A study of patients who leave without notice in an A & E department

Missing the boat: odds for the patients who leave ED without being seen

BACKGROUND

A patient left without being seen is a well-recognized indicator of Emergency Department overcrowding. The aim of this study was to define the characteristics of LWBS patients, their rates and associated factors from a tertiary care hospital of Pakistan.

METHODS

A retrospective patient record review was undertaken. All patients presenting to the Aga Khan University Hospital, Karachi, between April and December of the year 2010, were included in the study. Information was collected on age, sex, presenting complaints, ED capacity, month, time, shift, day of the week, and waiting times in the ED. A basic descriptive analysis was made and the rates of LWBS patients were determined among the patient subgroups. Logistic regression analysis was used to assess the risk factors associated with a patient not being seen in the ED.

RESULTS

A total of 38,762 patients visited ED during the study period. Among them 5,086 (13%) patients left without being seen. Percentage of leaving was highest in the night shift (20%). The percentage was twice as high when the ED was on diversion (19.8%) compared to regular periods of operation (9.8%). Mean waiting time before leaving the ED in pediatric patients was 154 minutes while for adults it was 171 minutes. More than 32% of patients had waited for more than 180 minutes before they left without being seen, compared to the patients who were seen in ED. Important predictors for LWBS included; Triage category P4 i.e. walk -in-patients had an OR of 13.62(8.72-21.3), Diversion status, OR 1.49(1.26-1.76), night shift , OR 2.44(1.95-3.05) and Pediatric age, OR 0.57(0.48-0.66).

CONCLUSIONS

Our study elucidates the LWBS population characteristics and identifies the risk factors for this phenomenon. Targeted interventions should be planned and implemented to decrease the waiting time and alternate services should be provided for high-risk patients (for LWBS) to minimize their number.

Leaving the paediatric emergency department without being seen: understanding the patient and the risks

AIM

The aim of this study is to examine the left-without-being-seen (LWBS) patient population of a tertiary paediatric emergency department (ED) to provide quality assurance and risk management data.

METHODS

This is a prospective observational study of patients who LWBS after presenting to the Royal Children's Hospital Melbourne ED between July and November 2005. Information was collected from electronic databases and follow-up telephone interviews performed by the principal investigator 3-5 days after the presentation.

RESULTS

Over the 17-week study period, 7.6% of attendances were recorded as having LWBS. These patients and their presentations resembled the general ED population in many respects. However, there were several significant differences, particularly in relation to age, insurance status, mode of arrival, referral status, arrival time and illness severity. Most families (74%) indicated they would have been equally happy to visit a general practitioner instead had one been available. Prolonged waiting times and recognition that their child's illness was not severe were the most frequent reasons for leaving. Most parents subsequently accessed alternate health care or were planning to do so, and the majority stated their child's illness was improving. Parents maintained a surprisingly positive attitude to their ED presentation.

CONCLUSION

The individual risks associated with leaving the ED before a child has been medically assessed are small. However, when multiplied several thousandfold as a function of the frequency of LWBS patients, the chance of serious adverse events becomes real. Potential risk management strategies include decreasing absolute LWBS numbers by addressing ED overcrowding and providing alternate sources for non-urgent care.

A population follow-up study of patients who left an emergency department without being seen by a medical officer

OBJECTIVES

To describe the population of emergency department patients who leave without being seen by a medical officer, to investigate the circumstances of their visit and to ascertain whether they subsequently receive alternative medical care.

METHODS

A follow-up study was conducted of patients who were initially triaged, but left without being seen by a medical officer between July 2003 and October 2003 in a tertiary referral hospital emergency department in Sydney, Australia. Emergency Department Information System data were reviewed for population demographics, presenting complaints and acuity rating of patients. Follow-up telephone interviews were conducted within 7 days after the patient left the emergency department.

RESULTS

During the study period, 8.6% (1272 of 14 741) of the emergency department patients left without seeing a doctor and 35.9% (457 of 1272) of these patients who walks out were contacted for follow-up. The results from bivariate and multivariate analyses showed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Young patients aged 0-29 years, and those with longer waiting time for triage and triaged as "less urgent" were more likely to walk out than others. Overcrowding in the emergency department had a significant association with walkout of patients. Prolonged waiting time was the most common reason for leaving emergency departments without being seen by a doctor. Only 12.7% (58 of 457) of the walkout patients revisited emergency departments within 7 days of their departure and of those who were subsequently admitted following their return to hospital accounted for 5.0% (23 of 457). Of the follow-up patients, 39.4% felt angry about their emergency department experiences.

CONCLUSIONS

The number of patients who leave an emergency department without seeing a doctor is strongly correlated with waiting time for medical review. Achieving shorter emergency department waiting times is central to reducing the numbers of people leaving without being seen. The rate of patients who leave without being seen is also strongly correlated with triage category. These findings highlight the importance of accurate triaging, as this clearly influences waiting time. It is also likely that there are patients who benefit from the reassurance of the triage assessment, and therefore feel less urgency for medical review. These may be cases where immediate medical review is not essential. This area should be further explored. These results are important for planning and staffing health services. Decision makers should identify and target factors to minimise walkouts from public hospital emergency departments.

Factors associated with walkout of patients from New South Wales hospital emergency departments, Australia

OBJECTIVE

To explore the association between daily patient numbers, sociodemographic, clinical and system characteristics and walkout rates of patients from New South Wales (NSW) public hospital ED (without seeing a medical officer).

METHODS

This was a secondary analysis of the NSW Emergency Department Data Collection, between 1 January 1999 and 31 December 2001, with a total of 4 356 323 ED attendances. Bivariate and multiple logistic regression analyses were performed to explore the relationship of walkout from ED and explanatory variables.

RESULTS

About 5.7% of the patients attending in NSW public hospital ED left without seeing a doctor. The results from bivariate and multivariate analyses revealed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Patient groups that more likely to walk out were those aged 15-44 years, from a non-English-speaking background, Aboriginal, with lower socioeconomic status, with no private health insurance coverage and longer waiting times for triage. Patient volume in the ED showed a significant positive association with walkout rates.

CONCLUSIONS

After adjusting for triage category (urgency of presentation) and triage time, patients from lower socioeconomic backgrounds and those without private health insurance coverage were more likely to leave ED without treatment. These results have important implications for Health Services. Future strategies aimed at minimizing walkouts from public hospital ED should prioritize and target factors identified in the present study.