Factors Associated with Patients Who Leave without Being Seen

Objectives: Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS. Methods: A modified case‐crossover design to determine the transient effects on the risk of acute events was used. Over a four‐month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed‐rank test, and conditional logistic regression analyses were used to determine significant variables. Results: Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important. Conclusions: ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.     

Return visit characteristics among patients who leave without being seen from a pediatric ED

Objectives

The primary aim of this study was to evaluate for differences in acuity level and rate of admission on return visit between patients who leave without being seen (LWBS) and those who are initially evaluated by a physician. Our secondary aim was as well as to identify predictors of which LWBS patients will return to the ED with high acuity or require admission.

Methods

A cross-sectional study using an administrative database at an academic tertiary-care pediatric hospital in the United States from January 1, 2006, to December 31, 2008 was done.

Results

There were 3525 patients who LWBS during the study period (1.2% of total ED visits). Of these, 87% were triaged as nonurgent, and 13% as urgent at their initial visit. Two hundred eighty-nine (8%) of LWBS patients returned to the ED within 48 hours. Compared with the population who returned to the ED after previous evaluation, patients who LWBS from their initial visit and returned had significantly lower odds of urgent acuity at time of return visit (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.15-0.32) and of being admitted (OR, 0.58; 95% CI, 0.40-0.84). Urgent acuity at initial visit (OR, 2.86; 95% CI, 1.35-6.04) and number of ED visits in last 6 months (OR, 1.24; 95% CI, 1.02-1.52) were significant predictors of admission at return visit among the LWBS population.

Conclusions

Generally, patients who LWBS from a pediatric ED were unlikely to return for ED care, and those who did were unlikely to either be triaged as urgent or require hospital admission. This study showed that urgent acuity during the initial visit and number of previous ED visits were significant predictors of admission on return. Identification of these predictors may allow a targeted intervention to ensure follow-up of patients who meet these criteria after they LWBS from the pediatric ED.     

National Study of Patient, Visit, and Hospital Characteristics Associated With Leaving an Emergency Department Without Being Seen: Predicting LWBS

Objectives: The objective was to estimate the national left‐without‐being‐seen (LWBS) rate and to identify patient, visit, and institutional characteristics that predict LWBS. Methods: This was a retrospective cross‐sectional analysis using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Bivariate and multivariate analyses were performed to identify predictors of LWBS. Results: The national LWBS rate was 1.7 (95% confidence interval [CI] = 1.6 to 1.9) patients per 100 emergency department (ED) visits each year. In multivariate analysis, patients at extremes of age (<18 years, odds ratio [OR] = 0.80, 95% CI = 0.66 to 0.96; and ≥65 years, OR = 0.46, 95% CI = 0.32 to 0.64) and nursing home residents (OR = 0.29, 95% CI = 0.08 to 1.00) were associated with lower LWBS rates. Nonwhites (black or African American (OR = 1.41, 95% CI = 1.22 to 1.63) and Hispanic (OR = 1.25, 95% CI = 1.04 to 1.49), Medicaid (OR = 1.47, 95% CI = 1.27 to 1.70), self‐pay (OR = 1.96, 95% CI = 1.65 to 2.32), or other insurance (OR = 2.09, 95% CI = 1.74 to 2.52) patients were more likely to LWBS. Visit characteristics associated with LWBS included visits for musculoskeletal (OR = 0.70, 95% CI = 0.57 to 0.85), injury/poisoning/adverse event (OR = 0.65, 95% CI = 0.53 to 0.80), and miscellaneous (OR = 1.56, 95% CI = 1.19 to 2.05) complaints. Visits with low triage acuity were more likely to LWBS (OR = 3.59, 95% CI = 2.81 to 4.58), whereas visits that were work‐related were less likely to LWBS (OR = 0.19, 95% CI = 0.12 to 0.29). Institutional characteristics associated with LWBS were visits in metropolitan areas (OR = 2.11, 95% CI = 1.66 to 2.70) and teaching institutions (OR = 1.33, 95% CI = 1.06 to 1.67). Conclusions: Several patient, visit, and hospital characteristics are independently associated with LWBS. Prediction and benchmarking of LWBS rates should adjust for these factors.     

Uncompleted Emergency Department Care: Patients Who Leave against Medical Advice

Objectives: To compare the patient characteristics, clinical conditions, and short-term recidivism rates of emergency department (ED) patients who leave against medical advice (AMA) with those who leave without being seen (LWBS) or complete their ED care.
Methods: All eligible patients who visited the ED between July 1, 2004, and June 30, 2005 ( N = 31,252) were classified into one of four groups: 1) AMA ( n = 857), 2) LWBS ( n = 2,767), 3) admitted ( n = 8,894), or 4) discharged ( n = 18,734). The patient characteristics, primary diagnosis, and 30-day rates of emergent hospitalizations, nonemergent hospitalizations, and ED discharge visits were compared between patients who left AMA and each of the other study groups. A Cox proportional hazards model was used to examine the influence of study group status on the risk of emergent hospitalization, adjusted for patient characteristics.
Results: Patients who left AMA were significantly more likely to be uninsured or covered by Medicaid compared with those admitted or discharged (p < 0.001). The AMA visit rates were highest for nausea and vomiting (9.7%), abdominal pain (7.9%), and nonspecific chest pain (7.6%). During the 30-day follow-up period, patients who left AMA had significantly higher emergent hospitalization and ED discharge visit rates compared with each of the other study groups (p < 0.001). Insurance status, male gender, and higher acuity level were also associated with a significantly higher emergent hospitalization rate.
Conclusions: Patients who leave AMA may do so prematurely, as evidenced by higher emergent hospitalization rates compared with those who LWBS or complete their care.     

Applying the Boston Syncope Criteria to Near Syncope

Background

We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well.

Objective

To determine if BSC accurately predict which near-syncope patients require hospitalization.

Methods

A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls.

Results

Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up.

Conclusion

Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.     

Prognostic factors for important clinical outcomes in patients with a severe infection

Background

Patients who are admitted with a suspicion of a severe infection usually enter the hospital through the emergency department (ED). The recognition of prognostic factors in an early stage affects further treatment and might improve clinical outcomes.

Aims

We examined possible prognostic factors for four important outcomes: intensive care unit (ICU) admission, positive blood cultures, mortality and re-admission.

Methods

All adult patients arriving at the ED with a suspected infection for whom admittance and intravenous (iv) antibiotics were indicated were included between March and December 2006. Possible prognostic variables were obtained from medical history, physical examination and laboratory results during the ED presentation. Data were analysed using logistic regression analysis.

Results

A total of 295 ED patients were evaluated, of whom 27 were referred to the ICU, 62 had a positive blood culture, 16 died and 48 were re-admitted. In multivariate analysis, patients with a respiration rate of >25/min were at higher risk for ICU admission. Patients with a positive blood culture had a higher heart rate and a higher percentage of segmented neutrophils. Patients who died during admission were more likely to be older, confused and had lower blood pressure. Patients who were re-admitted within 30 days were more likely to be male, younger and less likely to have a positive blood culture.

Conclusions

Routine clinical and biochemical information can be used to predict ICU admission, the presence of bacteraemia, mortality and re-admission (within 30 days) and should be taken into consideration for treatment decisions.     

Review article: People who present on multiple occasions to emergency departments

Research about people who present on multiple occasions to the ED began in the 1980s. Despite this, little is known of their journey as patients. Understanding ED use as a journey can help clinicians improve how they meet the needs of this patient group. Multiple terms were used to identify research on the use of the ED. Papers were included if they had a primary focus on multiple presentations by the general ED population. Integrative review methods were used to extract findings related to the patients' journeys. The findings confirm a sequence of events and processes that provide an outline of the journey through the experience of people who present on multiple occasions. The journey concerns people's decisions to present and re‐present to the ED, their assessments on arrival, dilemmas of treatment, outcomes of care and long‐term health outcomes. This patient group often have high and complex health needs, engage extensively with other health services and have poor long‐term health outcomes. The issue of multiple presentations to the ED is complex and ongoing because of the morbidity of the people concerned, the preference of patients to attend, the purpose of the ED and preparation and role of the personnel and the difficulties with continuity of care. The provision of care for people who present on multiple occasions can be improved within the ED and health services generally through a better understanding of presentations.     

Review article: Outcomes of patients who are not transported following ambulance attendance: A systematic review and meta‐analysis

The aim of this systematic review and meta‐analysis was to evaluate the outcomes of patients who are not transported to hospital following ambulance attendance. A database search was conducted using PubMed, Medline, Embase, CINAHL and Cochrane Library. Studies were included if they analysed the outcomes of patients who were not transported following ambulance attendance. The primary outcome of this review was subsequent presentation to an ED following a non‐transport decision. Secondary outcome measures included hospital admission, subsequent presentation to alternative service provider (e.g. private physician), and death at follow up. The search yielded 1953 non‐duplicate articles, of which 10 met the inclusion criteria. Three studies specified that the non‐transport decision was emergency medical services (EMS)‐initiated, seven studies did not specify. Meta‐analysis found substantial heterogeneity between estimates (I² >50%) that was likely because of differences in study design, length of follow up, patient demographic and sample size. Between 5% and 46% (pooled estimate 21%; 95% CI 11–31%) of non‐transport patients subsequently presented to ED. Few (pooled estimate 8%; 95% CI 5–12%) EMS‐initiated non‐transport patients were admitted to hospital compared to the unspecified group (pooled estimate 40%; 95% CI 7–72%). Mortality rates were low across included studies. Studies found varying estimates for the proportion of patients discharged at the scene that subsequently presented to ED. Few patients were admitted to hospital when the non‐transport decision was initiated by EMS, indicating EMS triage is a relatively safe practice. More research is needed to elucidate the context of non‐transport decisions and improve access to alternative pathways.     

Hot off the Press: SGEM #226. I Want a New Drug—One That Doesn't Cause an Adverse Drug Event

Adverse drug events (ADEs) are a significant cause of emergency department (ED) visits in North America and are frequently misdiagnosed. Despite evidence supporting improved health care outcomes for ED patients who have a pharmacist‐led medication review, EDs do not have sufficient clinical pharmacists to perform medication reviews on all patients. The study reviewed in this article aimed to validate clinical decision rules for use by clinical pharmacists and physicians to prioritize ED patients with ADEs.     

Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department

BackgroundEmergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics.MethodsWe performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models.ResultsA total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27–1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21–1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS.ConclusionNot only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.     

The ED‐inpatient dashboard: Uniting emergency and inpatient clinicians to improve the efficiency and quality of care for patients requiring emergency admission to hospital

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED‐inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time‐based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes.     

Negative health outcomes and adverse events in older people attending emergency departments: A systematic review

For the last 25 years, there have been mounting concerns that ED's fast-paced environment is not suitable to meet the care needs of the ever-increasing older population. This paper reviews the research-based literature regarding negative health outcomes and adverse events experienced by older patients in the emergency department (ED). Electronic databases were searched for relevant English references. Search terms included: ‘older person’; ‘emergency department’; ‘health outcome’; and ‘adverse event’. The literature outlines a number of negative health outcomes and adverse events in older ED patients, including outcomes related to changes in health status, administrative outcomes suggesting negative health outcomes, and adverse events potentially associated with suboptimal ED practice. Further research is needed on the extent to which these apparent outcomes and events are avoidable. There are potential gains to be made in quality of geriatric emergency care by establishing evidence-based care that attends to the identified adverse events to achieve desirable health outcomes in this vulnerable ED population.     

The Effect of Physician Triage on Emergency Department Length of Stay

Background: Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. Objectives: We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion. Methods: This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period. Results: We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month. Conclusion: Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.     

Setting wait times to achieve targeted left-without-being-seen rates

Background

Although several studies have demonstrated that wait time is a key factor that drives high leave-without-being-seen (LWBS) rates, limited data on ideal wait times and impact on LWBS rates exist.

Study Objectives

We studied the LWBS rates by triage class and target wait times required to achieve various LWBS rates.

Methods

We conducted a 3-year retrospective analysis of patients presenting to an urban, tertiary, academic, adult emergency department (ED). We divided the 3-year study period into 504 discrete periods by year, day of the week, and hour of the day. Patients of same triage level arriving in the same bin were exposed to similar ED conditions. For each bin, we calculate the mean actual wait time and the proportion of patients that abandoned. We performed a regression analysis on the abandonment proportion on the mean wait time using weighted least squares regression.

Results

A total of 143?698 patients were included for analysis during the study period. The R² value was highest for Emergency Severity Index (ESI) 3 (R² = 0.88), suggesting that wait time is the major factor driving LWBS of ESI 3 patients. Assuming that ESI 2 patients wait less than 10 minutes, our sensitivity analysis shows that the target wait times for ESI 3 and ESI 4/5 patients should be less than 45 and 60 minutes, respectively, to achieve an overall LWBS rate of less than 2%.

Conclusion

Achieving target LWBS rates requires analysis to understand the abandonment behavior and redesigning operations to achieve the target wait times.     

Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study

Objectives

For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events.

Methods

An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients > age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition.

Results

We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02).

Conclusions

A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.     

Uniting emergency and inpatient clinicians across the ED–inpatient interface: The last frontier?

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED–inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system‐wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.