Who Leaves the Emergency Department Without Being Seen?
Who Leaves the Emergency Department Without Being Seen?
The proportion of patients LWBS after presenting for emergency care varies considerably among hospitals and over time. A national study of patients who LWBS in the United States found an overall LWBS proportion of 1.7%, but proportions reported at individual institutions within the United States have ranged from 0.84% to 15%. In multiple reviews, the lowest LWBS proportion reported was 0.1% in Taiwan while proportions in Australia have been reported from 1.7% to 8.6%, proportions in the UK from 3.26% to 7.2%, and proportions in Canada from 1.4% to 4.5%. Although these are the proportions reported in the literature, true proportions may be different. Regardless, data from the developing world are limited but at a public teaching hospital in Trinidad, the proportion of injured patients who LWBS was found to be 11.6%. In this study we found the proportion of patients who LWBS was 5.7% for patients presenting to the major public referral hospital in the capital city of Guyana. The proportion of patients who LWBS at this hospital is high by some international standards but is still well below that seen in many urban public hospital systems in developed countries and below the best available data from other developing countries.
We found increased odds of LWBS among adults compared to pediatric age patients. Others have not noted a lower proportion of LWBS among pediatric patients presenting to general EDs. Notably, some pediatric hospitals in North America report extremely high LWBS rates, with some as high as 16.6%. The reasons for our finding are unclear but it is possible that pediatric patients seen in the ED in Guyana are sicker than the typical patient in North America or other developed areas and the parents are more likely to remain for care despite a long wait. It has also been noted that pediatric patients who LWBS in North America almost all have primary care providers. It is possible that a real or perceived decreased ability to access primary care would influence the decision of the parents to stay for care. In Guyana, although there is access to primary care, it is often not on an appointment basis and wait times in clinics can be prolonged.
Similar to previous studies, we found that presenting during the second shift (4PM-12AM) was associated with significantly higher odds of LWBS. The fact that the proportion of patients who LWBS differs by time of day is not unexpected given that high LWBS proportions are usually reflective of congestion within the ED and this has been noted in other studies. While the day shift (8AM - 4PM) at GPHC has a higher patient volume, the cumulative back up of patients starts during the mid-day time period and continues throughout the later shifts, likely contributing to an increased likelihood of LWBS during that time period. Although the mean time from arrival to triage was not statistically different between patients who waited for care and those who LWBS, this may be secondary to the fact that the decision to LWBS has more to do with longer wait time for care.
We noted increased odds of LWBS in patients with non-traumatic conditions. This finding is expected given that most patients with injuries require acute attention. Transfer from other health care facilities and mode of transportation (EMS vs. other methods) were not associated with statistically significant differences in LWBS on multivariate analysis. The lack of significance is possibly due to low patient numbers among those transferred and those arriving by EMS. In Guyana, EMS is markedly underdeveloped and often is unavailable, even in the setting of critical illness or injury.
In most studies, patients with more acute triage levels have lower rates of LWBS. We did not note a statistically significant difference in the proportions of LWBS in this three-level triage system on the multivariate analysis. There was, however, a strong trend toward significance. Lack of significance in this study was likely due to the small numbers of patients triaged to higher acuity levels and possibly to problems with the ability of the triage system in differentiating various levels of care. Although it would seem that those triaged as non-urgent could defer care, studies have found that these patients are potentially sick. Notably, 3.1% of the patients with the highest triage scores LWBS in this study. As unexpected as this would seem, other studies have found that patients in the highest triage categories will still LWBS.
Apart from patient characteristics associated with LWBS, there are numerous hospital-associated factors that make it likely that LWBS proportions would be high in developing countries. Hospital overcrowding is common in many developing countries and overcrowding is well known to lead to prolonged patient wait times. Not surprisingly, a prolonged wait time is the primary reason cited by patients who LWBS. Adequate clinical space for providing emergency care is a significant problem in many healthcare systems. This is clearly a factor at GPHC where the ED clinical space is limited in comparison to North American hospitals with similar patient volumes. A variety of hospital-related strategies, including use of multiple quality improvement measures, addition of a fast-track area, addition of mid-level practitioners, addition of higher level practitioners at triage and the use of queuing theory have been assessed for changes in LWBS proportions with mostly positive effects. Unfortunately, many of these modalities are not practical in a resource-constrained environment. Nevertheless, GPHC is actively seeking solutions to address this issue and has recently added a physician in triage. During peak hours, this physician is based in the triage area with the goal of identifying those in need of immediate treatment and expediting care for those with minor conditions. Anecdotal reports are positive, but the effect of this staffing plan on ED crowding, waiting times and LWBS proportions has yet to be formally studied.
Although this was a retrospective analysis of a quality assurance database, all data were collected prospectively and an a priori objective of the database was to determine the proportion of patients who LWBS. Thus, the retrospective use of this database was unlikely to have led to significant bias. GPHC had not previously collected detailed patient characteristics at registration. This data was initially collected for quality assurance purposes and GPHC administrators set the time limits on data collection. The database was collected over an isolated two-week time period. Ideally, we would have examined the LWBS proportion over a longer time period in order to eliminate seasonal variation or other causes of variation in LWBS proportions. However, accurate longer-term data regarding patients who LWBS or accurate demographic information are not currently available at GPHC. We excluded patients who were sent from triage directly to a hospital clinic for care. It is possible that following these patients and including them in the analysis would have changed our results. Similarly, patients who presented for care but left prior to triage were not included in this study as no data could be obtained on these patients. Including these patients may have increased the LWBS proportion, but inclusion of these patients would also have made it difficult to compare our results with other published studies. Patients leaving before registration or triage are not typically reported in similar studies. Another limitation of this study was the lack of patient outcomes for those who LWBS. There was no mechanism to determine if patients who LWBS suffered other adverse events such as re-presentation to the ED, hospitalization, procedural interventions, or death. Finally, although this study was conducted at the primary referral hospital in a developing country, it may be difficult to generalize these findings to other health care institutions in Guyana or in other developing countries.
Discussion
The proportion of patients LWBS after presenting for emergency care varies considerably among hospitals and over time. A national study of patients who LWBS in the United States found an overall LWBS proportion of 1.7%, but proportions reported at individual institutions within the United States have ranged from 0.84% to 15%. In multiple reviews, the lowest LWBS proportion reported was 0.1% in Taiwan while proportions in Australia have been reported from 1.7% to 8.6%, proportions in the UK from 3.26% to 7.2%, and proportions in Canada from 1.4% to 4.5%. Although these are the proportions reported in the literature, true proportions may be different. Regardless, data from the developing world are limited but at a public teaching hospital in Trinidad, the proportion of injured patients who LWBS was found to be 11.6%. In this study we found the proportion of patients who LWBS was 5.7% for patients presenting to the major public referral hospital in the capital city of Guyana. The proportion of patients who LWBS at this hospital is high by some international standards but is still well below that seen in many urban public hospital systems in developed countries and below the best available data from other developing countries.
We found increased odds of LWBS among adults compared to pediatric age patients. Others have not noted a lower proportion of LWBS among pediatric patients presenting to general EDs. Notably, some pediatric hospitals in North America report extremely high LWBS rates, with some as high as 16.6%. The reasons for our finding are unclear but it is possible that pediatric patients seen in the ED in Guyana are sicker than the typical patient in North America or other developed areas and the parents are more likely to remain for care despite a long wait. It has also been noted that pediatric patients who LWBS in North America almost all have primary care providers. It is possible that a real or perceived decreased ability to access primary care would influence the decision of the parents to stay for care. In Guyana, although there is access to primary care, it is often not on an appointment basis and wait times in clinics can be prolonged.
Similar to previous studies, we found that presenting during the second shift (4PM-12AM) was associated with significantly higher odds of LWBS. The fact that the proportion of patients who LWBS differs by time of day is not unexpected given that high LWBS proportions are usually reflective of congestion within the ED and this has been noted in other studies. While the day shift (8AM - 4PM) at GPHC has a higher patient volume, the cumulative back up of patients starts during the mid-day time period and continues throughout the later shifts, likely contributing to an increased likelihood of LWBS during that time period. Although the mean time from arrival to triage was not statistically different between patients who waited for care and those who LWBS, this may be secondary to the fact that the decision to LWBS has more to do with longer wait time for care.
We noted increased odds of LWBS in patients with non-traumatic conditions. This finding is expected given that most patients with injuries require acute attention. Transfer from other health care facilities and mode of transportation (EMS vs. other methods) were not associated with statistically significant differences in LWBS on multivariate analysis. The lack of significance is possibly due to low patient numbers among those transferred and those arriving by EMS. In Guyana, EMS is markedly underdeveloped and often is unavailable, even in the setting of critical illness or injury.
In most studies, patients with more acute triage levels have lower rates of LWBS. We did not note a statistically significant difference in the proportions of LWBS in this three-level triage system on the multivariate analysis. There was, however, a strong trend toward significance. Lack of significance in this study was likely due to the small numbers of patients triaged to higher acuity levels and possibly to problems with the ability of the triage system in differentiating various levels of care. Although it would seem that those triaged as non-urgent could defer care, studies have found that these patients are potentially sick. Notably, 3.1% of the patients with the highest triage scores LWBS in this study. As unexpected as this would seem, other studies have found that patients in the highest triage categories will still LWBS.
Apart from patient characteristics associated with LWBS, there are numerous hospital-associated factors that make it likely that LWBS proportions would be high in developing countries. Hospital overcrowding is common in many developing countries and overcrowding is well known to lead to prolonged patient wait times. Not surprisingly, a prolonged wait time is the primary reason cited by patients who LWBS. Adequate clinical space for providing emergency care is a significant problem in many healthcare systems. This is clearly a factor at GPHC where the ED clinical space is limited in comparison to North American hospitals with similar patient volumes. A variety of hospital-related strategies, including use of multiple quality improvement measures, addition of a fast-track area, addition of mid-level practitioners, addition of higher level practitioners at triage and the use of queuing theory have been assessed for changes in LWBS proportions with mostly positive effects. Unfortunately, many of these modalities are not practical in a resource-constrained environment. Nevertheless, GPHC is actively seeking solutions to address this issue and has recently added a physician in triage. During peak hours, this physician is based in the triage area with the goal of identifying those in need of immediate treatment and expediting care for those with minor conditions. Anecdotal reports are positive, but the effect of this staffing plan on ED crowding, waiting times and LWBS proportions has yet to be formally studied.
Limitations
Although this was a retrospective analysis of a quality assurance database, all data were collected prospectively and an a priori objective of the database was to determine the proportion of patients who LWBS. Thus, the retrospective use of this database was unlikely to have led to significant bias. GPHC had not previously collected detailed patient characteristics at registration. This data was initially collected for quality assurance purposes and GPHC administrators set the time limits on data collection. The database was collected over an isolated two-week time period. Ideally, we would have examined the LWBS proportion over a longer time period in order to eliminate seasonal variation or other causes of variation in LWBS proportions. However, accurate longer-term data regarding patients who LWBS or accurate demographic information are not currently available at GPHC. We excluded patients who were sent from triage directly to a hospital clinic for care. It is possible that following these patients and including them in the analysis would have changed our results. Similarly, patients who presented for care but left prior to triage were not included in this study as no data could be obtained on these patients. Including these patients may have increased the LWBS proportion, but inclusion of these patients would also have made it difficult to compare our results with other published studies. Patients leaving before registration or triage are not typically reported in similar studies. Another limitation of this study was the lack of patient outcomes for those who LWBS. There was no mechanism to determine if patients who LWBS suffered other adverse events such as re-presentation to the ED, hospitalization, procedural interventions, or death. Finally, although this study was conducted at the primary referral hospital in a developing country, it may be difficult to generalize these findings to other health care institutions in Guyana or in other developing countries.