The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers

Background

Every year, patients leave the Emergency Department against medical advice (AMA) and before an adequate evaluation can be performed. It is well known that many of these patients are at risk of subsequent complications.

Objective

The goal of this article is to explain the potential legal protections that may be created from a proper AMA discharge.

Discussion

In this article, the authors review the steps that need to be taken when performing an AMA discharge, including an assessment of capacity, proper documentation, and adequate disclosure. The authors then review the potential legal protections that can result from a properly documented and performed discharge. Among these protections are: proof that the provider's duty to the patient ended with discharge and that the patient assumed the risk of a subsequent complication.

Conclusion

The authors conclude that a properly executed discharge can provide significant legal protection from liability risks.     

Cost effectiveness analysis of elementary school-located vaccination against influenza—Results from a randomized controlled trial

School-located vaccination against influenza (SLV-I) has been suggested to help meet the need for annual vaccination of large numbers of school-aged children with seasonal influenza vaccine. However, little is known about the cost and cost-effectiveness of SLV-I. We conducted a cost-analysis and a cost-effectiveness analysis based on a randomized controlled trial (RCT) of an SLV-I program implemented in Monroe County, New York during the 2009–2010 vaccination season. We hypothesized that SLV-I is more cost effective, or less-costly, compared to a conventional, office-located influenza vaccination delivery. First and second SLV-I clinics were offered in 21 intervention elementary schools (n = 9027 children) with standard of care (no SLV-I) in 11 control schools (n = 4534 children). The direct costs, to purchase and administer vaccines, were estimated from our RCT. The effectiveness measure, receipt of ≥1 dose of influenza vaccine, was 13.2 percentage points higher in SLV-I schools than control schools. The school costs ($9.16/dose in 2009 dollars) plus project costs ($23.00/dose) plus vendor costs excluding vaccine purchase ($19.89/dose) was higher in direct costs ($52.05/dose) than the previously reported mean/median cost [$38.23/$21.44 per dose] for providing influenza vaccination in pediatric practices. However SLV-I averted parent costs to visit medical practices ($35.08 per vaccine). Combining direct and averted costs through Monte Carlo Simulation, SLV-I costs were $19.26/dose in net costs, which is below practice-based influenza vaccination costs. The incremental cost-effectiveness ratio (ICER) was estimated to be $92.50 or $38.59 (also including averted parent costs). When additionally accounting for the costs averted by disease prevention (i.e., both reduced disease transmission to household members and reduced loss of productivity from caring for a sick child), the SLV-I model appears to be cost-saving to society, compared to “no vaccination”. Our findings support the expanded implementation of SLV-I, but also the need to focus on efficient delivery to reduce direct costs.     

Hypnosis: Exploring the Benefits for the Role of the Hospital Social Worker

This article will provide an examination of Erickson's model of hypnosis and the impact hypnosis has made on the psychosocial well being of the medically ill patient. The intrinsic three stage process of a hypnotic intervention, as well as its value, practice assumptions, and its relevance to alleviating pain, distress, and anxiety with oncology patients will be discussed. We have found this approach to be particularly effective with adult oncology patients at alleviating the side effects of the arduous treatment that is often endured. Case vignettes will demonstrate the benefits of utilizing this intervention with adult patients in the hospital setting as well as provide specific insight into the creative methods in which we have woven hypnosis into our clinical work. Finally, we will explore the use and rationale of hypnosis in medical settings and the impact of using this intervention on the role of the hospital social worker.     

Design questions for Streptococcus pneumoniae vaccine trials with a colonisation endpoint

Evaluation of vaccine efficacy for protection against colonisation (VE_col) with Streptococcus pneumoniae and other bacterial pathogens is often based on a cross-sectional study design, in which only one nasopharyngeal sample is obtained per study subject. Here we investigate the feasibility of this study design by investigating a number of practical design problems. Specific questions are related to the timing of colonisation measurement with respect to the time of vaccination, the adjustment for the within-host replacement of vaccine-type colonisation by the non-vaccine type pneumococci, and the impact of multiple serotype colonisation on VE_col estimation. We also discuss the issue of choosing the control vaccine, including comparison of two active pneumococcal vaccines, as well as the sample size and the statistical power of colonisation endpoint trials. In addition, the statistical design with the specific aim to include information about VE_col in the licensure process of new pneumococcal vaccine products is discussed.     

综合评价安眠方剂对小白鼠戊巴比妥钠催眠、阈下催眠量影响随机平行对照研究

[目的]观察安眠方剂对小白鼠戊巴比妥钠催眠、阈下催眠量影响。[方法]使用随机平行对照方法,将410只健康昆明种小鼠编号按抽签随机分组,催眠作用组（安眠1号组、安眠2号组、安眠3号组、安眠4号组、百乐眠胶囊组、地西泮片组、空白对照组,10R／组）,催眠量组（安眠l号组、安眠2号组、安眠3号组、安眠4号组、百乐眠胶囊组、地西泮片组、空白对照组,20只／组）,急性毒性组（安眠1号组、安眠2号组、安眠3号组、安眠4号组,50只／组）。戊巴比妥钠催眠作用,各组灌胃给药40mL／kg,空白对照组给等容积蒸馏水,1次／d,连续给药5d。各组末次给药后50min,腹腔注射50mg／kg戊巴比妥钠,从开始注射戊巴比妥钠到翻正反射消失时间为入睡潜伏期,从翻正反射消失到翻正反射恢复时间为睡眠时间。戊巴比妥钠闽下催眠量,各组灌胃给药40mL／kg,空白对照组给等容积蒸馏水,1次／d,连续给药5d。各组末次给药50min后,腹腔注射35mg／kg戊巴比妥钠（生理盐水配制）,以给药后15min内小鼠翻正反射消失lminvX上的鼠数作为入睡指标。小鼠急性毒性,各组24h灌胃给药1次,给药眠1号药组61．60g／kg,安眠2号药组55．60g／kg,安眠3号药组50．00g／kg,安眠4号药组62．80g／kg;各给药组按剂量距l：0．90等比级数递减灌胃给药,容积为40mL／Kg。一次灌胃给药后立即观察动物24h反应,并连续14d观察动物毒性反应和死亡情况。[结果]入睡潜伏期安眠1号组与空白对照组无明显差异（P〉0．05）,其余各干预组均明显高于空白对照组（P〈0．01,P〈0．05）;睡眠时间各干预组均明显高于空白对照组（P〈0．01）;入睡鼠数安眠3号组与空白对照组无明显差异（P〉0．05）,其余各干预组均明显高于空白对照组（P〈0．01）。安眠1号组LD50为45-35g／kg～50．66g／kg,95％可信限45．35g／kg～50．66g／kg。安眠2号组LD50为44．14g／kg,95％可信限41.38g/kg～47．09g／kg。安眠3号组LD50为36．20g／kg,95％可信限34．29g／kg～38．21g/kg,安眠4号组LD50为16．41g/kg,95％可信限为12．91g／kg～20．85g／kg。安眠1号药组为18000。[结论]本试验将药效、毒性综合评估的方法运用到临床前药物研究,将药效与毒性分别进行三个级别赋分,根据药效／毒性比值,确定安眠1号药处方。     

天王补心丸全方及全方缺桔梗对少寐大鼠脑神经递质的影响

目的:为了了解天王补心丸全方的安神作用机制以及桔梗对天王补心丸催眠作用的影响.方法:建立小鼠戊巴比妥钠协同睡眠模型,考察天王补心丸全方及全方缺桔梗对小鼠睡眠的影响;建立少寐大鼠的模型,以睡眠觉醒相关神经递质5-HT,NA及DA为分析指标,通过HPLC-ECD检测,考察桔梗配伍与否对脑内神经递质及其代谢产物的影响.结果:天王补心丸全方能够显著地性增加阈下剂量戊巴比妥钠协同睡眠的入睡率(P<0.05),而天王补心丸全方缺桔梗组只有使睡眠率增加的趋势,而无统计学差异;给药后全方组、全方缺桔梗组均显著性升高了大鼠中缝核单胺类递质5-TH及5-HIAA水平(P<0.05),且全方缺桔梗组与全方组相比有显著性差异;而在海马区与纹状体区只有全方组显著性升高促睡眠递质5-TH水平(P<0.05),且与全方缺桔梗组相比有显著性差异(P<0.05);全方及全方缺桔梗组均显著降低大鼠下丘脑DA水平(P<0.05);全方及全方缺桔梗组均显著地降低纹状体内DA代谢产物DOPAC水平(P<0.05).结论:天王补心丸全方催眠作用机制在于促进了各脑区及核团内5-HT释放,而桔梗将有可能为调节的关键点.     

Effects of monoclonal antibodies against human stathmin I combined paclitaxel on proliferation of human hepatocellular carcinoma cell lines

Objective： We investigated the effects of monoclonal antibodies against stathmin 1 combined paclitaxel on the proliferation of HCC cells. Methods： HepG2 cells were treated with monoclonal antibodies against stathmin 1, paclitaxel alone or their combination, with the untreated cells used as the control, 24, 48, 72, 96 h later, the cell growth condition was observed by invert microscope and inhabitation rate was studied by MTT assay; The apoptosis was analyzed by flow cytometry with Annexin V/PI. Results： The population decreased and shape, size changed after treating with different concentration of experimental groups. Monoclonal antibodies against stathmin 1 and paclitaxel used alone or in combination both inhibited the proliferation of HepG2 cells, the inhibition ratio of their combination was more higher （P 〈 0.05）, and a synergistic effect of the two agents was noted in their combined action （P 〈 0.05）. Combined treatment of the cells resulted in significantly higher apoptosis rate than that in the other groups （P 〈 0.05）. Conclusion： Monoclonal antibodies against stathmin 1 and paclitaxel used alone or in combination both can inhibit proliferation of HepG2 cells and induce apoptosis. A synergistic effect is obsewed between the monoclonal antibodies against stathmin 1 and paclitaxel in their inhibition of HepG2 cell proliferation.     

Therapiezufriedenheit mund-, kiefer- und gesichtschirurgischer Patienten nach Operationen unter Klinischer Hypnose

The Department of Maxillofacial Surgery of the University Hospital Schleswig-Holstein/Campus Lübeck offers intraoperative hypnosis since 2002. Besides clinical evaluation by controlled studies, patients attitudes should be included in the judgement on such adjuvant procedure not established in general.70 patients of the department treated under combined local anaesthesia/hypnosis rated their individual postoperative patient satisfaction by standardised questionnaires. A control group of equal size and demographic/surgical features consisted of patients that were treated without hypnosis in the same interval.Results of the inquiry indicate that intraoperative hypnosis increases significantly postoperative satisfaction of oral and maxillofacial patients. Satisfaction is attributed decisively on the adjuvant procedure.     

肝癌高发区抗-HBc阳性慢性乙肝患者HBVDNA血清学分析

目的：了解启东肝癌高发区抗－HBc阳性慢性乙肝患者HDVDNA分布 情况。方法：采用ELISA法筛选慢性乙肝患者中抗－HBc阳性者，再用聚合酶链反应（PCR）检测这些血清中的HBVDNA。结果：HBVDNA总检出率为75．24％（158／210）。抗－HBc与HBsAg、HBeAg同在时HBVDNA阳性率最高，达97．26％（71／73），显著高于其它模式（P＜0．005）。抗－HBc/HBsAg阳性血清中HBVDNA检出率为81．08％（150／185），单纯抗HBc/HBsAg阳性血清中HBVDNA检出率为80．77％（42／52），单纯抗－HBc阳性血清中检出率为20％（1／5）。结论：抗－HBc是乙肝病毒感染的一个直接标志。判断患者的传染性应通过免疫学和基因学两种方法来检测。启东慢性乙肝患者中HBVDNA整合现象可能要高于其它地区，这或许是启东肝癌高发的机制之一，值得进一步研究。基因学和免疫学方法检测乙肝病毒感染情况各有利弊，应互补共存。