Introduction: Patients leaving against medical advice (AMA) have higher morbidity and mortality, rates of readmission, and overall healthcare costs. While prior work has shown that patients with substance use disorder (SUD) are more likely to leave AMA, potentially in part due to failure to adequately address withdrawal- and craving-related symptoms, this has not been studied among intensive care unit (ICU) patients who may be particularly medically vulnerable. We examined the relationship between positive drug screening and discharging AMA in the trauma ICU population.
Methods: We used data from American College of Surgeons Trauma Quality Improvement Project 2020 and 2021 data registry, with data from over 750 hospitals; we included traumas where the patient was 18 years or older and in ICU for 3 or more days and who were alive at discharge. We used Fisher’s exact test to compare AMA discharges among traumas with positive drug screens at admission to those with no substance use at admission.
Results: 253,701 traumas were included in our analysis; 15.6% of patients had a positive screen for a stimulant (amphetamine, cocaine, methamphetamine), opioid , hallucinogen (PCP, Ecstasy) or depressant (benzodiazepine, barbiturate) but these patients made up 42% of AMA discharges. 7.0% of patients with a positive stimulant screen, 4.9% with a positive opioid screen, 6.5% with a positive hallucinogen screen, and 4.2% with a positive depressant screen discharged AMA compared to 1.5% of patients with no positive drug screening (all p< 0.001). Patients testing positive for two or more classes of drug were also more likely to discharge AMA (2 classes: 7.1%, 1 class: 5.1%).
Conclusions: Patients presenting with a positive drug screen make up a disproportionate share of AMA discharges among trauma patients admitted to ICU level of care, likely reflecting the complex interplay between SUD, withdrawal, disease pathology, and the psychologic impact of trauma. Further research is needed to understand the motivations of this vulnerable population in leaving AMA to find potential intervention targets and harm reduction strategies.
