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

doi:10.1016/0735-6757(95)90079-9

The American Journal of Emergency Medicine

Volume 13, Issue 2, March 1995, Pages 136-141

https://doi.org/10.1016/0735-6757(95)90079-9 Get rights and content

Abstract

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.

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Cited by (26)

Comparing patients who leave the ED prematurely, before vs after medical evaluation: A National Hospital Ambulatory Medical Care Survey analysis
2016, American Journal of Emergency Medicine
Citation Excerpt :
Increased rates of patients who leave before medical assessment are associated with high ED volumes and crowding (Weiss 2005 [7], Hobbs 2000 [15], McMullan 2004 [16]). Patients consistently identify wait times as a major reason for leaving before medical assessment (Rowe 2006 [3], McNamara 1995 [17], Johnson 2009 [18], Mohsin 2007 [19], Monzon 2005 [20], Arendt 2003 [21], Baker 1991 [2]). 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.
Many patients leave the Emergency Department (ED) before beginning or completing medical evaluation. Some of these patients may be at higher medical risk depending on their timing of leaving the ED.
To compare patient, hospital, and visit characteristics of patients who leave before completing medical care to patients who leave before ED evaluation.
Retrospective cross-sectional analysis of ED visits using the 2009-2011 National Hospital Ambulatory Medical Care Survey.
A total of 100 962 ED visits were documented in the 2009-2011 National Hospital Ambulatory Medical Care Survey, representing a weighted count of 402 211 907 total ED visits. 2646 (2.62%) resulted in a disposition of left without completing medical care. Of these visits, 1792 (67.7%) left before being seen by a medical provider versus 854 (32.3%) who left after medical provider evaluation but before a final disposition. Patients who left after being assessed by a medical provider were older, had higher acuity visits, were more likely to have visited an ED without nursing triage, arrived more often by ambulance, and were more likely to have private insurance than to be self-paying or to have other payment arrangements (e.g. worker's compensation or charity/no charge).
When comparing all patients who left the ED before completion of care, those who left after versus before medical provider evaluation differed in their patient, hospital, and visit characteristics and may represent a high risk patient group.
Characteristics of Patients Who Leave the ED Triage Area Without Being Seen By a Doctor: A Descriptive Study in an Urban Level II Italian University Hospital
2011, Journal of Emergency Nursing
In this paper, we describe demographic and clinical features of patients who left the triage area before the visit in the emergency department of Azienda Ospedaliera Universitaria Careggi in 2006.
This is a descriptive retrospective study. Data was collected from electronic medical charts.
We recorded 45,019 patients who arrived in the emergency department. Of those, 904 left without being seen (2%; Male 51.5%; Female 48.2%). The mean age was 41 years (median 37; range 14-95). We found that this was more common during June and July (114 and 107 cases) and on Mondays (20.5%), with lower rates on Saturdays and Sundays (11.3% and 9%). Two-hundred thirty-nine patients were not Italian. Patients' waiting times before leaving without being seen collected from the nursing notes were recorded in 457 cases (50.5%), and showed a median of 70 minutes (range 0-386). There was a significant difference between this value and the median of waiting times (95 minutes) calculated from the ending time of medical charts in the same group of patients (Wilcoxon Signed Rank Test - P < 0.0001). It confirms the hypothesis that the patients' length of stay before leaving the triage area, gathered from medical charts, isn't reliable because of the delayed ending of charts. After 72 hours from the leave, 17 patients returned. The outcome were: 2 admissions in general ward and 6 new cases of leaving without being seen.
There was a prevalence of low-priority triage-level patients compared to the general ED case mix. The rate of patients' leaves follows the indications of Tuscany Region (patients' leaves <5% total ED population).
Survey of elderly trauma patients with prolonged emergency department stays
2008, International Journal of Gerontology
This study was undertaken to determine the factors occurring in elderly trauma patients that cause emergency department (ED) physicians to spend much time evaluating them, thereby delaying their discharge or admission, and how misdiagnosis or malpractice can be avoided. A subgroup of elderly and severely injured patients in the ED was examined, and their disposition and eventual temporal efficiency were determined.
A retrospective review of the trauma registry and medical records over a 2-month period (May 2002 to June 2002) identified 400 patients as trauma patients. Variables selected for examination included age, sex, length of ED stay, arrival time, injury severity triage, injury types, disposition, and times at registration, physician attendance, reports returned and discharge/leaving. Time-consuming measures were obtained in patients requiring different stations, and the durations were tested for all patients attending the Mackay Memorial Hospital ED.
Among the 400 patients, the mean length of ED stay was 118.3 minutes (range, 94.7–350.2 minutes) and the mean age was 33.3 years (range, 1–92 years). In our age subgroups, the young group (< 18 years) contained 74 patients (18.5%), the middle-aged group (18–65 years) contained 290 patients (72.5%), and the elderly group (> 65 years) contained 36 patients (9.0%). On stratifying the durations by the three age groups, there were significant differences for D3 (duration of total treatment; p < 0.05) and D6 (duration of waiting for reports; p < 0.001). The elderly group had longer waits and longer stays than the other groups. The correlation between the age groups and attending doctors was significantly different (p < 0.001). The elderly group had a tendency to be attended by senior doctors and had the shortest waiting time among the groups (1.69 ± 0.32 minutes). In all three age groups, the waiting time for senior doctors was shorter than those for junior doctors or residents.
Despite tremendous resource utilization, the majority of elderly trauma patients with prolonged ED stays had varying degrees of triage level. A subgroup of severely injured elderly patients had a significantly shorter waiting time when attended by senior doctors. However, the elderly trauma patients who entered our ED facility fared as well as the younger patients.
Characteristics and temporal trends of "left before being seen" visits in US Emergency Departments, 1995-2002
2007, Journal of Emergency Medicine
Citation Excerpt :
Recent strains on the US ED system suggest that the proportion of LBBS visits may have increased over time. The existing LBBS literature is based on single-center/regional, single time-point studies, and we are unaware of nationally representative data that address temporal trends in LBBS visits (1–8). Using nationally representative data from the 1995–2002 National Hospital Ambulatory Medical Care Survey (NHAMCS), we describe characteristics and temporal trends in LBBS visits.
The purpose of this study was to describe nationally representative characteristics and temporal trends in “left before being seen” (LBBS) visits in US emergency departments (EDs). The ED portion of the federal National Hospital Ambulatory Medical Care Survey, 1995–2002, was analyzed. Of the 810.6 million ED visits during the 8-year study period, an estimated 11.4 million (1.41%, 95% confidence interval [CI] 1.30–1.52) had an LBBS disposition. The number and proportion of LBBS visits have increased over time, from 1.1 million visits in 1995 (1.15%, 95% CI 0.95–1.35) to 2.1 million visits in 2002 (1.92%, 95% CI 1.67–2.17). LBBS patients were more likely to be younger, non-White, Hispanic, urban, and uninsured compared to non-LBBS patients. The number and proportion of LBBS visits have increased over time. LBBS visits disproportionately affect vulnerable populations. These findings suggest that recent strains on the US ED system are adversely affecting healthcare quality and access.
Prospective survey of patients the leaving emergency department without being attended by a physician
2000, Medicina Clinica
Definir el perfil epidemiológico, los motivos y la evolución posterior de los enfermos que abandonan la unidad de urgencias de medicina sin ser atendidos.
Durante 26 semanas consecutivas se identificaron de forma prospectiva los pacientes que abandonaron la unidad de urgencias de medicina antes de ser atendidos. Por cada paciente no atendido (NA) se incluyó como control (C) el siguiente enfermo visitado en la unidad. Mediante los datos de la historia clínica y entrevista personal de pacientes NA y C, se recogieron variables clinicoepidemiológicas y, en los pacientes NA, los motivos que le condujeron a abandonar urgencias y su evolución posterior.
De los 21.022 pacientes que acudieron a urgencias, 383 (1,8%) fueron NA. La edad inferior a 50 años, haber acudido a urgencias solo, no haber consultado previamente con un médico y una expectativa de tiempo de espera corto aumentan el riesgo de abandonar urgencias sin ser atendidos (p < 0,01, p < 0,01, p < 0,05 y p < 0,0001, respectivamente). Como razón principal para abandonar el servicio de urgencias, un 35% refirió encontrarse mejor, un 30% se encontraba demasiado mal para esperar más, y el 25% estaba muy enfadado para seguir esperando. Un 46% de NA buscó atención médica durante las siguientes 72 h y, en total, un 6,5% requirió ingresar, resultando ser los pacientes cuyos trastornos fueron valorados a su llegada como graves y los que habían consultado previamente a un médico aquellos con mayor riesgo de ingresar (p = 0,01 y p = 0,001, respectivamente).
El enfermo que se va de urgencias antes de ser atendido suele ser un paciente relativamente joven, con estudios, que acude a urgencias sin consultar previamente con un médico y con síntomas de enfermedad menor. La principal causa de marcharse es la percepción de su propia enfermedad como no grave; menos de la mitad consulta posteriormente con un médico y su índice de ingresos es relativamente bajo. Se debería ser especialmente cauto con los pacientes que son remitidos por otro médico y que se valoran como graves a su llegada al hospital, ya que son los de mayor riesgo de ingresar posteriormente.
To define epidemiological characteristics, the main reasons, and outcome of patients who leave the emergency department (ED) without being seen by a physician.
We performed a prospective survey of patients who left the ED before medical visit over a period of 26 consecutive weeks. For every non-visited patient (NV), the next visited patient (V) was included as a control. Clinical and epidemiological data, reasons to leave ED and outcome were obtained from clinical records and personal telephonic interview.
Out of a total of 21.022 patients who were attended in the ED, 383 (1.8%) were NV. To be under 50-year-old, to come the ED alone, to be previously visited by a community physician, and to previous expect short waiting times for ED visit were associated with higher risk for being NV (p < 0.01, p < 0.01, p < 0.05 and p < 0.0001, respectively). The main reasons noted to leave the ED were: feeling better (35%), feeling too sick to wait longer (30%) and being too angry to wait (25%). Only 46% of the NV looked for medical care in the 72 following hours and 6.5% of them needing to be further to hospital. NV-patients considered as suffering a serious pathology at ED arrival, and those being visited by a community physician previously to go to ED were found to be at increased risk to be subsequently admitted (p = 0.01 and p = 0.001, respectively).
Patients who leave ED department before being seen by a doctor are usually young, literate, have not previously visited their community physician, and consulted for minor complaints. The main reason to leave is their own impression of suffering a minor disease, and less than 50% visit another physician after their leaving, being the rate of hospital admission low. We should be particularly cautious with those patients referred by a community doctor and those identified as to have a seriously affected health status at their arrival at the hospital, since they are at increased risk to be admitted.
Reducing risk with telephone follow-up of patients who leave against medical advice or fail to complete an ED visit
2000, Journal of Emergency Nursing
Citation Excerpt :
Originally it was speculated that excessive waiting time was the most likely reason patients left. A study reported by McNamara9 revealed that 69% of their studied population who left without being seen (comparable to our FTC patients) did so because of perceived prolonged waiting times. In a related study, Jeremiah10 examined patients who left AMA from the inpatient sector to characterize the factors associated with leaving.

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^☆: The Chief, Navy Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program sponsored this study, #S-93-057, as required by HSETCINST 6000.41A. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

^☆☆: This is a US government work. There are no restrictions on its use.

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Original contributionPatients leaving the ED without being seen by a physician: Is same-day follow-up indicated?☆,☆☆

Abstract

Am Coll Emerg Physicians

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Curing Health Care

Challenges in Health Care

Quality healthcare in 1995

Quality Progress

Indigent care and overcrowding threatens EDs

Hospitals

Patterns of Medical Care Among Users of Hospital Emergency Units

Med Care

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