Faculty Triage Shortens Emergency Department Length of Stay

OBJECTIVE: To determine whether faculty triage (FT) activities can shorten emergency department (ED) length of stay (LOS). METHODS: This was a comparison study measuring the impact of faculty triage vs no faculty triage on ED LOS. It was set in an urban county teaching hospital. Subjects were patients presenting to the registration desk between 9 AM and 9 PM on 16 consecutive Mondays (August 2 to November 15, 1999). On eight Mondays, an additional faculty member was stationed at the triage desk. He or she was asked to expedite care by rapid evaluation orders for diagnostic studies and basic therapeutic interventions, and by moving serious patients to the patient care areas. He or she was not provided with detailed instructions or protocols. The ED LOS, time of registration (TIMEREG), inpatient admission status (ADMIT), x-ray utilization (XRAY), total patients registered each day between 9 AM and 9 PM (TOTREG), and patients who left without being seen (LWBS) were determined using an ED information system. The LOS was analyzed in relation to FT, ADMIT, and XRAY by the Mann-Whitney U test. The LOS was related to TIMEREG and TOTREG by simple linear regression. Stepwise multiple linear regression models to predict LOS were generated using all the variables. RESULTS: Patients without FT (n = 814) had a mean LOS of 445 minutes. Patients with FT (n = 920) had a mean LOS of 363 minutes. Mean difference in LOS was -82 minutes (95% CI = -111 to -53), a reduction of 18%. The LOS was also related to: ADMIT +203 minutes (95% CI = 168 to 238), TOTREG -2.7 min/additional patient registered (95% CI = -1.15 to -4.3), and TIMEREG +0.14 min/min since 9 AM (95% CI = 0.07 to 0.21). The LWBS was reduced by 46% with FT. In multiple regression analysis, ADMIT, FT, TIMEREG, and XRAY were all related to LOS, but the model explained only a small part of variance (adjusted R(2) = 0.093). The faculty cost is estimated to be $11.98/patient. CONCLUSIONS: Faculty triage offers a moderate increase in efficiency at this ED, albeit with relatively high cost.     

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.     

Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED

OBJECTIVE: We hypothesize that the number of patients who leave without being seen is correlated with the simple-to-use National Emergency Department Overcrowding Scale (NEDOCS). METHODS: Results of a 6-item ED overcrowding scale (NEDOCS) were collected prospectively over a 17-day study period. The following additional data were extracted from records for each 2-hour study period: (1) number of registered patients, (2) number of ambulances that arrived, and (3) number of patients signed in that hour who eventually left without being seen. Spearman correlation coefficients were computed for the leaving without being seen (LWBS) rate with the NEDOCS score at the time of patient presentation and 2, 4, and 6 hours later. RESULTS: The study period represents two hundred fourteen 2-hour periods. The LWBS rate was determined for 100% of the times; NEDOCS scores were determined for a sampling of 62% of the times spread equally over all hours of the day and days of the week. Correlation between the NEDOCS score and LWBS was 0.665. CONCLUSION: The NEDOCS score is well correlated with LWBS.     

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.     

Freestanding emergency departments in Texas do not alleviate congestion in hospital-based emergency departments

ObjectivesEver since the passage of the Texas Freestanding Emergency Medical Care Facility Licensing Act in 2009, freestanding Emergency Departments (FrEDs) have spread throughout Texas. This study aims to determine whether the entry of FrEDs has been associated with less congestion in hospital-based EDs.MethodsThe dependent variables of interest were hospital-based ED annual visit volume, median wait time, length of visit for discharged patients and the percent of patients who left without being seen (LWBS). The explanatory variables of interest were the numbers of FrEDs within the same local market of each hospital-based ED, and an indicator variable for whether the hospital owned satellite FrEDs in outlying areas.ResultsHospital ED visits, wait times, length of visit for discharged patients, and LWBS rates were not associated with the number of competitor FrEDs in the local market. Hospitals that opened satellite FrEDs had significantly higher visit volume in general, but did not experience shorter wait times, length of visit or LWBS rates if located in large metropolitan areas.ConclusionsThe entry of FrEDs did not help relieve congestion in nearby hospitals in major metropolitan areas in Texas. By offering more treatment options to patients, FrEDs are associated with increased usage of emergency services.     

Review article: Leaving the emergency department without being seen

Patients who leave the ED without being seen (LWBS) are unlikely to be satisfied with the quality of the service provided and might be at risk from conditions that have not been assessed or treated. We therefore examined the available research literature to inform the following questions: (i) In patients who attend for ED care, what factors are associated with the decision to LWBS? (ii) In patients who attend for ED care, are there adverse health outcomes associated with the decision to LWBS? (iii) Which interventions have been used to try to reduce the number of patients who attend for ED care and LWBS? From the available literature, there was insufficient evidence to draw firm conclusions; however, the literature does suggest that patients who LWBS have conditions of lower urgency and lower acuity, are more likely to be male and younger, and are likely to identify prolonged waiting times as a central concern. LWBS patients generally have very low rates of subsequent admission, and reports of serious adverse events are rare. Many LWBS patients go on to seek alternative medical attention, and they might have higher rates of ongoing symptoms at follow‐up. Further research is recommended to include comprehensive cohort or well‐designed case–control studies. These studies should assess a wide range of related factors, including patient, hospital and other relevant factors. They should compare outcomes for groups of LWBS patients with those who wait and should include cross‐sectoral data mapping to truly detect re‐attendance and admission rates.     

Estimation of unregistered patients who left without being seen: At an urban mid-sized Canadian community emergency department

ObjectiveTo determine whether changes to the appearance of an emergency department (ED) waiting room influenced the number of patients who left without being seen (LWBS).DesignRetrospective analysis using National Ambulatory Care Reporting System data collected at the time of patient registration.SettingThe ED of Belleville General Hospital, a mid-sized secondary care community hospital in Ontario with a catchment population of 125 000.ParticipantsAll unscheduled patients registering at the hospital to be seen in the ED from July 1 to December 31, 2016 (control period), and from July 1 to December 31, 2017 (study period).Main outcome measuresThe volume of patients registering by Canadian Triage and Acuity Scale (CTAS) level to be seen in the ED during the study period compared with the volume of patients registering during the control period, and the number of LWBS during the 2 time periods.ResultsThe average number of patients registered per month was significantly greater in the study period than in the control period (t₁₀ = -5.53, P < .01). A total increase of 1881 registrations was recorded in the study period, or 10.47% (increase per month ranged from 9.59% to 11.66%). The proportion of patients with less acute triage scores decreased in the study period; however, the differences in CTAS levels between the 2 years was not statistically significant (χ² = 1.05, P = .90). The number of LWBS according to CTAS level was lower in all categories in the study period, including those in the less acute levels, decreasing from 60 in CTAS 5 in 2016 to 45 in 2017, and 585 in CTAS 4 in 2016 to 330 in 2017. Overall, the distribution of LWBS by CTAS level was significantly different between the control and study periods (P < .01).ConclusionThe number of patients registering is influenced by the apparent high or low occupancy of the waiting area at the time of registration.     

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.     

多维急诊科拥挤评分量表编制

目的 通过对急诊科拥挤相关变量筛选,共纳入急诊总床位占用率、抢救室床位占用率、廊厅/过道诊治患者数、候诊患者数量和时间、正在使用的生命脏器功能支持设备数量、新进抢救室病例数、ICU满负荷状况、急诊满负荷状况(持续时间)、流出道梗阻率、救护车转向和LWBS现象等12项易在中国城市医院急诊科获得的有效的拥挤相关指标,并对之进行赋值,依据Robert F.DeVellis等编著的量表编制指南,构建新的多维急诊科拥挤评分量表(MEDOS,系统得分范围0 ～ 40分).随后进行为期6个月量表测试,初步研究结果显示,MEDOS均值(n =552)为25.4±5.8 (5～39),90百分位数为34分,75百分位数为31分,中位数为26分,25百分位数为21分,10百分位数为17分.折半信度检验MEDOS内部一致性,Split-half系数为0.817 (P＜0.01),提示MEDOS量表评分法有良好的可信度.     

Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis

IntroductionEmergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research.Study objectivesThe objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput.MethodsWe searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI).ResultsTwelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from −82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity.ConclusionImplementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.     

Effects of a fast-track area on emergency department performance

To determine if a fast-track area (FTA) would improve Emergency Department (ED) performance, a historical cohort study was performed in the ED of a tertiary care adult hospital in the United States. Two 1-year consecutive periods, pre fast track area (FTA) opening-from February 1, 2001 to January 31, 2002 and after FTA opening-from February 1, 2002 to January 31, 2003 were studied. Daily values of the following variables were obtained from the ED patient tracking system: 1) To assess ED effectiveness: waiting time to be seen (WT), length of stay (LOS); 2) To assess ED care quality: rate of patients left without being seen (LWBS), mortality, and revisits; 3) To assess determinants of patient homogeneity between periods: daily census, age, acuity index, admission rate and emergent patient rate. For comparisons, the Wilcoxon test and the Student's t-test were used to analyze the data. Results showed that despite an increase in the daily census (difference [diff] 8.71, 95% confidence interval [CI] 6 to 11.41), FTA was associated with a decrease in WT (diff -51 min, 95% CI [-56 to -46]), LOS (diff -28 min, 95% CI [-31 to -23]) and LWBS (diff -4.06, 95% CI [-4.48 to -3.46]), without change in the rates of mortality or revisits. In conclusion, the opening of a FTA improved ED effectiveness, measured by decreased WT and LOS, without deterioration in the quality of care provided, measured by rates of mortality and revisits.     

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.     

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.     

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.     

Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department

Objective: To quantify the number of patients seen per hour by non–emergency medicine (non–EM) residents in a university hospital ED.
Methods: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24–hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non–EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated.
Results: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0. 95 ± 0. 20 patients/ hour, with a range from 0. 58 to 1. 75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey–Kramer test (α = 0. 05).
Conclusion: The rate at which non–EM residents work up patients is consistent with previously reported rates for EM residents.