Percentage of admitted patients who discharged against medical advice 

Rationale

Discharge against medical advice (DAMA) refers to patients leaving hospital against the advice of their treating medical team or without advising hospital staff (e.g. take own leave, left without notice, or missing and not found). Patients who do so have a higher risk of readmission and mortality and have been found to cost the health system 50 per cent more than patients who are discharged by their physician.

Between July 2017 and June 2019 Aboriginal patients (4.3%) in WA were 7.7 times more likely than non-Aboriginal patients (0.6%) to discharge against medical advice, compared with 4.2 times nationally (3.8% and 0.7% respectively). This statistic indicates a need for improved responses by the health system to the needs of Aboriginal patients. This indicator is also being reported in the Report on Government Services 2023 under the performance of governments in providing acute care services in public hospitals. 

This indicator provides a measure of the safety and quality of inpatient care. Reporting the results by Aboriginal status measures the effectiveness of initiatives within the WA health system to deliver culturally secure services to Aboriginal people. While the aim is to achieve equitable treatment outcomes, the targets reflect the need for a long-term approach to progressively closing the gap between Aboriginal and non-Aboriginal patient cohorts.

DAMA performance measure is also one of the key contextual indicators of Outcome 1 “Aboriginal and Torres Strait Islander people enjoy long and healthy lives” under the new National Agreement on Closing the Gap, which was agreed to by the Coalition of Aboriginal and Torres Strait Islander Peak Organisations, and all Australian Governments in July 2020.

Target

The 2023 targets for admitted patients who discharged against medical advice are: 

Improved or maintained performance is demonstrated by a result below or equal to target. 

Results

Commentary

Although performance outcomes in 2023 did not achieve targets, the results are comparable to those reported in prior years. EMHS is committed to implementing strategies to address DAMA across its hospital sites.

In December 2023, the EMHS DAMA Action Plan was endorsed. DAMA initiatives are managed and evaluated by well-established site DAMA Working Groups, with oversight of progress at a site Executive level. 

Key strategies supporting DAMA performance across EMHS in 2023 included:

• Continued implementation of the EMHS Aboriginal Cultural Competency Learning Framework to improve cultural competence across EMHS staff, including expansion of the Aboriginal Health Champions Program.
• To prevent patients leaving hospital due to boredom, Royal Perth Bentley Group (RPBG) trialled the provision of a bedside television to Aboriginal patients at risk of DAMA. In 2024, the pilot was extended based on initial evaluation and a reduction in DAMA rates among the trial cohort.  
• RPBG provided outdoor bush tucker meals on a regular basis, and created a culturally safe and inclusive environment through displaying Aboriginal artwork.
• Progressed implementation of a process at RPBG for safely discharging surgical patients whose surgery has been delayed or cancelled in target areas.
• A Patient of Concern Management Plan is to be launched by the RPBG Aggression Prevention Team to mitigate some of the DAMA risk. It will be trialled for use with patients who frequently DAMA and those at risk of DAMA.
• Education of all clinical and clerical staff for Patient Initiated Discharge (PID) Form implementation at Armadale Kalamunda Group (AKG).
• At AKG, the Aboriginal Health Team actively engages with hospital staff and provides support to Aboriginal patients throughout their admission, ensuring each patient has contact with an Aboriginal Health Liaison Officer and receives culturally safe and secure health care at every step of their hospital journey. 
• Implementation of strategies to reduce DAMAs at St John of God Midland Public Hospital (SJGMPH), with a focus on enhancing culturally secure care and environments. This includes facilitating medical education to enable consistency of informed decision making and patient initiated discharge.