American Association for Hand Surgery
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Investigating Predictors of Patient-Directed Discharge in Hand Infection Hospitalizations
Daniel Soroudi, BS1, Micaela Rosser, MD2, Alap Patel, MD2, Matthew McLaughlin, B.A.3, Raymond Yin, MS1 and Scott L Hansen, MD2, (1)University of California, San Francisco School of Medicine, San Francisco, CA, (2)Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, CA, (3)UC San Francisco, San Francisco, CA

Patients who leave the hospital prior to completing recommended medical treatment have elevated readmission and mortality rates compared to conventionally discharged (CD) patients. Patients with substance use disorders cite staff interactions, withdrawal symptoms, and hospital restrictions as reasons for patient-directed discharge (PDD). Adequate housing and social support also play an important role in patient experience and health outcomes. The aim of this retrospective review was to provide insight into the factors that contribute to PDD in patients admitted with hand infections.

Materials & Methods: A retrospective review was conducted of Emergency Department (ED) consults for adult hand infections at an urban safety net hospital over the study period of 2021 to 2022. Information was collected on race, intravenous drug use (IVDU), and housing status. Information regarding inpatient addiction care consults was also collected. In this study, we utilized the term "unstable housing" to encompass a wide range of living situations including homelessness, temporary housing arrangements, shelter stays, and Single Room Occupancy (SRO) dwellings. Patients who discharged themselves against medical advice (AMA) or were absent without leave (AWOL) were said to have undergone PDD. A chi-squared test was performed to examine the association between these factors and PDD. Risk Ratios (RR) were also calculated.

Results: 131 patients met the inclusion criteria. The mean age was 43.4. 67.2% of patients had unstable housing, 71% lived alone, and 54.2% were IVDU. 27.5% of discharges were PDD. Patients with IVDU were 4.2 times more likely to undergo PDD compared to non-IVDU (P=.0060). Patients living alone were 4.5 times more likely to undergo PDD than those living with family, friends, or strangers (P=.0085). Those with unstable housing were 3.9 times more likely to undergo PDD compared to housed patients (P=.0060). There was no relationship between race or inpatient addiction care team assessment and PDD.

Conclusion: Patients with housing insecurity, living alone, or IVDU are more likely to undergo PDD. These findings underscore opportunities for the healthcare system to consider patients’ background information during seemingly straightforward hospital admissions to reduce PDD. Further studies should identify why these populations are more prone to PDD, so more targeted interventions could be utilized to reduce recidivism and improve outcomes.

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