Refusal of emergency medical care: An analysis of patients who left without being seen,eloped, and left against medical advice

ObjectiveEmergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.MethodsThis prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.ResultsAmong 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).ConclusionED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.     

Patients leaving the ED without being seen by a physician: Is same-day follow-up indicated?

A prospective study was performed to determine acuity levels, waiting times, and reasons why patients who sought care in an emergency department (ED) left without being seen by a physician, and to evaluate whether timed telephone follow-up improved their health outcomes. A comparison and follow-up survey was conducted on all patients who registered for care in the ED at the Naval Medical Center, San Diego, CA, and left without being seen (n = 32) and a 20% systematic sampling of patients who waited until they were seen (n = 170) during a one-week period in Spring, 1993. Baseline demographics and health statuses on reporting to the ED were gathered on all patients waiting to be seen that agreed to participate in the study (n = 533). Demographics for those seen versus those who left without being seen (LWBS) were similar (mean age 23.9 v 23.2, not significant [NS]; percent male 50.5% v 50.0%, NS). Seen versus LWBS had a similar proportion of patients triaged urgent (15% v 6%, NS), and nonurgent (85% v 69%, NS). Twenty-five percent of LWBS left before triage. Acuity levels were compared for patients seen versus LWBS for level I (1.5% v 3%, NS), level II (75% v 78%, NS), and level III (23.5% v 19%, NS). For the 25% that left before triage, level I was 9%, level II was 64%, and level III was 27%. Sixty-nine percent of patients who LWBS were seen for evaluation within 48 hours, 9% in an ED and 60% in a clinic. One patient was admitted with a diagnosis of possible lithium toxicity and remained hospitalized for 7 days. Fifty-one percent of those seen received further care within one week, 3% in an ED and 48% in a clinic, with 80% being status checks rather than care because the patients said they felt worse. Mean waiting time of patients seen was 1.17 hours versus 1.78 hours for patients LWBS (significant at .05). The primary reason for a patient to LWBS was waiting time (69%). On follow-up, patients rated how they felt on a scale of 1 to 6, with 1 being much worse, and 6 being 100% better. Seen versus LWBS ratings were 5.10, much better (seen) versus 4.28, somewhat better (LWBS), significant at .01. When asked if they felt better as a direct result of their care/phone call, seen versus LWBS ratings were 5.1, to a large degree (seen) versus 4.0, to some degree (LWBS), significant at .01. The one acuity level I patient who LWBS said that her phone follow-up directly improved her health outcome (5, to a large degree). It was concluded that ED patients who LWBS have similar acuity levels to those who remain to be seen. The primary reason they leave is waiting time. Waiting time is directly related to limited access to primary care facilities after hours. This ultimately leads to ED overcrowding and increases the number of patients who LWBS, which potentially leads to poor health outcomes. Call-backs to patients who LWBS affects and, in certain cases, may improve health outcomes for this population.     

The Association between Emergency Department Crowding and Hospital Performance on Antibiotic Timing for Pneumonia and Percutaneous Intervention for Myocardial Infarction

Background: Antibiotics within four hours of arrival for patients with pneumonia and percutaneous intervention (PCI) within two hours for patients with acute myocardial infarction (AMI) are standard measures of emergency department (ED) quality. Objectives: To assess the institutional‐level association between measures of ED crowding and process measures for pneumonia and AMI. Methods: The authors used summary data from 24 academic hospitals in the University Health Consortium. Analysis included the 2004 ED cycle time survey and performance data from January to December 2004 regarding the Joint Commission for Accreditation of Healthcare Organizations' PN‐5b (initial antibiotic administration within four hours) for pneumonia and AMI‐8a (PCI received within 120 minutes). Spearman correlation coefficients were used to determine associations between crowding and performance measures. Results: Across all institutions, 59% (range 43%–77%) of pneumonia patients received antibiotics within four hours, and 57% (range 22%–95%) of AMI patients received PCI within two hours. An increase in overall ED length of stay (?0.44, p = 0.04) and for admitted patients (?0.37, p = 0.08) was associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. An increase in chest x‐ray turnaround time (?0.83, p < 0.001) and an increase in the left‐without‐being‐seen rate (?0.51, p = 0.01) were also associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. No measures of crowding exhibited an association with time to PCI for AMI patients. Conclusions: Administrative measures of ED crowding showed an association with poorer performance on pneumonia quality of care measures but not with AMI quality of care measures. Hospitals might consider improving ED throughput, reducing boarding times for admitted patients, and reducing chest x‐ray turnaround times to improve pneumonia care.     

Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative

IntroductionPatients leaving the emergency department before treatment (left without being seen) result in increased risks to patients and loss of revenue to the hospital system. Rapid assessment zones, where patients can be quickly evaluated and treated, have the potential to improve ED throughput and decrease the rates of patients leaving without being seen. We sought to evaluate the impact of a rapid assessment zone on the rate of patients leaving without being seen.MethodsA pre- and post-quality improvement process was performed to examine the impact of implementing a rapid assessment zone process at an urban community hospital emergency department. Through a structured, multidisciplinary approach using the Plan, Do, Check, Act Deming Cycle of process improvement, the triage area was redesigned to include 8 rapid assessment rooms and shifted additional ED staff, including nurses and providers, into this space. Rates of patients who left without being seen, median arrival to provider times, and discharge length of stay between the pre- and postintervention periods were compared using parametric and nonparametric tests when appropriate.ResultsImplementation of the rapid assessment zone occurred February 1, 2021, with 42,115 ED visits eligible for analysis; 20,731 visits before implementation and 21,384 visits after implementation. All metrics improved from the 6 months before intervention to the 6 month after intervention: rate of patients who left without being seen (5.64% vs 2.55%; c² = 258.13; P < .01), median arrival to provider time in minutes (28 vs 11; P < .01), and median discharge length of stay in minutes (205 vs 163; P < .01).DiscussionThrough collaboration and an interdisciplinary team approach, leaders and staff developed and implemented a rapid assessment zone that reduced multiple throughput metrics.     

The effectiveness of a provider in triage in the emergency department: a quality improvement initiative to improve patient flow

Hospital emergency departments (EDs) throughout the United States are faced with overwhelming challenges due to the high demand for services, an increasing number of visits, overuse and misuse of services, and escalating healthcare costs. The result of this situation is that EDs are overcrowded, patients are experiencing long wait times, ambulances are being diverted, admitted patients are being boarded, and patients in need of emergency medical care are leaving without treatment. The purpose of this article is to present a quality improvement initiative designed and implemented to improve patient flow through an ED by redesigning the triage process to increase the efficiency and timeliness of initial patient contact with a licensed medical provider, increasing patient satisfaction, and decreasing the number of patients who leave without being seen. To accomplish these goals, a nurse practitioner/physician assistant medical provider was reallocated to the triage area to perform an initial assessment and initiate diagnostic studies. The results of this initiative have proven to be positive in goal attainment. The time from patient arrival to initial contact with a licensed medical provider has decreased from 75 to 25 min. The percentage of patients who leave without being seen has decreased from 3.6% to 0.9%.     

Fast track: Has it changed patient care in the emergency department?

Objective: To determine whether the introduction of a designated fast‐track area altered the time to care and patient flow in an Australian mixed adult and paediatric ED. Methods: Retrospective cohort study of all patients presenting to the ED between 08.00 and 22.00 hours, during a 6 month period before and after the opening of a fast‐track area. Data were stratified according to Australasian Triage Scale (ATS) category, and comparisons were made for performance indicators, waiting time, length of stay and did‐not‐waits. Results: During its operational hours, fast track managed 14.9% of all patients presenting to the ED. There was a significant increase in the proportion of all ATS 4 patients seen within their target times (77.8% to 79.9%, P < 0.001). There was a trend towards improved performance in ATS categories 2, 3 and 5. Median patient waiting times were significantly decreased in ATS 4 (24 to 22 min, P < 0.001) and ATS 5 (27 to 25 min, P < 0.05), but increased in ATS 2 (3 to 4 min, P < 0.05). No deterioration in performance or waiting time for ATS 1 was shown. There was a decreasing trend in the proportion of patients who did not wait to be assessed by a doctor in ATS categories 4 and 5. These improvements occurred despite a 12% increase in patient attendances and no change in medical staffing levels. Conclusions: Fast track in an Australian mixed ED can help meet the demand of increasing patient attendances, allowing lower‐acuity patients to be seen quickly without a negative impact on high‐acuity patients.     

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.     

Effect of a physician assistant on quality and efficiency metrics in an emergency department: Population cohort study

ObjectiveTo determine the effect of a physician assistant (PA) working in a secondary care hospital emergency department (ED) on the overall performance of the ED.DesignA retrospective review of ED data from April 1, 2017, to September 30, 2017.SettingBelleville General Hospital, a secondary care hospital, ED in Ontario.ParticipantsA physician assistant, 13 emergency physicians, and 7 family physicians.Main outcome measuresOverall ED performance was evaluated using metrics from the Ontario Ministry of Health and Long-Term Care: rate of patients who left without being seen, provider initial assessment time at the 90th percentile, and the average provider initial assessment time for all patients over a 6-month period.ResultsIn the PA group, there was a lower average daily left without being seen rate (3.4% vs 5.2%; P < .001), a lower provider initial assessment time at the 90th percentile (3.9 hours vs 4.5 hours; P < .001), a lower average provider initial assessment time (114.83 minutes vs 139.46 minutes; P < .001), and a lower average length of stay (313.85 minutes vs 348.91 minutes; P < .001).ConclusionThis study suggests that a PA has a statistically significant positive effect on the overall performance of an ED. Future studies should examine the effect of a PA on quality of care and hospital funding.     

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.     

Hospital factors associated with emergency center patients leaving without being seen

We developed a statistical model that would identify and quantify the relative contributions of different factors hypothesized to impact the frequency of emergency center (EC) patients who leave without being seen (LWBS). We performed an analysis of the daily counts of patients that registered in our EC during a 21-month period who then LWBS. Candidate predictor variables included the number of patients seen, and the number admitted to the hospital, for each area of our EC, as well as the hours of faculty double coverage, and the day of the week. Univariate analyses were performed using standard methods. Multivariate analysis was performed using the general linear model. A backward selection procedure was used to eliminate statistically insignificant variables until all remaining independent variables had P-values < or = .05. External validation and analysis of the stability of the estimated regression coefficients of the model were evaluated using bootstrap methods. Two-tailed tests and a type I error of 0.05 were used. During the period studied, 133,666 patients were registered in the EC and 9,894 (7.4%) left. Multivariate analysis identified six variables that were significantly associated with LWBS. The fitted model containing all six variables explained 52.8% of the variability observed in LWBS frequency. The most powerful predictor of LWBS was total number of patients cared for in the main ED. This accounted for 46.4% of the observed variation in LWBS. The total number of trauma and resuscitation patients, and the total number of observation unit admissions to the hospital were also associated with increased LWBS. More pediatric cases seen in the main ED, weekends, and additional faculty coverage were associated with fewer patients leaving. Efforts to decrease the LWBS rate will be most successful if they address the issue of main ED volume.     

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.     

Improving Emergency Department Time to Provider,Left-Without-Treatment Rates,and Average Length of Stay

Background

Emergency Department (ED) overcrowding and ensuing concern about patients who leave without treatment have become a mounting national concern. In addition, the Centers for Medicaid and Medicare Services released regulatory standards for EDs requiring reporting of time from initial triage to decision to admit, as well as actual time of admission.

Objectives

To implement an improved ED patient flow process.

Methods

We performed a comparative, pre- and post-intervention ED redesign study evaluating three primary end points between two similar, seasonal time periods.

Results

Despite an 11% increase in daily patient volume in 2010, analysis of time to provider pre-ED redesign and post-ED redesign implementation revealed a mean of 126.7 min in 2009 (SD 37.03) vs. a mean of 26.3 min in 2010 (SD 1.17). The p-value was significant at <0.001. Overall ED average length of stay (ALOS) in 2009 was 5.5 h (SD 0.68) and 3.6 h (SD 1.16) in 2010, reflecting a mean reduction in ALOS of 1.9 h. The p-value was significant at <0.01. The proportion of patients who left without treatment (LWOT) also decreased. The proportion of LWOTs during the 2009 study period was 8.7% (95% confidence interval [CI] 6.14–11.26%), compared to 0.2% (95% CI 0.14–0.36%; p < 0.005) in the 2010 study period. Although the overall ED-visit Press Ganey patient-satisfaction scores improved during the 2010 study period, the results were not statistically significant (p < 0.1).

Conclusion

Our study demonstrated that a tailored ED redesign process can dramatically decrease the time to provider, ALOS, and LWOT rates.     

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center. Methods: This was a pre‐post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five‐month pre‐expansion period (November 1, 2004, to March 1, 2005) and a five‐month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders. Results: From pre‐expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI =?74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI =?4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI =?4.0 to 3.5). Mean (±SD) total LOS increased from 4.6 (±1.9) to 5.6 (±2.3) hours, and mean (±SD) admission hold LOS also increased from 3.0 (±0.2) to 4.1 (±0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre‐expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode. Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.     

Quality and effectiveness of an emergency department during weekends

Methods: Quality and effectiveness markers were determined during 539 consecutive days, comparing them according to the day of the week. Quality markers were the daily percentage of patients who died in the internal medical unit (deaths, D), leave ED without being seen (flights, F); returned to the ED (revisits, R), and the percentage of registered complaints (C). Effectiveness markers were: the "number of patients waiting to be seen" (WP), the "waiting time to be seen" (WT), and the "length of visit" (LV).

Results: Quality and effectiveness of ED do not worsen during weekend days and some markers significantly improved during such days: C experienced a 26% decrease (p = 0.001), WT decreased 65% (p<0.001), WP 59% (p<0.001), and LV 24% (p<0.01). Assessing the relation between daily number of visits to ED and the quality and effectiveness markers, a significant and direct association was found of the number of visits with D, F, R, and WP.

Conclusion: Some of the quality and effectiveness markers of the ED improved during weekend days compared with workdays.

     

Health Care Provider in Triage to Improve Outcomes

ProblemEmergency departments throughout the nation are experiencing crowding related to increased patient volumes and decreased hospital inpatient bed capacity. As a result of lengthy wait times, patients are leaving without having medical treatment, and satisfaction is poor. The purpose of this quality improvement initiative was placing a provider in triage to complement the existing split-flow process aimed to decrease wait times to see a provider, length of stay (LOS), left without being seen (LWBS) rates, and improve patient satisfaction.MethodsA multiprofessional team was established. Nurses, advanced practice providers, and physicians collaborated on a project to place a provider in triage to assist in seeing patients as soon as possible and begin care or treatment.ResultsThe outcomes of the initiative were positive for ED LOS metrics and patient satisfaction. Door-to-provider time decreased from a high of 56 minutes to a low of 13 minutes. The percentage of patients LWBS decreased from a high of 12% to a low of 1.62%.DiscussionThe project showed that the evidence-based practice of a combined split-flow and provider-in-triage model resulted in improvements in throughput for patients who were treated and released from the emergency department.     

Assessing the impact of streaming in a regional emergency department

Objective: To evaluate the impact of a streaming model, previously validated in metropolitan EDs, on selected performance indicators in a regional ED. Method: Multiple linear regression models were applied to monthly time series data from 43 months prior to the intervention and 15 months following the intervention to measure the impact of the streaming model on the following performance indicators: (i) percentage of emergency patients admitted to an inpatient bed within 8 h; (ii) percentage of non‐admitted emergency patients with a length of stay of less than 4 h; and (iii) percentage of emergency patients who left without being seen by a doctor or nurse practitioner. Setting: Bendigo Health ED in regional Victoria. Results: Prior to the introduction of streaming, there was a downward trend in both the percentage of emergency patients admitted to an inpatient bed within 8 h, and the percentage of non‐admitted emergency patients with a length of stay of less than 4 h. After the introduction of streaming, these trends were reversed (P = 0.008 and P = 0.004, respectively). There was no statistically significant change in the trend associated with the percentage of emergency patients who left without being seen (P = 0.904). Conclusions: The implementation of the streaming model had an impact on the two performance indicators associated with length of stay in this regional ED, but did not have a significant impact (positive or negative) on the percentage of patients who did not wait to be seen. These results might interest other EDs in regional hospitals.