Predictors of discharge against medical advice in pediatric trauma patients: A nationwide analysis

BACKGROUND Discharge from hospital against medical advice (AMA) carries a significant risk of readmission and has increased rates of morbidity and mortality. Little is known about the characteristics of pediatric trauma patients discharged AMA. We aimed to identify predictors for discharge AMA in pediatric trauma patients. METHODS A 3-year retrospective cohort analysis of the 2017-2019 American College of Surgeons (ACS) Trauma Quality Improvement Program was performed. All pediatric (younger than 18 years) trauma patients were included. Patients with missing data on hospital discharge disposition were excluded. Two groups were compared: those discharged AMA and those who were not. Bivariate analysis using χ² test was performed. A multivariable logistic regression analysis was performed to identify predictors for discharge AMA adjusting for age, sex, race, ethnicity, comorbidities, positive drug or alcohol screen, insurance status, injury severity, 4-hour packed red blood cells requirements, vitals, mechanisms of injury, and ACS Pediatric Trauma Center Verification Level. RESULTS A total of 259,363 pediatric trauma patients were identified 436 (0.2%) were discharged AMA. Patients discharged AMA were older (mean age, 13 vs. 10 years p < 0.001) and were more likely to be males (70% vs. 65%, p < 0.001), Black (31% vs. 18%, p < 0.001), and uninsured to have a penetrating mechanism of injury (17% vs. 9%, p < 0.001) to be a victim of an assault and to be treated at a non-pediatric-ACS-verified trauma center. Patients discharged AMA were more likely to test positive for alcohol or illicit drugs at time of admission. They were also more likely to undergo an abuse investigation and to be reported to Child Protective Services. CONCLUSION Discharge AMA is affected by different patient- and system-related factors. Understanding these factors could enable targeted interventions in clinical practice and policy. Our findings highlight the important role of pediatric trauma centers in addressing the needs of injured children. LEVEL OF EVIDENCE Therapeutic/Care Management Level III.