Patients Who Leave the Emergency Department Without Being Seen

doi:10.1016/j.jen.2008.05.006

Journal of Emergency Nursing

Volume 35, Issue 2, March 2009, Pages 105-108

https://doi.org/10.1016/j.jen.2008.05.006 Get rights and content

Introduction

Patients who present to the ED for care and leave without being seen (LWBS) represent a significant problem. The objective of this study was to determine why patients LWBS, how long they perceived waiting versus actual time waited before leaving, and factors that might have prevented LWBS.

Methods

We conducted a prospective, scripted phone survey of all patients who left without being seen over a two-month period in 2006 at an ED with approximately 65,000 yearly visits. Outcome measures were number leaving, ability to obtain care after leaving, reason for leaving, would they return to this ED, perceived and actual time waited, number with a primary physician, and factors associated with leaving.

Results

One-hundred and twenty-seven of 11,147 total patients (1.1%) patients left without being seen. Seventy-two (56.7%) were interviewed within 8 days. Eighty-four and seven-tenths percent stated they had a primary physician. The mean age was 29.9 years, and 44.4% were male. The patient-reported mean time waited before leaving was 73.2 minutes while the actual mean time waited was 70.4 minutes. The reasons for leaving were the length of wait (76.7%), the problem resolved (12.3%), and for other reasons (11.0%). During the week after leaving the ED, 56.3% were able to obtain medical care. Sixty-five percent would seek future emergency care at this ED, 15.3% would not, and 19.7% would possibly return. During the wait, patients wanted information, lab tests/X-rays, and analgesics.

Discussion

Most would return for future ED care. Most had a physician and were able to obtain care elsewhere. Reduced LWBS might be accomplished by triage testing, communication and attention to pain.

Section snippets

Study Design

This was a prospective descriptive study of patients who left the ED triage/waiting room area before being seen by a physician.

Study Setting and Population

The study took place in a mid-Atlantic level II trauma center and community teaching hospital with approximately 65,000 annual patient visits. The staffing in the triage area during 11 am to 11 pm, the peak hours for patient volume, consisted of 1 emergency care technician at the front desk and 2 registered nurses (RNs) in the triage examination rooms. After 11 pm,

Results

During the study period, 127 patients left without being seen. In the LWBS patient population, the mean age was 27.9 years, and 42.7% were male; in the total ED population, the mean age was 41.3 years and 48% were male (P < .001 for age). The LWBS population represented 1.1% of our total ED visits (11,147) during the 2-month study period. Of the eligible patients, 72 (56.7%) were contacted by phone, consented to be interviewed within 8 days of their LWBS ED visit, and completed the survey; thus

Discussion

ED crowding is defined, in part, as waiting more than 1 hour to see a physician.¹⁰ Our study has shown that this is the point in time when a patient may LWBS. The pediatric patients in this study waited approximately 23 minutes longer than adults before leaving without being seen. A large number of our patients (84.7%) had a primary physician, and over half of the patients were able to obtain medical care within 8 days of leaving the emergency department. The reasons for not initially seeing

Limitations

One limitation of this study is our small sample size. In addition, we were unable to contact by telephone 43.3% of the patients who left without being seen during our study period despite 3 attempts to do so. However, these patients had similar age and gender distributions when compared with the final sample. Of the 55 patients who we were unable to contact, age and gender data were available on 41 patients. Their mean age was 24.5 years and 41.5% were male (compared with 29.9 years and 44.4%

Implications for Emergency Nurses

The emergency nurse at triage should be aware that in our study, the mean wait time for patients who left without being seen was 70.4 minutes. Although the national wait time is slightly shorter, at 56 minutes, the triage nurse should pay careful attention to waiting patients as their wait reaches the 1-hour point. In addition, ED waiting room patients should be kept informed, offered comfort measures such analgesics, ice packs for painful injuries, and so on, and possibly diagnostic testing,

Conclusions

Patients leaving the emergency department without full evaluation are a significant problem in US emergency departments from both a health care and financial perspective. The triage nurse can potentially reduce this number through improved patient communication, attention to patient discomfort, and initiation of diagnostic testing. Younger patients are more likely to leave and do so just beyond the first hour of waiting.

Acknowledgment

The authors gratefully acknowledge Kristin Thomas, MA, Senior Research Specialist, Emig Research Center, York Hospital, Pa., for her participation in this project (statistical analysis).

Michele Johnson, Member, ENA Chapter 49, is Clinical Nurse, Department of Emergency Medicine, York Hospital, York, PA.

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Cited by (46)

Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice
2021, American Journal of Emergency Medicine
Citation Excerpt :
Patients who refused ED care cited three common reasons, including wait time, expectations not met, and negative interaction with ED staff. These findings confirm previous studies which found that a long wait time is the top reason patients LWBS [19–21]. ED wait times vary significantly and are related to triage acuity.
Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.
This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.
Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).
ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.
Characterization of emergency department abandonment using a real-time location system
2020, American Journal of Emergency Medicine
Citation Excerpt :
We used median wait times to make our analysis robust against outliers, especially the ones observed in the smaller ESI 2 population which skewed mean wait times in this group. Consistent with previous study findings were our average total LWBS rates of 1–3%, [3,13,16] as well as previous studies' findings of a discrepancy between actual abandonment times and traditional means of capturing this data. One study showed a discrepancy of roughly 25 min between the earliest recorded time a patient was noted to have left and the official end time of their medical chart [14]; this study shows an even larger gap, with a mean discrepancy of 92 (median 70) minutes between staff-recorded and RTLS departure time.
Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting.
Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates.
This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included.
Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5).
Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.
Fluid approximations and control of queues in emergency departments
2017, European Journal of Operational Research
Citation Excerpt :
The implication of this simplified assumption is that a patient (more generally a customer) can only abandon while in the queue, which is a common assumption in Erlang-A queueing systems (e.g. see Garnett et al., 2002; Hampshire et al., 2009; Rudolph, 2011). Although, in reality, patients can abandon the ED at any stage of the medical care process, including before triage (Johnson, Myers, Wineholt, Pollack, & Kusmiesz, 2009). The final modeling assumption relates to the medical care service process.
Long queues in emergency departments (EDs) lead to overcrowding, a phenomenon that can potentially compromise patient care when medical interventions are delayed. There are several causes of this problem, one of which is inadequate resource allocation. In this paper, we propose using a modified version of the square root staffing (SRS) rule to satisfy the probability of delay target. We use the concepts of kinetics and biological modeling to approximate the fluid behavior of the queueing process. We are then able to estimate the offered load and the appropriate service grade necessary to construct a staffing policy that meets the target. Additionally, we show how to utilize Pontryagin’s maximum principle to find the optimal number of providers that minimizes delay and staffing costs. Finally, we demonstrate the implementation of our model using data from a hospital in upstate New York.
An agent-based model for quantitatively analyzing and predicting the complex behavior of emergency departments
2017, Journal of Computational Science
Hospital based emergency departments (EDs) are highly integrated service units devoted primarily to handling the needs of patients arriving without prior appointment, and with uncertain conditions. In this context, analysis and management of patient flows play a key role in developing policies and decisions for overall performance improvement. However, patient flows in EDs are considered to be very complex because of the different pathways patients may take and the inherent uncertainty and variability of healthcare processes. The agent-based model provides a flexible platform for studying ED operations, as it predicts the system-level behavior from individual level interactions. In this way, policies such as staffing can be changed and the effect on system performance, such as waiting times and throughput, can be quantified. The overall goal of this study is to develop tools to better understand the complexity, evaluate policy and improve efficiencies of ED units. The main contribution of this paper includes: an agent-based model of ED, a flexible atomic data monitoring layer for agent state tracing, and a master/worker based framework for efficiently executing the model and analyzing simulation data. The presented model has been calibrated to imitate a real ED in Spain, the simulation results have proven the feasibility of using agent-based model to study ED system.
A simulation and optimization based method for calibrating agent-based emergency department models under data scarcity
2017, Computers and Industrial Engineering
To tackle the problem of efficiently managing increasingly complex systems, simulation models have been widely used. This is because simulation is safer, less expensive, and faster than field implementation and experimenting. To achieve high fidelity and credibility in conducting prediction and exploration of the actual system with simulation models, a rigorous calibration and validation procedure should firstly be applied. However, one of the key issues in calibration is the acquisition of valid source information from the target system. The aim of this study is to develop a systematic method to automatically calibrate a general emergency department model with incomplete data. The simulation-based optimization was used to search for the best value of model parameters. Then we present a case study to particularly demonstrate the way to calibrate an agent-based model of an emergency department with real data scarcity. The case study indicates that the proposed method appears to be capable of properly calibrating and validating the simulation model with incomplete data.
Comparing patients who leave the ED prematurely, before vs after medical evaluation: A National Hospital Ambulatory Medical Care Survey analysis
2016, American Journal of Emergency Medicine
Citation Excerpt :
Increased rates of patients who leave before medical assessment are associated with high ED volumes and crowding (Weiss 2005 [7], Hobbs 2000 [15], McMullan 2004 [16]). Patients consistently identify wait times as a major reason for leaving before medical assessment (Rowe 2006 [3], McNamara 1995 [17], Johnson 2009 [18], Mohsin 2007 [19], Monzon 2005 [20], Arendt 2003 [21], Baker 1991 [2]). Conversely, high rates of patients leaving after provider assessment have not been shown to correlate with ED overcrowding (Ding 2007 [9]), and reasons for leaving prematurely have not been clearly identified in this group.
Many patients leave the Emergency Department (ED) before beginning or completing medical evaluation. Some of these patients may be at higher medical risk depending on their timing of leaving the ED.
To compare patient, hospital, and visit characteristics of patients who leave before completing medical care to patients who leave before ED evaluation.
Retrospective cross-sectional analysis of ED visits using the 2009-2011 National Hospital Ambulatory Medical Care Survey.
A total of 100 962 ED visits were documented in the 2009-2011 National Hospital Ambulatory Medical Care Survey, representing a weighted count of 402 211 907 total ED visits. 2646 (2.62%) resulted in a disposition of left without completing medical care. Of these visits, 1792 (67.7%) left before being seen by a medical provider versus 854 (32.3%) who left after medical provider evaluation but before a final disposition. Patients who left after being assessed by a medical provider were older, had higher acuity visits, were more likely to have visited an ED without nursing triage, arrived more often by ambulance, and were more likely to have private insurance than to be self-paying or to have other payment arrangements (e.g. worker's compensation or charity/no charge).
When comparing all patients who left the ED before completion of care, those who left after versus before medical provider evaluation differed in their patient, hospital, and visit characteristics and may represent a high risk patient group.

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Michele Johnson, Member, ENA Chapter 49, is Clinical Nurse, Department of Emergency Medicine, York Hospital, York, PA.

Stephanie Myers, Member, ENA Chapter 49, is Clinical Nurse, Department of Emergency Medicine, York Hospital, York, PA.

June Wineholt, Member, ENA Chapter 49, is Clinical Nurse, Assistant Nurse Manager, Department of Emergency Medicine, York Hospital, York, PA.

Marc Pollack is Research Director, Department of Emergency Medicine, York Hospital, York, PA.

Amy L. Kusmiesz is Clinical Research Associate, Department of Emergency Medicine, York Hospital, York, PA.

View full text

ResearchPatients Who Leave the Emergency Department Without Being Seen

Introduction

Methods

Results

Discussion

Section snippets

Study Design

Study Setting and Population

Results

Discussion

Limitations

Implications for Emergency Nurses

Conclusions

Acknowledgment

J Emerg Med

J Emerg Med

Ann Emerg Med

J Emerg Nurs

Ann Emerg Med

Accid Emerg Nurs

Research
Patients Who Leave the Emergency Department Without Being Seen