EDs finish last in national quality report — steady decline noted

Statistics are seen as a reflection of lack in customer service

In an unsavory distinction, the lead author of the Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ) has singled out the nation’s EDs as the worst performers in its 2005 National Healthcare Quality Report. While overall quality of care for all Americans across 44 core measures in the report improved at a rate of 2.8%, there was a 10% deterioration in the percentage of people who go to the ED and leave before they are treated.

This is "our worst performing measure and it has been getting worse for a number of years," notes Dwight McNeill, PhD, lead author on the National Healthcare Quality Report and an AHRQ expert in quality measurement and improvement.

This sad statistic comes as no surprise for ED managers, one of whom called it "a catastrophic failure of customer service." Pat Scanlon, RN, ED manager at Northside Hospital in Atlanta, says, "This is always a concern for everyone, because this is the population that decides, for one reason or another, that they want leave — whether they have waited too long or were unhappy with their interaction with staff."

If you have a high percentage of patients who leave without being seen [LWBS], "it could be a service indicator — that you don’t give care," adds Kathy Hendershot, RN, ED clinical director at Methodist Hospital in Indianapolis. "It certainly has a financial impact, but there is also a medical/legal risk surrounding people presenting and not being able to get them seen and having them walk away."

Besides the fact that the thought of acutely ill patients getting up and leaving "keeps me up at night," says Hendershot. "There’s always a legal risk that if they present and then walk away before they have a medical screening, you can get into an EMTALA [Emergency Medical Treatment and Labor Act] situation."

It may be difficult to find one common national benchmark for an acceptable LWBS percentage, but most ED experts agree that when you start hitting 3% or 4%, you are losing too many potential patients.

The Oakbrook, IL-based University HealthSystem Consortium (www.uhc.edu) says 1% is good benchmark, "but emergency medicine has to start somewhere," says Hendershot. She has seen statistics for the national average that range up from 4%. "Four percent of a 20,000-visit department is significant; however, 4% of a 100,000 volume is not as bad," Hendershot explains.

Her ED sees 100,000 patients annually, and in 2004-2005, her department’s LWBS rate was 2.2%. "This year, I would think we will get close to 2%," Hendershot says. Eventually, she’d like to have the rate reach 1%, she adds.

Deb Richey, MPA, director of emergency services at Parkview Hospital, Fort Wayne, IN, estimates that most EDs are in the 2%-5% range. "We generally range around 1%," she reports.

Through regular contact with the American College for Emergency Physicians (ACEP), Scanlon has concluded that ED managers should strive to have their LWBS rate lower than 1.5%. "We usually hit between 1.5% and 2%," she says. "We’re not serving our community if people are walking out."

Strategies that work

The good news is that there are proven strategies for getting those LWBS numbers down.

"When we very first started looking at this [eight to 10 years ago], our LWBS rate was more in the 2%-3% range," Richey recalls. "We determined that on average people were waiting 45 minutes in the lobby to get back to a room because of the front-end process."

Her ED began a bedside registration process, as well as quick triage. "We use a five-level triage, and the nurses only gather enough information to determine the appropriate level for the patient," Richey explains. This process usually involves chief complaint and history, to rule out a chronic illness; vitals usually are taken at the bedside.

"We do a more extensive triage if needed — for example, if the patient has chest pain and requires monitoring — but we don’t use extensive triage assessments if all rooms are full," she reports says. "This has cut 45 minutes from our overall length of stay."

Hendershot says she knows you can decrease LWBS rates if you expedite the time to physician. "If you get them to the doc quick enough, they are not going to leave," she says. "We’ve done several things in the last few years, including a fast-track, dedicated area for low acuity patients; having bedside registration; and quick-reg.’"

This quick registration is a two-step process, Hendershot explains. "You come into the department, and we just ask your name, date of birth, and if you’ve been here before. If you have, we click the mouse, and we already have your record." That may have been the biggest change her ED has made in terms of cutting door-to-doc times, she adds.

At Northside Hospital, "the other thing we’ve done that’s new this year is a dedicated triage staff that does a rapid triage assessment," says Scanlon. This system involves having a physician at triage between 1 p.m. and 9 p.m., the busiest times in the ED. Only a year ago, she notes, LWBS for her ED was at 3.3%.

Abbreviated triage helps LWBS rate

Northside’s ED uses several processes to keep LWBS low, says Scanlon. "We have abbreviated triage, so at least we know the acuity of the patient that’s waiting," she says, noting that in most cases it’s sufficient to determine if the patient is really sick and needs to get to the back or if they can wait.

"If they have to wait," Scanlon explains, "We have patient relationship advocates come down to see them." These representatives try to give the patients a better idea of how much time they might wait to be seen, she says. They try not give an exact time but provide general comments such as, "It should be soon," she says. "Without any kind of guideline, the patients get frustrated."

Her ED has standard guidelines for specific complaints and will initiate them at triage. "Patients really appreciate that," says Scanlon. "They feel like at least you are starting them on another path; it makes them feel you are doing something."

Northside also uses a "pull-through" triage. "If there are open beds in the back and a patient comes in with a big group, say six at once, we won’t have them queue up, but will rather pull them to the back and triage them there," Scanlon explains.

Constant monitoring critical

Another important strategy in keeping LWBS low is to remain constantly vigilant, Richey says.

"It’s very important to watch it on a monthly basis," she says. For example, during a time when the census was going up and LWBS was going up, Richey calculated their average revenue per visit. "When I told the administrator the hospital was losing this much revenue, I was able to get a $50,000 budget increase to add rooms to the ED," she says.

Finally, Hendershot recommends, it would be valuable for all EDs to agree on a common definition of LWBS, to make benchmarking more accurate. "The definition we use is, A patient presents to your hospital to be seen and leaves prior to a medical screening exam,’" she shares.

Sources/Resource

For more information on reducing patients who leave without being seen, contact:

  • Kathy Hendershot, RN, ED Clinical Director, Methodist Hospital, I-65 at 21st Street, P.O. Box 1367, Indianapolis, IN 46206. Phone: (317) 962-8880.
  • Dwight McNeill, PhD, Lead, "National Healthcare Quality Report," Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. Phone: (301) 427-1734. E-mail: dmcneill@ahrq.gov.
  • Deb Richey, MPA, Director, Emergency Services, Parkview Hospital, 2200 Randalia Ave., Fort Wayne, IN 46805. Phone: (260) 373-6040. E-mail: Deb.Richey@parkview.com.
  • Pat Scanlon, RN, ED Manager, Northside Hospital, Atlanta. Phone: (404) 851-8000.

The AHRQ 2005 National Healthcare Quality Report is available free on-line at www.qualitytools.ahrq.gov. Scroll down to "Quality Tools News" and click on "2005 National Healthcare Quality Report." Also, you can obtain a free copy by calling (800) 358-9295 or by sending an e-mail to ahrqpubs@ahrq.gov.