Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?

doi:10.1016/S0736-4679(97)00030-9

The Journal of Emergency Medicine

Volume 15, Issue 3, May–June 1997, Pages 397-399

https://doi.org/10.1016/S0736-4679(97)00030-9 Get rights and content

Abstract

Previous studies have suggested that most emergency department (ED) patients who leave without being seen by a physician (LWBS) are nonurgent. Our institution developed a fast-track process to reduce length of stay (LOS) for these patients. The present study was conducted to determine the effect of reducing LOS on the number of ED patients who leave without seeing a physician and the acuity of this subset of ED patients. We retrospectively audited, at a tertiary care teaching hospital, the number of LWBS patients and their triage status over two 1-mo periods. These sampling periods corresponded to immediately before and after implementation of five solutions developed by a continuous quality improvement (CQI) process to facilitate patient flow through the triage and fast-track areas of our ED. Before the CQI process was begun, 2.4% of patients ( $1104553$ ) left without being seen in a 1-mo study period. Of these, 82 were nonurgent and 28 were urgent. After implementation of the CQI process, 1.1% of patients ( $514514$ ) left without being seen. Of these, 35 were nonurgent and 16 were urgent. There was a significant decrease in the LWBS proportion after the CQI process was implemented. We conclude that (1) reducing LOS is associated with a decrease in the number of ED patients who leave without seeing a physician and (2) many patients who leave without being seen are classified as urgent at presentation.

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Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample
2023, Academic Pediatrics
To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED).
We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity.
We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76–0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83–1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63–0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64–0.89), and the Midwest region (HR 0.77, 95% CI 0.69–0.87). No differences in wait times were observed for children of Black race or other races.
Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.
Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department
2021, American Journal of Emergency Medicine
Emergency 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.
We 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.
A 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.
Not 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.
Characterization of emergency department abandonment using a real-time location system
2020, American Journal of Emergency Medicine
Citation Excerpt :
Previous studies have identified length of wait, updates on expected wait time, triaged priority level, time of day, and month of year [2-6] as important factors which increase likelihood of LWBS and impact time to abandonment. The most commonly identified reason for leaving was the length of waiting time, and many studies have focused on identifying and implementing interventions to cut down on wait times in an attempt to reduce LWBS rates, with some success [6-11]. However, accurately quantifying exact ED abandonment times has historically been challenging, with up to 31% of calculated LWBS waiting times deemed to be inaccurate [12].
Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting.
Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates.
This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included.
Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5).
Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.
Impact of a hospitalwide quality improvement initiative on emergency department throughput and crowding measures
2016, Joint Commission Journal on Quality and Patient Safety
This pre- and postintervention analysis evaluates the impact of a systemwide, comprehensive, executively supported quality improvement (QI) project on emergency department (ED) throughput measures and crowding in a large nonacademic community hospital.
The two primary endpoints used to assess the impact of the project were (1) the percentage of all patients who were door-in to door-out in less than three hours and (2) the percentage of patients who left without being seen (LWBS). Secondary endpoints for throughput were mean door-in to door-out, door-in to physician, physician to disposition, and disposition to door-out times for all patients. Secondary endpoints for crowding were median disposition to door-out time of admitted patients and the percentage of admitted patients with a disposition to door-out time of ≥ one, two, and six hours.
A total of 666,640 patient visits were included in the primary endpoint analyses, with no patients excluded. The percentage of patients meeting the three-hour door-in to door-out goal after the QI project was 81.4%, versus 46.5% in the pre-QI group (difference, 34.9 percentage points; 95% confidence interval [CI] = 34.7–35.1; p < 0.0001). The postintervention LWBS rate was 0.49%, versus 4.00% in the pre-QI group (difference, 3.51 percentage points; 95% CI = 3.43–3.58; p < 0.0001). A total of 417,673 patient visits were screened for inclusion for the secondary endpoint analyses. The pre-QI and post-QI groups were also compared for secondary endpoints, and significant improvement was noted in all analyses.
This study suggests that a comprehensive systemwide and executively supported QI project can make sustained multiyear improvements in ED throughput and LWBS. Further research is needed to determine if this standardized set of changes can be generalized to other hospital systems.
Implementation of a front-end split-flow model to promote performance in an urban academic emergency department
2016, Joint Commission Journal on Quality and Patient Safety
In an urban academic emergency department (ED), a front-end split-flow model, which entailed deployment of an attending-physician intake model, implementation of a 16-bed clinic decision unit, expanded point-of-care (POC) testing, and dedicated ED transportation services, was created.
A retrospective, observational, pre-post intervention comparison study was conducted at a large academic urban hospital with 74,000 ED annual visits that serves as a Level 2 Trauma Center. The new flow model was implemented in April 2013, coincident with the opening of a new ED space.
During the six-month pre- (July 2012–December 2012) and postimplementation (July 2013–December 2013) periods, there were 17,307 and 27,443, respectively, walk-in encounters during the intake times. Despite this 59% increase and a 35% increase in overall ED patient census, implementation of the innovative novel process redesign resulted in a clinically meaningful reduction (median minutes pre vs. post and one-year post) in (1) overall length of stay (LOS) for all walk-ins (220 vs. 175 and 140), discharged (216 vs. 170 and 140), and inpatient admissions (249 vs. 217 and 181); (2) door-to-physician time (minutes) (54 vs. 15 and 12); and (3) left without being seen (LWBS) rates (5.5% vs. 0.5% and 0.0%). The left before visit complete (LBVC) rates were 0.8% vs. 1.1% and 0.6%. The average total relative value unit (RVU) per patient discharged from intake was 2.31. During the pre-post analysis periods, no significant increase in reported safety events were identified (10 vs. 9 per 1,000 patient encounters).
Implementation of a novel multifaceted process redesign including an attending physician–driven intake model had a clinically positive impact on ED flow. Validation of this model should be conducted in other practice settings.

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^☆: This material was presented at the SAEM annual meeting, Denver, May 1996, and at the Royal College of Physicians and Surgeons of Canada annual meeting, Halifax, NS, Canada, September 1996.

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Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?☆

Abstract

Ann Emerg Med

J Emerg Med

QRB

JACEP

Ann Emerg Med

Ann Emerg Med

Analysis of patients who leave the emergency center prior to physician evaluation [abstract]

Ann Emerg Med

Patients who leave a public hospital emergency department without being seen by a physician

JAMA