age group (36.2%). This finding is similar to what has been reported in most of the previous studies (1, 8, 9). This could be du to the subtle symptoms among this age group that will alert the doctors for possible risks but not the parents. Similar to other studies, this study found a slightly higher rate of DAMA among male patients which we can not explain from the data collected in the current study. Table 1: Age of child at DAMA and Duration of admission The most prevalent reason for signing DAMA was child improvement (40.4%), based on clinical and laboratory results. The second reason was social problems (29.8%) such as looking after other children at home. Such reasons were reported by other researchers (3, 8). There is a need for intervention to help families with their social commitments and better communication about the risk of early discharge prior to full recovery so that premature discharge of sick children is prevented. Around 80% of the mothers reported that the treating team explored with them the reasons of DAMA or tried to prevent it. However, such attempts should be tried with all cases and should be documented in all of the patients medical records as such documentation were done for only 57.4% of the patients. The outcome of the DAMA after 2 weeks indicates the need of proper follow up and clear discharge plan. 57.4% (n= 27) of the cases were reported by the mothers to be better and improving, 17% either admitted or following up in the clinics. The fact that 21.3% still suffer the same symptoms is worrying and violate the child right to receive the optimal health care. Unrevealing the condition of the child in 4.3% of the cases is more worrying and indicate a need for urgent attention for DAMA among children. Conclusion Neonates are the most common victims of DAMA and the diagnoses of some the cases at discharge were life threatening. It is obvious that in some cases, the documentation of DAMA is poor and do not cover the essential information including reasons of signing DAMA and efforts made by physicians to prevent DAMA. It is important to initiate child protection measures to save children life and conduct more studies to evaluate this problem. References 1. Al Sadoon M, Al Shamousi K. (2013). Discharge against medical advice among children in Oman:. SQUMJ. 13 (4), p534_ Okoromah CN, Egri-Qkwaji MT. Profile of and control measures for paediatric discharges against medical advice. Niger Postgrad Med J 2004; 11:21–5. 3. Aliyu ZY. Discharge against medical advice: Sociodemographic, clinical and financial perspectives. Int J Clin Pract 2002; 56:325–7. 4. Gloyd S, Kone A, Victor AE. Pediatric discharge against medical advice in Bouake Cote d’Ivoire, Health Policy Plan 1995; 10:89– Onyiriuka AN. Discharge of hospitalized under-fives against medical advice in Benin City, Nigeria. Niger J Clin Pract 2007; 10:200–4. 6. Parkash J, Das N. Pattern of admissions to neonatal unit. J Coll Physicians Surg Pak 2005; 15:341–4. 7. Bernadette C. (2012). Pediatrician's perspectives on discharge against medical advice (DAMA) among pediatric patients: a qualitative study. Macrohon BMC pediatrics. 12 (75), p2. 8. Roodpeyma S, Hoseyni SAE. Discharge of children from hospital against medical advice. World J Pediatr 2010; 6:353–6. 9. Opera P, Eke G. (2009). Discharge against medical advice.12(2), p67-82 Figure 1: Consequences of DAMA Reason for DAMA N (%) Total 47 Refusing investigation12 (25.5) Refusing treatment modality7 (14.9) Seeking other opinion13 (27.7) Looking for traditional treatment3 (6.4) Social problems14 (29.8) Financial problems1 (2.1) Not satisfied with treatment7 (14.9) Not satisfied with doctors0 (0) Not satisfied with doctors0 (0) Child improvement19 (40.4) Parents assumption of improvement14 (29.8) No improvement6 (12.8) CharacteristicsTotal (N47) N (%) Age of child Neonate 1-12 months 1-6 years 6 years and above 17 (36.2) 14 (29.8) 11 (23.4) 5 (10.6) Duration from admission to DAMA Within 24 hours 1-2 Days 3 Days and more 30 (63.8) 11 (23.4) 6 (12.8) Table 2: Reasons of DAMA as reported by mothers Treating team role in DAMA preventing N (%) Total 47 Explain complications and provide plan for follow up and management at home 12 (25.5) Explain complications20 (42.6) Arrange follow up appointment1 (2.1) Advise to repeat investigation3 (6.38) Conduct physical examination and document finding 2 (4.3) No efforts done to prevent DAMA9 (19.15) Table 3: Role of doctors and treating team to prevent DAMA readmitted