Crowding Linked to Higher Risk of Children Leaving Without Assessment
Pediatric patients who present to an ED seeking medical care but leave without being seen (LWBS) pose significant patient safety and medical/legal risks for the healthcare system.
“LWBS is a sign of poor access to medical care — not an isolated ED problem, but a larger hospital and healthcare system issue,” says Cory D. Showalter, MD, regional medical director of pediatric emergency medicine at Riley Hospital for Children at Indiana University Health.
Showalter and colleagues wanted to study the effect of crowding on LWBS rates. “New access to very granular crowding data, years of steady growth in ED patient volumes, and then more recent high variability in census and crowding associated with COVID-19 all increased our ability to study the relationship at a deeper level,” Showalter explains.
Using the National Emergency Department Overcrowding Study (NEDOCS) score and the ED occupancy rate, Showalter and colleagues analyzed the association between LWBS risk and crowding over a 14-month period at the Riley Hospital ED, a level I trauma center serving children of Indiana. Of 54,890 patient encounters, 1.22% were LWBS. The LWBS risk increased as ED occupancy rate increased. Crowding was the single most important factor determining how likely it was that pediatric ED patients would LWBS. “There are significant safety, medicolegal, and patient experience costs to LWBS,” Showalter warns.
Each LWBS case represents a family seeking emergent treatment for their child. However, unable to access ED care in a timely manner, they were forced to choose to leave the ED without assessment.
“This study, for the first time, has defined the strong correlation between LWBS and ED crowding,” Showalter says. “LWBS should no longer be considered an isolated ED problem, but rather a costly consequence of ED crowding resulting from poor patient flow through the hospital and across the system.”
Patient flow bottlenecks occur at multiple levels, leading to ED crowding. Inpatient flow is inhibited by delays in discharge, prolonged waits for room turnover, and delays in admissions, all leading to boarding. In turn, it limits available rooms for new patients as they continue to arrive. “Ultimately, delays occur in door-to-room time for patients,” Showalter observes.
Additionally, inappropriate ED use, resulting from limited access to better alternative options for low-acuity patients, leads to more front-end bottlenecks and extra crowding. “This further diminishes access to ED care,” Showalter adds. Leaders can use NEDOCS trends to improve access to care for patients, with a goal to prevent LWBS by minimizing ED crowding. It answers the question: How are we doing right now? “NEDOCS [scores are] simple to calculate, offering real-time status and data trends to drive decisions at multiple levels, and minimize medicolegal and patient experience risks,” Showalter offers.
It appears EDs can operate at a high maintain level — until crowding reaches a breaking point. At Riley Hospital for Children, clinicians use NEDOCS to keep a close watch on crowding. “ED leadership can begin to use NEDOCS trends for decision-making to improve access to care,” Showalter says.
- Gorski JK, Arnold TS, Usiak H, et al. Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department. Am J Emerg Med 2021;48:73-78.
Researchers argue leave without being seen rates should no longer be considered an isolated problem, but rather a costly consequence of ED crowding resulting from poor patient flow through the hospital and across the system.
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