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Self-Discharge Against Medical Advice from Northern Territory Hospitals

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Self-Discharge Against Medical Advice from Northern Territory Hospitals Self-discharge against medical advice from Northern Territory Hospitals Prevalence rates, experiences and suggestions, economic implications and recommended strategies for improvement A Report Prepared for the Department of Health and Community Services Initial work conducted by Barbara Henry, Terry Dunbar and Lesley Barclay with additional work contributed by Robyn Thompson on behalf of the Graduate School for Health Practice and the School for Social and Policy Research, Charles Darwin University and the Cooperative Research Centre for Aboriginal Health Acknowledgments The Northern Territory Department of Health and Community Services, Acute Care Division commissioned this study on self-discharge against medical advice. The authors wish to thank and acknowledge the Office of Indigenous Health, the doctors, nurses, Aboriginal Liaison Officers, Social Workers and administrative staff of the Royal Darwin, Tennant Creek, Alice Springs, Gove and Katherine Hospitals for their participation in this project. We also wish to acknowledge in particular the considerable assistance received during this project from the Health Gains Planning Branch staff, Steven Guthridge and Jiqiong You, who assisted in retrieving and analysing the complex data. We would also like to acknowledge the members of the steering committee who provided guidance and perspectives, which we found valuable. Principal Researcher Barbara Henry Research Fellow Terry Dunbar Professor Lesley Barclay Senior Research Fellow Robyn Thompson Departmental Steering Committee Members Lesley Barclay Meribeth Fletcher Steven Guthridge Barbara Henry John Heslop Bhavini Patel Fred Stacey Jiqiong You February 2007. Table of Contents Executive summary……………………………………………………………………………. 1 Introduction…………………………………………………………………………………….. 1 Data……………………………………………………………………………………….. 1 Main statistical findings………………………………………………………………... 2 Costs of self-discharge………………………………………………………………….. 3 Reasons for self-discharge……………………………………………………………… 3 Key Issues and Recommendations ………………………………………………………….. 4 Background …………………………………………………………………………………….. 9 Methodology…………………………………………………………………………………… 10 Statistical Data Collection ……………………………………………………………… 11 Selective Literature Review ………………………………………………………………….. 13 Introduction……………………………………………………………………………… 13 Profiling patients who self-discharge …………………………………………………. 13 Why patients choose to self-discharge ………………………………………………... 14 The extent of the problem ……………………………………………………………… 15 Readmission following an episode of self-discharge ……………………………….. 15 Australian research and publications …………………………………………………. 16 Themes emerging from the literature: Implications for Northern Territory Medical Services…………………………………………………… 19 Culture and History …………………………………………………………………….. 19 Trust and Utilization of Health Care ………………………………………………….. 21 Health Literacy and Language………………………………………………………… 22 The Need for Health Systems Change……………………………………………….. 23 Statistical Data Aggregate Report…………………………………………………………… 26 Rates, Frequency and Trends of Self-discharge……………………………………… 26 Self-discharge by Districts……………………………………………………………… 29 Seasonal Change of Self-discharge…………………………………………………… 30 Self-Discharge by Age Groups………………………………………………………… 31 Length of Stay (LOS) of Self-discharge Patients…………………………………….. 33 Readmission Rate of Self-discharge Patients………………………………………… 34 Self-discharge by Discharge Unit……………………………………………………… 36 Economic Analysis……………………………………………………………………………. 38 The Costs of Self-discharge……………………………………………………………. 38 Perceptions of Staff and Indigenous Informants…………………………………………. 40 Introduction……………………………………………………………………………… 40 Perceptions of the characteristics of self-discharging patients…………………….. 39 Perceived reasons underlying patient self-discharge against medical advice………………………………………………………………….. 43 Current management of self-discharging patients………………………………….. 47 Perceptions about the clinical, ethical and duty-of-care consequences of premature and self-discharge ………………………………..……. 49 Staff suggestions for new ways to minimise and manage self-discharge…………………………………………………………………. 50 Discussion and Findings…………………………………………………………………….. 53 Conclusion……………………………………………………………………………………… 60 Attachments……………………………………………………………………………………. 61 References………………………………………………………………………………………. 66 List of Tables Table 1: Self-discharge and Self-discharge Rate, NT Public Hospitals 1999/00- 2003/04……………………………………………………….………………………. 26 Table 2: Rates of Self-discharge by Hospitals, NT Public Hospitals 1999/00-2003/04 …………………………………………………………………….. 26 Table 3: Rates of Self-discharge by Indigenous Status and Hospitals, NT Public Hospitals 1999/00-003/04……………………………….......................................... 27 Table 4: Frequency of Self-discharge Episodes by Self-discharged Patients NT Public Hospitals 1999/00-2003/04 ……………………………………….. ………………. 27 Table 5: Self-discharge Rate by District and Indigenous Status NT Public Hospitals 1999/00-2003/04…………………………………………………. ………………….. 29 Table 6: Age-specific Number of Self-discharge and Separations, NT Public Hospitals 1999/00-2003/04……………………………………………………………………... 32 Table 7: Summarisation of Self-discharge Patients’ LOS Compared to the National Average Length of Stay, NT Public Hospitals 1999/00-2003/04……………………………………………………………………… 33 Table 8: Summarization of Self-discharged Patients’ LOS Longer/Shorter than the National Average LOS, NT Public Hospitals 1999/00-2003/04............................ 33 Table 9: Self-discharge Related Readmission, NT Public Hospitals 1999/00-2003/04……………………………………………………………………… 34 Table 10: Readmission Rate Versus Self-discharge Rate, NT Public Hospitals 1999/00-2003/04……………………………………………………………………… 34 Table 11: Readmission Rates by Indigenous and Self-discharged Status, NT Public Hospitals 1999/00-2003/04…………………………………………….. 35 Table 12: Number of Day Gaps Between Admission and Readmission for Self- discharged Patients by Indigenous Status NT Public Hospitals 1999/00-2003/04……………………………………………………………………… 35 Table 13 The Annual Actual and Adjusted Acute Care Costs Incurred by Self-discharged Patients, NT Public Hospitals, 1999/00-003/04…………….. 38 Table 14: Distribution of Self-discharge Episode by Indigenous Status, NT Public Hospitals 1999/00-2003/04....................................................................... 62 Table 15: Self-discharge Rate by Indigenous Status and Hospitals, NT Public Hospitals 1999/00-003/04……………………………………………………………………….. 63 Table 16: Top 10 Longest LOS Compared to the National Average LOS…………………………………………………………………………………… 64 Table 17: Top 10 Most Frequent DRGs of LOS Longer than the National Average……………………………………………………………………………… 65 List of Figures Figure Annual Trend of Self-discharged Rate by Hospitals, NT Public 1: Hospitals 1999/00-2003/04 …………………………………………….. 28 Figure Monthly Change of Self-Discharge Rate by NT Public Hospitals 2: 1999/00-2003/04………………………………………………………... 30 Figure Age-specific Self-discharge and Self-discharged Rates by NT 3: Public Hospitals 1999/00-2003/04……………………………………. 31 Figure Percentage of Self-discharge by Discharge Unit, NT Public 4: Hospitals 1999/00-2003/04 …………………………………………… 36 Figure Percentage of Self-discharge by Indigenous Status and Discharge 5: Unit, NT Public Hospitals 1999/00-2003/04 ………………………… 36 Figure The Annual Actual and Adjusted Acute Care 6 Costs Incurred by Self-discharged Patients, NT Public Hospitals, 1999/00-2003/04……………………………………………. 39 Figure Annual Trend for Readmission Rates and Average 7 Cost, Self-discharge versus Non-Self-discharge, Northern Territory Public Hospitals, 1999/00-2003/04…………….. 39 Executive Summary Introduction The research detailed in this report was commissioned by the Northern Territory Department of Health and Community Services (DHCS) to assist the Department’s response to managing the risks and challenges of patients self-discharging against medical advice from Territory hospitals. The six key project objectives identified following discussions with the Department of Health and Community Services were to: 1. Explore reasons underlying patient self-discharge. 2. Determine whether this behaviour is associated with more general patient non-compliance and/or resource constraints that prevent appropriate management of these at-risk patients. 3. Explore the fiscal, clinical, ethical and duty-of-care consequences of premature Self-discharge. 4. Identify better ways to prevent and or manage inpatients that prematurely self- discharge. 5. Assess the costs and benefits of different options for better managing this group of patients. 6. Interview patients who had left hospital prematurely. Data Statistical and economic data and analysis for the period 1999 to 2004 were provided by the Health Gains Planning Branch of the Department of Health and Community Services based on reports from all Northern Territory hospitals – Royal Darwin Hospital, Gove Hospital, Katherine Hospital, Tennant Creek Hospital and Alice Springs Hospital. The quantitative data was supplemented with findings from interviews and focus groups with staff in hospitals and Aboriginal Health services and by individual key Indigenous informants conducted in June 2005 and from April to June 2006. Over 40 hospital staff participated directly, and many more indirectly, by contributing their experiences and innovative ways of dealing with self-discharge. Many years of experience informed the opinions of these staff, which were evident in the quality and succinctness of their comments. Staff were generous with their time and were also very keen to assist in reducing
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