Comparing patients who leave the ED prematurely, before vs after medical evaluation: a National Hospital Ambulatory Medical Care Survey analysis

Reduced Emergency Department Length of Stay and Proportion of Patients Who Left Without Being Seen Following Implementation of an Interprofessional Vertical Flow Track With Pivot Triage: A Retrospective Pre-/Postintervention Evaluation

Our objective was to assess change in length of stay and patients who left without being seen following implementation of a pivot triage and interprofessional vertical flow track process at a midwestern academic medical center emergency department. The intervention leveraged an existing interprofessional staffing model including a registered nurse and a paramedic to staff a vertical flow track daily from 1100 to 2300. Pre- and postintervention data were retrospectively abstracted from the electronic charting software. Outcomes included emergency department length of stay and percentage of patients leaving without being seen. Visits for patients during the postintervention period (May 10, 2019, to August 31, 2019) were compared with a corresponding preintervention time period 1 year prior (May 10, 2018, to August 31, 2018). The percentage of patients routed to the vertical flow track increased from 5% to 22% following the process intervention. Median emergency department length of stay decreased from 199 (interquartile range [IQR]: 129-282) to 159 (IQR: 98-232) min. The percentage of patients leaving without being seen decreased from 2.9% to 0.5%; between 1100 and 2300, these changes were more pronounced. Odds of a patient experiencing emergency department length of stay under 180 min increased nearly twofold (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.79-2.08) and odds that a patient stayed to be seen by a medical professional increased sixfold (OR: 5.94, 95% CI: 4.08-8.63). Overall, more than 20% of patients were routed through the vertical flow track following the process change. Implementation of an emergency department pivot triage approach with a dedicated interprofessional vertical flow track was associated with significantly shorter emergency department length of stay and reduced patients leaving without being seen.

Patients Who Leave the Emergency Department Before Treatment Completion: A Retrospective Cohort Study

BACKGROUND

Patients leaving the emergency department (ED) before treatment completion (LBTC) is a common universal occurrence. We hypothesized that the characteristics of the Israeli health care system, as well as its policy, intended to reduce the burden of nonurgent ED visits, may have an impact on factors associated with LBTC.

OBJECTIVES

The purpose of this study was to explore factors associated with LBTC in the Israeli context.

METHODS

This was a retrospective cohort study of patients who visited the ED in a major hospital located in northern-central Israel during 2016-2019. Characteristics of 130 randomly sampled LBTC patients and of 130 non-LBTC patients that constituted the control group, were compared. Odds ratios (OR) are presented.

RESULTS

A low-acuity triage score (OR 8.18, p < 0.01) and a longer length of stay (OR 1.15, p < 0.01) were found to be risk factors for LBTC, and female gender (OR 0.40, p < 0.01) was found to be a protective factor. In contrast, age and nationality were not found as risk factors. Significant differences were found between the two groups with regard to the main presenting complaint. However, both groups had similar rates of presentations with a psychiatric condition. Approximately half of the LBTC patients presented at times when primary clinics were active.

CONCLUSIONS

These findings reflect the strengths of the Israeli health care system. Despite the policy intended to reduce the burden of nonurgent ED visits, there are possible shortcomings in the system that should be addressed.

Characteristics of youth who leave the emergency department without being seen following sports-related concussion

Aim:

Despite the rising incidence of emergency department (ED) visits for sports-related concussion, the frequency and characteristics of youth leaving before being seen are unknown.

Methodology:

National estimates of ED visits for sports-related head injuries among youth (10–18 years) were generated for 2006–2017 using the National Electronic Injury Surveillance System. Logistic regression models estimated the odds of leaving without being seen across patient characteristics and time.

Results:

From 2006 to 2017, 985,966 (95% CI: 787,296–1,184,637) ED visits were identified for sports-related concussions, of which 5015 (95% CI: 3024–7006) left without being seen.

Conclusion:

Youth with sports-related concussion must receive timely care and ED improvements may reduce rates of leaving without being seen.

Over the last decade, more and more youth have visited the emergency department (ED) for sports-related concussion. At the same time, EDs are becoming more crowded, with long wait times and many patients leaving before being evaluated. An increase in the proportion of youth with concussion who left without being seen (LWBS) is possible. We used national data of ED visits to examine the rate of youth (aged 10–18 years) who LWBS for sports-related concussion from 2006 to 2017. While the rate of LWBS has not changed over time, more nonwhite youth and youth who were not injured at school left before being evaluated.

Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

Introduction

The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.

Methods

This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.

Results

Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.

Conclusion

ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

Left without being seen in a hybrid point of service collection model emergency department

OBJECTIVE

This study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses "point-of-service" (POS) collection for low acuity patients.

METHODS

This was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS.

RESULTS

133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year.

CONCLUSION

In an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care.

"Should I stay or Should I go": patient who leave Emergency Department of an Italian Third-Level Teaching Hospital

Background and Aim: Patients could leave ED not receiving the desired care either Without Being Seen by a doctor (LWBS) or Against Medical Advice (DAMA). In term of care quality, LWBS may be related to inappropriate access and process of care, while DAMA may lead to increased risk of mortality and re-admissions. This study aims to identify frequency of patients who leave ED, determine their characteristics and identify associated factor. Methods: This was a retrospective observational study of patients that attended EDs of University Hospital Trust of Verona in 2017. Demographic and ED access associated variables were collected for LWBS, DAMA and completed-ED-treatment patients. Univariate and multivariate data analyses was based on EMUR-PS administrative data.Results: 5,901 of 127,180 ED accesses were uncompleted treatment (4.64%); LWBS were 4,664 (79.04%) and DAMA 1,237 (20.96%). Those who leave ED tended to be younger (39.35 vs. 45.56, p<0.01). Independent factors associated with ED leaving resulted: i) non-urgent triage category (OR: 2.941, 95%CI: 2.405-3.596) ii) non-Italian-nationality (OR: 1.695, 95%CI: 1.493-1.924) and requiring psychiatric consult (OR:6.16 95%IC 4.82-7.87); while protective factors resulted: i) female gender (OR: 0.713, 95%CI: 0.633-0.803); i) Paediatric ED (OR: 0.593, 95%CI: 0.437-0.805); ii) Obstetrics-Gynaecology ED (OR: 0.284, 95%CI: 0.193-0.416) iii) inclusion in fast track pathways (OR: 0.747, 95%CI: 0.602-0.927). Higher ED leaving rate were observed during night-time and Sunday, either overcrowding resulted not associated.Conclusion: Results show the necessity to implement primary care-ED integrated pathway, mainly in frail sub-population, improve awareness on healthcare service use and refine communication skills in ED-team. (www.actabiomedica.it)