Left-without-being-seen patients and nurse counselling

It is with great interest that we acknowledge the recent publication concerning improvements that could prevent departures of patients that left-without-being seen (LWBS) (1). Children who LWBS are an important concern in our emergency department (ED) and we have previously reported a proportion of LWBS of 17% during the year 2008 (2). With the implementation of many strategies, we were able to reduce that number to 10% in two years. Such improvements include screening patients for minor symptoms using pre-established criteria during the quick look evaluation. Once identified, these patients can be fast tracked without being triaged, to a minor care clinic within the ED where they are seen by a physician that is working collaboratively with a nursing assistant. Other measures have also been suggested (3).

Ibanez et al suggest that when the personnel is aware of a patient who is about to LWBS, appropriate information should be provided (1). This should be emphasized, as we have recently demonstrated that patients who receive counselling by a nurse before leaving have a 24% relative risk reduction in their return visits within the next 48 hours compared to those who left without warning and thus could not be warranted the appropriate counselling (2). Indeed, only 6.1% of patients counselled prior to departure returned to the ED compared to 8.1 % who did not benefit from any advice before leaving the ED (2). Without necessarily decreasing the rate of LWBS, this measure, also greatly improves the quality of care provided to these patients.

Interestingly enough, our waiting room is about to undergo a major make-over using a Cirque du Soleil theme. We are hopeful that, with your results suggesting that patients request more comfortable waiting rooms, this measure will also contribute to decreasing the LWBS in our ED.

Benoit Bailey MD MSc FRCPC, Michael Arseneault MD FRCPC, Arielle Levy MD MEd FRCPC, Jocelyn Gravel MD MSc FRCPC Division of Emergency Medicine Department of Pediatrics CHU Sainte-Justine Montreal, Qc

Competing Interest: None to declare. Word count: 296 (excluding title and references) Key word: paediatric emergency medicine; management. References

1. Ibanez G, Guerin L, Simon N. Which improvements could prevent the departure of the left-without-being-seen patients? Emerg Med J 2011; 28: 945-947.

2. Gaucher N, Bailey B, Gravel J. For children leaving the emergency department before being seen by a physician, counselling from nurses decreases return visits. Int Emerg Nurs 2011; 19: 173-177.

3. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med 2010; 55: 142-160.

Conflict of Interest:

None declared