Patient characteristics and institutional factors associated with those who “did not wait” at a South East Queensland Emergency Department

Those who opt to leave: Comparison by triage acuity of emergency patients who leave prior to seeing a medical practitioner

BACKGROUND

People who present to an emergency department but leave before seeing a medical practitioner (LWBS) pose a potential risk, especially those triaged with higher acuity care needs.

OBJECTIVE

To describe and compare characteristics of emergency patients who LWBS by triage acuity.

METHOD

Retrospective review of administrative data for a 1-year period. Chi-square and logistic regression analyses conducted to investigate differences in characteristics specific to individual and the timing of presentation between patients who LWBS and were triaged as higher acuity compared to those who left but were triaged as less- or non-urgent.

RESULTS

During study period, 12.6 % of patients LWBS with 30.0 % of these cases triaged as higher acuity. Number triaged as higher acuity who LWBS tended to be higher during days with a higher volume of higher acuity cases. The likelihood of LWBS for those triaged as higher acuity was higher among older age groups and those with a primary care provider who presented on weekdays, during evening and night shifts, and in the winter months.

CONCLUSIONS

Findings highlight differences in LWBS cases by triage acuity and raise questions about emergency nurses' professional responsibility to follow-up with those who LWBS if they have been triaged as higher acuity based on an assessment of their presenting complaint and risk for complications or deterioration. While continuing to work to reduce wait times and improve patient flow, it is important to identify factors affecting patients' decision to LWBS, especially for those triaged with higher acuity healthcare needs.

Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020

OBJECTIVE

Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave.

METHODS

Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed.

RESULTS

A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001).

CONCLUSION

A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.

Contemporary evaluation of adverse outcome risks associated with 'did not wait' emergency department presentations

OBJECTIVE

Did not wait (DNW) is a frequently cited ED key performance indicator. We conducted a network-based observational study of consecutive DNW presentations.

METHODS

Prospective cohort study of Western Sydney Local Health District with a primary outcome measure of reported 30-day all-cause mortality and secondary outcomes of demographic characteristics and representation risk. For re-presenting patients who were subsequently admitted, a manual review of electronic records and incident report systems based on a priori plan assessed each case for the length of stay and adverse outcomes.

RESULTS

During the study window, there were 1114 DNW presentations with 172 (15.4%) re-presentation within 72 h. The analysis of re-presented patients did not reveal adverse outcomes or prolonged length of stay. A review of available outcomes data revealed one DNW patient died within 30 days but had a previous palliative plan for terminal illness.

CONCLUSION

While a proportion of DNW patients re-presented within 72 h, an excess prevalence of poor outcomes were not observed.

Identifying and quantifying general practice-type emergency department presentations

OBJECTIVE

This research aims to (i) identify general practice-type (GP-type) presentations to EDs in South-East Queensland, Australia and (ii) compare and quantify the clinical, socio-demographic and time-varying characteristics between GP-type and non-GP-type presentations.

METHODS

Data were collected from presentations to four EDs in Queensland from 2009 to 2014. A modified version of the Australasian College for Emergency Medicine (ACEM) method for identifying GP-type ED presentations was used.

RESULTS

The four EDs have different proportions of GP-type presentations, between 7% and 33%. Between 2009 and 2014, the amount of GP-type presentations increased in three EDs, by between 5% and 16%, and decreased by 30% in the other ED. Different holidays, for example, the public holidays over the Christmas to New Year period, impact GP-type presentations. Over 50% of GP-type presentations occurred in those aged 0-34 years, and <1% were aged 85+ years. Injury-related diagnoses made up around 37% of the GP-type presentations, and around 13% did not wait for a diagnosis, averaged over the EDs. GP-type presentations are more likely to present to EDs outside standard general practitioner hours.

CONCLUSIONS

Existing methods for identifying GP-type presentations have drawbacks, and modified methods are required to better identify these types of presentations. Temporal effects not previously investigated in Australian studies, such as holidays, are significantly associated with GP-type presentations. These findings aid strategic planning and interventions to support review of GP-type presentations, instead, in primary-care facilities, and such interventions may be assistive in some EDs more than others.

An exploration of the reasons why people attend but do not wait to be seen in emergency departments

AIM

The aim of the study was to explore the reasons why people do not always wait to receive treatment after registering in emergency departments (EDs).

METHOD

Patients who attended the ED at a general hospital in the south of England and left without being seen (LWBS) were recorded between 1 June and 31 August 2016 and 597 patient records were analysed. Six patients participated in semi-structured interviews. Data were manually coded.

FINDINGS

The most common presenting complaint for people who LWBS was limb problems, however some had potentially more serious conditions such as chest pain. The six interviewees accessed the ED because of a perceived urgent need, and reasons for leaving before being seen included long waiting time, other commitments, non-availability of specialty services, perceiving their problem as less urgent, resolution of condition and discomfort in the waiting area.

CONCLUSION

People who LWBS may not have trivial health problems, which is a risk for them and hospital trusts. Although many of the people who LWBS did so because of the lengthy waiting time, there may be other factors involved some of which could be prevented.

Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department

BACKGROUND

Classification of Psychiatric Emergency Presentations (PEP) is not sufficiently clear due to their inherent high inter-subjectivity and lack of validated triage instruments. In order to improve current classification of psychiatric emergency presentations (PEP) at Emergency Departments, we implemented and validated the Color-Risk Psychiatric Triage (CRPT), an instrument for classifying PEP risk by sorting one to five color/risk levels and one to thirty-two possible conditions arranged by risk.

METHODS

Users who visited the Emergency Department (ED) of a Mexican psychiatric hospital from Dec 1st, 2008 to Dec 1st, 2009 were included. One CRPT was assessed by an ED psychiatrist to each patient upon their arrival to ED. Some patients were randomly assessed simultaneously with an additional CRPT and a Crisis and Triage Rating Scale (CTRS) to test validity and reliability of the CRPT.

RESULTS

A total of 7,631 CRPT assessments were included. The majority of PEP were non-urgent (74.28 %). For the validation phase n = 158 patients were included. CRPT score showed higher concurrent validity than CRPT color/risk. CRPT level/risk and score showed highest concurrent validity within dangerousness domain of CTRS (r = 0.703, p < 0.0001). CRPT and CTRS scores showed similar predictive validity (p < 0.0001). High intraclass correlation coefficient (0.982) and Cohen's Kappa (0.89) were observed for CRPT score (r = 0.982, p < 0.0001).

CONCLUSIONS

CRPT appeared to be a useful instrument for PEP classification due to its concurrent validity, predictive validity and reliability. CRPT score showed higher correlations than the CRPT color/risk. The five levels of risk provided by the CRPT appear to represent a simple and specific method for classifying PEP. This approach considers actual or potential risk, rather than severity, as the main factor for sorting PEP, which improves upon the current approach to emergency classification that is mainly based on the criterion of severity. Regardless of the triage procedure, emergency assessments should no longer classify PEP as "not real emergencies."