Department of Neonatology, Chittagong Medical College, Chattogram, Bangladesh.
Department of Public Health, Chittagong Medical College, Chattogram, Bangladesh.
PLoS One. 2023 Apr 20;18(4):e0284705. doi: 10.1371/journal.pone.0284705. eCollection 2023.
Discharge against medical advice (DAMA) is an unexpected event for patients and healthcare personnel. The study aimed to assess the prevalence of DAMA in neonates along with characteristics of neonates who got DAMA and, causes and predictors of DAMA.
This case-control study was carried out in Special Care Newborn Unit (SCANU) at Chittagong Medical College Hospital from July 2017 to December 2017. Clinical and demographic characteristics of neonates with DAMA were compared with that of discharged neonates. The causes of DAMA were identified by a semi-structured questionnaire. Predictors of DAMA were determined using a logistic regression model with a 95% confidence interval. A total of 6167 neonates were admitted and 1588 got DAMA. Most of the DAMA neonates were male (61.3%), term (74.7%), outborn (69.8%), delivered vaginally (65.7%), and had standard weight at admission (54.3%). A significant relationship (p < 0.001) was found between the variables of residence, place of delivery, mode of delivery, gestational age, weight at admission, and day and time of outcome with the type of discharge. False perceptions of wellbeing (28.7%), inadequate facilities for mothers (14.5%), and financial problems (14.1%) were the prevalent causes behind DAMA. Predictors of DAMA were preterm gestation (AOR 1.3, 95% CI 1.07-1.7, p = 0.013), vaginal delivery (AOR 1.56, 95% CI 1.31-1.86, p < 0.001), timing of outcome after office hours (AOR 477.15, 95% CI 236-964.6, p < 0.001), and weekends (AOR 2.55, 95% CI 2.06-3.17, p < 0.001). Neonates suffering from sepsis (AOR 1.4, 95% CI 1.1-1.7, p< 0.001), Respiratory Distress Syndrome (AOR 3.1, 95% CI 1.9-5.2, p< 0.001), prematurity without other complications (AOR 2.1, 95% CI 1.45-3.1, p < 0.001) or who were referred from north-western districts (AOR 1.48, 95% CI 1.13-1.95, p = 0.004) had higher odds for DAMA.
Identification of predictors and reasons behind DAMA may provide opportunities to improve the hospital environment and service related issues so that such vulnerable neonates can complete their treatment. We should ensure better communication with parents, provide provision for mothers' corner, especially for outborn neonates, maintain a standard ratio of neonates and healthcare providers, and adopt specific DAMA policy by the hospital authority.
拒绝出院（DAMA）对于患者和医护人员来说是一个意外事件。本研究旨在评估新生儿 DAMA 的发生率，以及 DAMA 新生儿的特征、DAMA 的原因和预测因素。
本病例对照研究于 2017 年 7 月至 2017 年 12 月在吉大港医学院医院的新生儿特殊护理病房（SCANU）进行。将 DAMA 新生儿的临床和人口统计学特征与出院新生儿进行比较。通过半结构式问卷确定 DAMA 的原因。使用具有 95%置信区间的逻辑回归模型确定 DAMA 的预测因素。共有 6167 名新生儿入院，1588 名新生儿出院。大多数 DAMA 新生儿为男性（61.3%）、足月（74.7%）、外地出生（69.8%）、阴道分娩（65.7%），入院时体重标准（54.3%）。居住地、分娩地点、分娩方式、胎龄、入院时体重以及结局时间与出院类型之间存在显著关系（p<0.001）。对健康状况的错误认知（28.7%）、母亲设施不足（14.5%）和经济问题（14.1%）是 DAMA 的主要原因。DAMA 的预测因素是早产（AOR 1.3，95%CI 1.07-1.7，p=0.013）、阴道分娩（AOR 1.56，95%CI 1.31-1.86，p<0.001）、下班后（AOR 477.15，95%CI 236-964.6，p<0.001）和周末（AOR 2.55，95%CI 2.06-3.17，p<0.001）。患有败血症（AOR 1.4，95%CI 1.1-1.7，p<0.001）、呼吸窘迫综合征（AOR 3.1，95%CI 1.9-5.2，p<0.001）、无其他并发症的早产儿（AOR 2.1，95%CI 1.45-3.1，p<0.001）或来自西北区的转诊新生儿（AOR 1.48，95%CI 1.13-1.95，p=0.004）发生 DAMA 的可能性更高。
确定 DAMA 的预测因素和原因可能为改善医院环境和服务相关问题提供机会，使这些脆弱的新生儿能够完成治疗。我们应该确保与父母更好地沟通，为母亲提供角落，特别是为外地出生的新生儿，保持新生儿和医护人员的标准比例，并由医院管理部门采取具体的 DAMA 政策。
