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When a woman accompanied by her husband told the triage nurse she "wanted admission," the nurse told them there was a wait to be seen. "The family offered no other information, and the nurse assessment did not reveal anything in her documentation that would lead you to believe she needed an emergent screening," says Michelle Myers-Glower, RN, MS, former director of emergency and trauma services for Elmhurst (IL) Hospital and a consultant in Glencoe, IL, specializing in staffing issues. The woman left and went to another ED, where she was admitted because she was suicidal.
In another case, a 70-year-old man complained of coughing. A chest X-ray was performed, but after an hour wait, the man left without seeing a physician. "The next day, the radiologist reading came back and showed a huge mass indicative of a tumor," says Myers-Glower. When contacted, the man was reluctant to return and had not planned any follow-up care, but he agreed to be admitted and scheduled for surgery. "These are high-risk patients, and overcrowded EDs are faced with these situations daily," warns Myers-Glower. "They are in your waiting room like a time bomb."
Here are ways to reduce risks of patients who leave without being seen (LWBS):
• Consider your waiting room to be an extension of your ED. Consider waiting areas as a room assignment because there are sick patients in it, says Myers-Glower. You may be in violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) if you routinely keep patients waiting so long that they leave without being seen, she says. "This is particularly risky if the hospital does not attempt to determine and document why the patient is leaving," she adds. "You also need to reiterate to the patient that you are prepared to see them in a timely fashion."
• Never assume patients are not seriously ill or injured. Any one of your LWBS patients could die after leaving your ED, Myers-Glower says. "That is why it is so important to make attempts to prevent the walkouts." Myers-Glower gives the example of a coughing toddler whose family decides to leave after a long wait. "The parents assume it’s only a cold, when in fact the child may have swallowed something and needs to be assessed further for possible foreign body obstruction," she explains.
• Document a patient’s refusal. At the minimum, ask the patients to sign a statement that they have been offered a medical screening examination as required by EMTALA and have refused, says William T. Briggs, RN, MSN, CEN, ED assistant nurse manager at Brigham and Women’s Hospital in Boston. "This signature should be witnessed, timed, and dated," Briggs adds. If the patient refuses to sign or leaves without notifying the staff, this should be documented, he says. In this case, the ED attaches a sticker to the patient’s chart that says, "Refusal of Medical Screening Exam."
• Ask the patient to return. Myers-Glower recommends calling LWBS patients before the end of the shift to encourage them to come back. If this is not possible, the triage or charge nurse should call every LWBS the following day, document the call, and ask the patient if he or she would like to return, she says. "If the patient returns, make every effort to see them quickly. Give them the name of the nurse to ask for so she will expect them," she advises.
• Track reasons for patients who leave. It is imperative that LWBS patients are registered and appear in your log, even if you have minimal information, says Briggs. "For this reason, the triage nurse or receptionist should get a full name and date of birth on every patient." (To see sample LWBS log, click here.)
Myers-Glower recommends having every LWBS chart copied so you can review it the following morning and discussing all LWBS in monthly staff meetings.
Watch for "red flags" that include patients leaving because of payment issues, such as a co-payment requirement, problems with obtaining approval from managed care organizations, or inability to pay, says Briggs. "These issues should be taken care of after the medical screening exam," he urges.
Inspectors from the Baltimore-based Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration, may ask if the patient was asked to leave or coerced to leave, says Briggs. "They may also check the patient’s payer status and diagnosis," he says.
• Keep statistics. To prepare for surveys by the Joint Commission on Accreditation of Healthcare Organizations, Myers-Glower recommends careful documentation of your quality improvement efforts to reduce wait times. "Surveyors may ask you to show evidence of how you have addressed this problem. This can help you avoid Type 1 recommendations," she explains. There is another compelling reason to keep these statistics, according to Myers-Glower. "LWBS patients must be calculated into your ED volumes," she says. "If you do not calculate those numbers when budget time comes, your ED does not get the credit for that time spent triaging and FTEs may be cut."
For more information about patients who leave without being seen, contact:
• William T. Briggs, RN, MSN, CEN, Emergency Department, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Telephone: (617) 732-8508. Fax: (617) 278-6977. E-mail: firstname.lastname@example.org.
• Michelle Myers-Glower, RN, MS, 640 Grove St., Glencoe, IL 60022. Telephone: (847) 242-0825. Fax: (847) 242-0826. E-mail: email@example.com.