Want to drastically cut LWBS numbers? Try ice packs and adding a fast track

Comfort and quick care can reduce risk of EMTALA violations

Somewhere deep in an ED manager’s mind, maybe when you’re feeling cynical at 3 a.m., the patients who left without being seen (LWBS) might seem like a blessing. After all, your ED is too busy, and they probably didn’t need emergency care in the first place.

Then you snap to your senses and realize that high LWBS numbers are a reflection on the overall quality of care in your ED and, at the very least, reflect poorly on customer service and satisfaction. But is there anything you can do, or are LWBS patients just inevitable in today’s overcrowded, understaffed EDs?

There always will be some LWBS patients, but you can keep that number to a minimum with strategies aimed at the specific reasons patients get up and walk out the door. Uncertainty about the waiting time and lack of comfort items, such as ice packs, are major contributors,1 says Annie T. Sadosty, MD, an attending physician in the department of emergency medicine at Mayo Clinic in Rochester, MN, and assistant professor at Mayo Medical School. Sadosty recently studied the reasons patients leave the ED.

The first step in addressing LWBS patients is to acknowledge that it’s an important issue, she says. ED managers should care how many people walk out for several reasons, Sadosty explains.

With growing populations being turned away from office doors and other EDs closing, the EDs that exist become the safety net for people who can’t find access to primary care," she points out.

"If we aren’t able to see these people who have nowhere else to turn, it’s an unraveling of the safety net," she says.

LWBS rates are a quality marker in many ways, Sadosty states. "Cynics would say that people who leave aren’t sick, but there are very good data to the contrary," she says.2

The notion that they will self-triage, and if they’re sick enough, they will wait, does not hold true, Sadosty continues. "They have other pressing concerns, such as family who depend on them, that force them to leave anyway," she says.

LWBS patients also represent potential lost revenue, since many of them may be paying patients. And there is the potential for a poor public image. People who leave are going to talk to a lot of friends and family about their experiences.

There also is the risk of an Emergency Medical Treatment and Labor Act (EMTALA) violation, says Matthew Rice, MD, JD, senior vice president and chief medical officer for Northwest Emergency Physicians in Seattle. He also is chair of the medical/legal committee for the American College of Emergency Physicians (ACEP) in Irving, TX. The federal Centers for Medicare & Medicaid Services (CMS) in Washington, DC, has investigated and cited some hospitals for using long ED delays as a way to discourage some patients from seeking care.

Although not common, such cases make ED managers concerned that they could be cited, Rice says. "If a patient leaves and has a bad outcome, there is a potential for an EMTALA violation," he says. "There is a risk, even if it’s not a huge risk. CMS does not seem to find it acceptable that we’re getting busier and busier and there may be times when people have to wait."

It is most likely that CMS would require some evidence that the ED was purposefully using long waiting times to discourage undesirable patients, but Rice also says that it might not be hard to prove an EMTALA violation in an individual case. If the patient waited for hours, finally gave up and left, then died on the sidewalk a few blocks away, it would not be hard to argue that the ED staff mismanaged his triage and should have seen him earlier, Rice says.

"And of course, medical malpractice attorneys would be interested in picking up on a case where a person waited three hours and left and suggest that better care could have been provided, that it was, in fact, negligent," he says.

Research on the LWBS problem has identified some strategies that work and some that should work even though they haven’t been extensively studied yet, adds Sadosty. Most of them boil down to identifying what would keep patients just a little bit more comfortable and satisfied during a long wait in the ED — the small difference between them staying in their seats or walking out in a huff.

Here are some of the strategies you can employ to lower your LWBS rate:

Hand out analgesia and comfort items.

Sadosty’s study revealed that patients would be more likely to wait if they were given temporary analgesia such as Tylenol and comfort items such as ice packs and temporary bandages for lacerations. Since Sadosty published her results, the Mayo ED staff have made a stronger effort to use this technique.

The triage nurses now are very attentive to the person’s needs and obtain ice packs on a regular basis, she says. "They’re also on the lookout more for the patient whose needs aren’t so obvious, like the person with a migraine who might need analgesia and a quiet place to wait," she says. "It’s always a fair question to ask how practical that is in a busy ED, but it doesn’t take much time to get someone an ice pack."

As in any ED, their practices change with the volume. "Some of the things we can do when we’re not so busy we can’t always do during a rush of patients," Sadosty says.

Announce waiting times.

This strategy has been recommended by some ED experts as a way to keep patients better informed and willing to wait. However, the Mayo ED doesn’t announce waiting times because it can backfire, she says.

"If you tell them it’s going to be 20 minutes and then a bus crashes and you’re deluged with a rollover accident, your 20-minute estimate becomes six hours," she says. "It’s hard to really and truly provide an accurate estimate, and there is tremendous possibility for dissatisfaction if your estimate turns out to be way off."

Entertainment for children.

A long wait can be unbearable for a parent with fussy children, so anything that keeps the kids entertained will delay that moment when Mom or Dad just can’t take it anymore and storms out. Showing children’s movies on one of the televisions is a good idea, as are toys such as coloring books and reading material, she says.

Fast track patients to improve flow through.

The LWBS population is intimately related to ED waiting times, Sadosty says. If you can increase your throughput, your LWBS rates presumably are going to be less. "So much of the research related to increasing throughput time can be extrapolated to LWBS rates as well," she says. "Address one problem, and you’re bound to improve the other also."

Fast tracking certain patients can have a tremendous impact on wait times and LWBS, Sadosty says. The Mayo ED doesn’t fast track because it is a high-acuity ED and Mayo has a separate urgent care center, but Sadosty says other hospitals have shown good results with the strategy.

The ED at Onslow Memorial Hospital in Jacksonville, NC, has dramatically reduced its LWBS rate by implementing a fast-track strategy. Pat Stark, RN, BSN, nurse manager for the ED, says the ED treats about 37,000 patients a year. When the hospital opened its minor emergency care unit (MECU) in May 2001, the LWBS rate was 14%, or about 180 patients per month.

Now the ED’s LWBS rate is down to a steady 2% per month. The LWBS rate varies considerably nationally, but one study found that it ranges from 2.4% in private hospitals to 7.3% in public hospitals.3

The MECU was a major reason for the drop, but Stark says other initiatives also contributed. Stark and the other managers in the ED put much more emphasis on LWBS overall and started holding individual staffers accountable for their role in patients walking out.

Knowing nothing would change if staff didn’t consider LWBS a real problem, Stark and the other ED managers explained the ramifications of high LWBS numbers. And then they told staff that they would be required to improve their customer service as a means of reducing those numbers.

ED staff were required to watch instructional videotapes on improving customer service, and Stark instituted a zero-tolerance policy for disrespect to patients. Then she carefully started assessing the LWBS numbers by posting goals in the ED for that month and keeping staff abreast of how well they were doing — as a team and individually. "We provided the triage nurses with a breakdown of how they were doing, and we posted the overall numbers so they could compare themselves to everyone else," she says.

The process was competitive, she says. "We ended up with some nurses running after patients in the parking lot, yelling, Come back inside! We’ll see you!’" Stark adds.


1. Arendt KW, Sadosty AT, Weaver AL, et al. The left-without-being-seen patients: What would keep them from leaving? Ann Emerg Med 2003; 42:317-323.

2. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergency department without being seen by a physician: Causes and consequences. JAMA 1991; 299:1,085-1,090.

3. Stock LM, Bradley GE, Lewis RJ, et al. Patients who leave emergency departments without being seen by a physician: Magnitude of the problem in Los Angeles County. Ann Emerg Med 1994: 23:294-298.