Every ED leader can attest there are a certain number of patients who present for care but leave without being seen (LWBS). “It’s a big issue for quality reasons, and it’s a big issue for financial reasons. But most importantly, it’s a risk management issue,” says Niels Rathlev, MD, a professor of emergency medicine at Tufts University School of Medicine in Medford, MA.
Baseline LWBS rates were 7% at Baystate Medical Center’s ED in Springfield MA, according to an analysis by Rathlev and colleagues.1 They examined the characteristics of patients who LWBS. “This is a little different than patients who are seen by the provider and leave without completing treatment,” Rathlev observes. A few factors were linked to higher LWBS rates:
- The number of arrivals in the ED per hour;
- The door-to-provider time;
- The numbers of ED boarders;
- The number of patients in the ED waiting room.
Younger adults with low-acuity visits were more likely to leave than older adults with higher-acuity visits. “There can be a sense that it’s just people who aren’t very sick who are leaving,” Rathlev notes. “But that’s not universally true. There are plenty of older patients who walk out and really should have been seen earlier.”
Surprisingly, Rathlev and colleagues found no link between staffing levels (of doctors, residents, nurses, or technicians) and LWBS rates. “We have always assumed that staffing with nurses is critically important. If we don’t have enough nurses scheduled, it really affects these throughput measures and process times,” Rathlev explained.
The authors analyzed staffing based on the number of nurses scheduled, not those who actually were working. Thus, it is possible staffing levels really do affect LWBS rates. “Providers are important for decision-making. But it’s the nurses who do the majority of the work, and certainly have the most face time with patients,” Rathlev says. Hospital administrators might be unaware of the adverse effects of ED boarding, which Rathlev says was one of the reasons for conducting this analysis. Placing an EP at triage is one way to reduce risks of boarding and packed waiting rooms.
“If all you are doing is taking an EP who was working inside the ED and seeing patients, and are now repurposing that role in working at triage, you probably don’t accomplish very much,” Rathlev cautions.
Door-to-doctor time probably will decrease. Yet on the back end, things take longer because there are not enough EPs to evaluate and discharge patients. Adding an additional EP to work with the triage nurse requires a financial investment. “But not only will that decrease walkouts, it will also negate the negative impact on the back end,” Rathlev offers.
Putting an EP up front also can stop some bad outcomes from happening to people in the waiting room. “Certainly, that happens. People show up with shortness of breath and look relatively OK, but things can change in a hurry,” Rathlev says.
Asking someone to continually assess each person who is waiting is important for this reason. “It doesn’t have to be a nurse or a doctor. It could be a social worker who is checking in just to make sure patients know they are not being forgotten. That’s an important piece,” Rathlev adds.
There is a tendency to assume that if someone left the ED, he or she probably was not that sick. That is a dangerous assumption, according to Purva Grover, MD, MBA. “It’s very well-known that patients who leave without a complete assessment are one of the highest-risk groups that we see in the department,” she reports.
Long waits are the most common reason why patients leave, caused by staffing, boarding, or crowding. “For patients who are in the waiting room, if you were there an hour after triage or two hours after first vital signs got done, and have not been seen, the chances of leaving the department are very, very high,” says Grover, medical director of the Cleveland Clinic Health System’s pediatric ED.
Some of those people will experience a bad outcome and come back to the ED in worse shape. Others will go to a different ED. “Both of those groups pose great risk,” Grover says. “The fact of the matter is once the patient is on your property, the patient is yours in every way.” To reduce risks of LWBS patients, Grover offers some recommendations:
• EDs can use LWBS rates as a major quality indicator.
• EDs can do everything possible to ensure patients are seen in a timely matter. “That is easier said than done,” Grover acknowledges.
• If a patient tells someone they are leaving, ED providers can intervene to see if there is a way to accommodate that person immediately. “If we identify a patient who is leaving, it’s such a big deal to us that the triage nurse calls the EP to ask what can be done,” Grover reports.
Many times, the patient is seen right away, but not always. “You can reduce the number, but it will never be zero,” Grover says.
If the patient leaves anyway, staff ask him or her to sign a form stating they are leaving against medical advice and are aware of the risks. Staff might hesitate to make this kind of request. The patient is angry already. “The last thing you want is more confrontation,” Grover says. “There’s a tendency to forgo the form, which could really help the ED if things go badly.”
• ED providers can document all conversations with the patient. If the patient says something like, “I’m leaving if you don’t see me in two minutes,” EPs can document those words and also how they responded to the patient. Providers can show they cared enough to offer a phone number to reach the on-call nurse. That nurse can provide good follow-up instructions and encourage the person to come back to the ED any time.
• If the patient left without telling anyone, providers can document that staff tried to find the patient. An ED chart that suddenly goes blank appears suspicious to anyone reviewing it after the fact. Documentation of “no answer at 9:00” and “no answer at 9:10” is better because it brings closure to the case.
“If an outside entity reviews the chart, even that piece of information shows that you were following protocol but that the patient had left,” Grover says.
Grover recommends that for all patients who LWBS, the nurse manager calls within 24 hours. This gives the nurse manager a chance to state, “We are really concerned about you. We are so sorry you left. We hope you are doing better. What can we do for you?”
“It gives you some degree of protection if you document that you reached out to the patient,” Grover adds. It also gives the nurse manager the chance to instruct the patient to return to the ED if necessary. Grover makes a practice of calling patients who were discharged, or patients who left during her shift. It is a way to provide closure, but sometimes emergencies are identified.
One mother had left the previous night without being seen. During the follow-up call, she reported her child was still having diarrhea and was now seeking care at urgent care center. Grover urged her to go to the ED instead.
There, the child was seen immediately and was sick enough to be admitted to the ICU. Grover expected the mother to be angry, but the opposite was true. Shortly after the ED visit, the mother sent a thank you note to Grover for preventing a possible terrible outcome by calling back. “To me, this was reinforcement that this was the right thing to do, and we should absolutely do it,” Grover says.
Over the past several years, the practice of calling discharged patients has become standard at the health system’s EDs. During the follow-up calls, people remain angry about the long wait. Nevertheless, virtually all of them appreciate the chance to be heard. “We have seen a documented decrease in our complaints, which hopefully leads to a decrease in litigation,” Grover says.
- Rathlev NK, Visintainer P, Schmidt J, et al. Patient characteristics and clinical process predictors of patients leaving without being seen from the emergency department. West J Emerg Med 2020;21:1218-1226.