Health policy and clinical practice/original researchPatients Who Leave Without Being Seen: Their Characteristics and History of Emergency Department Use
Introduction
During the past decade, emergency department (ED) crowding has become a prevalent and worsening problem in the United States and other countries.1, 2, 3, 4, 5, 6 There is a growing concern that patient safety is being compromised.7, 8, 9, 10 One of the ways that ED crowding can harm patient safety is when patients leave without being seen by a physician. When crowding occurs, patients wait longer. The longer they wait, the more likely they are to leave without being seen.11, 12, 13, 14, 15 A small but significant proportion of patients who leave without being seen have persistent problems that can jeopardize their health.13, 14
Rates of leaving without being seen are higher during periods of increased ED volume, as well as when the overall patient acuity (ie, greater proportion of trauma/admitted patients) in the ED is elevated.11, 12, 16, 17 Rates of leaving without being seen are also higher among larger hospitals, teaching hospitals, and hospitals that treat a high proportion of uninsured patients.1, 11
Although lower patient acuity has consistently been associated with more uncompleted visits, the relationship with other patient characteristics is unclear.13, 14, 15, 18, 19 For example, a cohort study conducted in the United Kingdom with 5,512 patients who left without being seen found that younger patients were significantly more likely to leave compared with older patients.18 In contrast, 2 studies conducted in the United States did not find any relationship between uncompleted visits and age.13, 14 The conflicting results among the studies conducted to date are due to differences in study design, patient populations, and risk factors examined. Only 2 of the studies controlled for the ED environment, as well as patient acuity, when identifying patient characteristics associated with uncompleted visits. One of the studies matched 30 patients who left without being seen to 14 who did not, according to age, sex, urgency of complaint, and time of ED presentation, but the sample size was too small to draw any rigorous conclusions.19 The other used multivariate regression techniques to control for the time of ED presentation and acuity when different patient characteristics were evaluated.18 However, because the study was conducted in the United Kingdom, major differences in the health care system there could cause different patient characteristics to be associated with uncompleted visits compared with those in the United States.
Although past studies have identified specific hospital characteristics that are associated with uncompleted visits, it is still unclear what patient factors are important. Most of the previous research that examined patient characteristics associated with uncompleted visits has been largely descriptive or conducted outside the United States. This study examines the association between different patient factors such as sociodemographic characteristics, past ED utilization, and proximity of residence to the ED on the risk of an uncompleted visit. By knowing more about patients who left without being seen, we will have better insight into the potential patient safety issues associated with these types of ED visits.
The purpose of this study was to identify patient characteristics associated with uncompleted visits, controlling for the ED and hospital environments, as well as the clinical urgency of the patients. To do this, patients who left without being seen (cases) were matched to patients who stayed and were treated (controls) by their registration date and time and triage level. The study was designed to answer the following question: among patients who present to the ED on the same day, at the same time, with the same acuity, what differentiates patients who stay and are treated from those who leave without being seen?
Section snippets
Study Design
We used a pair-matched case-control design to examine the influence of different patient characteristics on the likelihood of an uncompleted visit during a 6-month period. Cases were matched to controls according to registration date and time (±2 hours) and triage level. By matching on registration date and time, the matched case-control pairs experienced similar hospital and ED conditions at their ED visit. In addition, we matched on triage level so that we could focus on patient
Results
During July 1, 2004, to December 31, 2004, the overall uncompleted visit rate for the study ED was 6.4%. The uncompleted visit rate was highest during July (8.1%) and lowest during December (4.1%) (P<.001). It was also highest on Wednesdays (7.5%) and lowest on Saturdays and Sundays (5.5%) (P=0.001). There was a strong dose-response relationship between the uncompleted visit rate and triage acuity: 0.1% of level 1 (sickest), 4.9% of level 2, 8.1% of level 3, and 15.2% of level 4 (least sick) (P
Limitations
The results of this study must be considered in light of the following limitations. First, we were limited to examining exposure variables that are routinely collected in the patient registration and billing databases. For example, Goodacre and Webster18 found that patients who did not arrive by ambulance were significantly more likely to have an uncompleted visit compared with those who did. We were unable to examine this factor because mode of arrival is not recorded in either database
Discussion
Hospital EDs have become an integral component of the Unites States’ health care safety net.23, 24, 25, 26 Initially developed to treat patients with life-threatening conditions, they have evolved into facilities that also treat patients for a variety of unplanned, nonemergency but needed health care services.26 Emergency medicine has become a specialty that “bridges primary and specialty services, offering elements of both while maintaining a unique position of ready access and availability.”25
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Those who opt to leave: Comparison by triage acuity of emergency patients who leave prior to seeing a medical practitioner
2023, International Emergency NursingLeaving Without Being Seen From the Pediatric Emergency Department: A New Baseline
2023, Journal of Emergency MedicineThe Quality of Care in the Emergency Management of Cancer Patients With Febrile Neutropenia: A Records-Based Cohort
2020, Journal of Emergency NursingCitation Excerpt :The frequency of patients who LWBS was 1.4%, which represented the proportion of patients with a failed attempt to access the emergency department. Previous studies suggest that a rate of less than 5.0% for patients who LWBS is deemed to be safe for patients with a low acuity rating.27 Nevertheless, this cannot apply to patients with FN as delayed emergency care is associated with severe adverse consequences.11
An agent-based model for quantitatively analyzing and predicting the complex behavior of emergency departments
2017, Journal of Computational ScienceCitation Excerpt :However, the service capability of the healthcare staff is limited, some patients, especially those triaged as low AL may face long waiting time and they may leave without being seen (LWBS). As investigated by Ding et al. [40], it is common to see above 6% of patients LWBS due to physician unavailability. LWBS is a crucial efficiency and effectiveness metric for public EDs.
A simulation and optimization based method for calibrating agent-based emergency department models under data scarcity
2017, Computers and Industrial EngineeringComparing patients who leave the ED prematurely, before vs after medical evaluation: A National Hospital Ambulatory Medical Care Survey analysis
2016, American Journal of Emergency MedicineCitation Excerpt :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. Previous research has concluded that many of these patients come from vulnerable populations with poor overall access to care (Ding 2006 [22], Sun. 2007 [23]), so minimizing attrition is important.
Supervising editor: Brent R. Asplin, MD, MPH
Author contributions: All of the authors contributed to the scientific content of the article. All authors participated in the concept and design and interpretation of the data, as well as revising the manuscript. RD, MLM, and GL are responsible for the analysis of the data. MLM takes responsibility for the manuscript as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Publication dates: Available online June 30, 2006.
Reprints not available from the authors.