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Patients Who Leave the ED Without Being Seen

2005; Lippincott Williams & Wilkins; Volume: 27; Issue: 11 Linguagem: Inglês

10.1097/00132981-200511000-00013

1552-3624

James R. Roberts,

Emergency and Acute Care Studies

FigureAuthor Credentials and Financial Disclosure: James R. Roberts, MD, is the Chairman of the Department of Emergency Medicine and the Director of the Division of Toxicology at Mercy Health Systems, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia. Dr. Roberts has disclosed that he has no significant relationships with or financial interests in any commercial companies that pertain to this educational activity. Wolters Kluwer Health has identified and resolved all faculty conflicts of interest regarding this educational activity. Learning Objectives: After reading this article, the physician should be able to: Describe the characteristics of patients who leave the ED without being seen. Identify the reasons patients leave prior to being seen. Discuss the medical outcomes of those patients who leave without being seen. Release Date: November 2005 Emergency physicians have enough to worry about when it comes to diagnosing and treating patients already in an ED bed. But we have all been in the situation where, after spending considerable time, effort, and resources on patients already physically in the ED, the nurse or clerk informs you that someone has left from the waiting room without being seen. This is a frustrating dilemma, one fraught with a plethora of potential and real complications for the patient and physician. In the midst of a busy ED and after extending tremendous, nay maximum, effort during a busy shift, it is only human nature for the physician and nursing staff to throw up their hands and simply ignore the departed (or departing) individual. Perhaps you get advanced warning and have a chance to speak with the patient who is about to leave or his relative, but usually they are too angry or frustrated to engage in useful dialogue. Some are too hostile to confront at all.Table: Patients Who Leave Without Being Seen vs. Those Who Wait to Be Seen.It seems reasonable to try to salvage the visit, and get some mutual benefit of the hours spent waiting, but once a patient makes up his mind to leave, it may be difficult to dissuade him from this poor decision. A normal reaction from an overworked and maximally stressed medical staff is simply to allow the patient to fend for himself and brand him as either ignorant or ungrateful. Clearly he doesn't understand how busy you are! Although a “good riddance” reaction may seemingly settle the issue, things are much more complicated then they initially seem.Figure: It would be preferable if all patients who opt to leave the ED without being seen would communicate with someone before bolting. Many will leave on their own accord and not tell anyone. Most security guards and other ancillary personnel in the waiting room do not want to become involved, and the triage nurse is likely busy with other patients. A patient advocate or a big sign might help, but it's a group effort to identify the potential premature egress. Although not always possible, the emergency physician should be aware of the patient who is about to leave and try to intervene. It's a good idea to document the chart, gestalt the severity of the medical problem, ascertain the mental competence of the patient, or at least try to explain the situation. Patients with legitimate medical problems will leave your ED, and the usual reason is long waits, which are almost always due to omnipresent overcrowding.We all have certain tricks, negotiating tactics, and bargaining chips to play to soothe ruffled feathers, to keep an angry letter from reaching an administrator, or worse yet, to prevent an untoward medical outcome at home. Sometimes all you need to do is to let the patient know that you did not forget about him, and promise to try to expedite his care. Of course, this may anger other patients in the waiting room who are in the same situation, so speak softly. This month's column discusses data on patients who leave without being seen, along with some relevant issues and possible remedies. It's difficult for the family or public to believe that something more could not be done to orchestrate a more efficient ED, or to provide rapid care to someone who is obviously ill or in need of attention. The most difficult issue for patients to understand is why minor problems, so easily dealt with, take forever to address. Some patients who leave without being seen have serious problems and a bad outcome, but fortunately the majority do not have life-threatening conditions, and somehow they seem to get by on their own, in spite of our inefficiencies. Patients Who Leave a Public Hospital Emergency Department Without Being Seen by a Physician: Causes and Consequences Baker D, et al JAMA 1991;266:1085 This article is about 15 years old, but the underlying scenario has not changed significantly. Similar results have been repeatedly found when other investigators have studied this issue. For many years, the ED has been the safety net for medical care. EDs are certainly perceived as a source of medical intervention for economically depressed inner-city populations. These days, the ED is the safety net even for the well insured, affluent, educated, VIP individual. Today, “go to the ED if you have a problem” is a common message on the answering machine of even the most attentive private clinician. This article is from UCLA Medical Center, an institution that recognized ED overcrowding as early as 1990. The issues have always been the same. Increasing numbers of patients, transfers of complicated and uninsured patients from private hospitals, the growing number of indigent patients, and the inexhaustible demand for ambulatory care have relegated the ED to a veritable war zone. Not surprisingly, the omnipresent and universal pressures on the UCLA ED resulted in an increased number of patients who left without being seen by a physician. Previous investigators found that patients who left the ED without being seen usually had a recent onset of symptoms, and experienced a relatively short wait before they left. Those articles concluded that patients who leave without being seen have a lower tolerance for long waits, and leaving the hospital without treatment did not adversely affect their health. Even pediatrics patients who were purloined from the waiting room prior to being seen were considered to be there for nonemergent complaints. The majority were minimally ill or injured, and had not sought subsequent emergency medical care within 48 hours when they could be contacted. This is not the current scenario, however. Times have certainly changed. Throughout the country, the acuity of patients visiting the ED has increased, along with their numbers. The authors of this study tried to determine the significance of patients who leave without being seen. In this study, they addressed such issues as the need for immediate examination and treatment, how long the patients wait before leaving, why they left, and what medical care they subsequently obtained.Figure: Although it is desirable to have advanced notice from any patient who is about to leave the ED, often the first indication is when no one answers a nurse's call. If the patient has been triaged, a chart will exist. The physician should document the encounter (or lack thereof) and the attempts to remedy the problem with specific information. When possible, a call to the patient or a relative for an update is proactive and good public relations, patient-friendly, and good medical practice. It is impossible to interview all patients who want to leave, but it is desirable to retrospectively address those patients who already had an encounter with the triage nurse. This mock chart looks bad enough from a triage perspective, but at least the clinician addressed the situation. The lack of demographic information gleaned at triage and losing an elderly and likely confused patient during the registration process make the hospital look sloppy and uncaring, despite the gargantuan efforts of the entire staff to keep this from happening.UCLA Medical Center was then a 500-bed, Level I trauma center. The ED saw approximately 110,000 patients per year, and only 10 percent had private insurance. Overall, only about one in three patients in Los Angeles have private medical insurance. There were only a few patients on Medicare. The study looked at a two-week time block in the spring of 1990, and the study was performed using a questionnaire given in the emergency department with follow-up one week later. No patient was brought by ambulance. Patients in the study were processed through the emergency department in a normal manner; the only variable was that they were given a questionnaire. This was a case-controlled study designed to assess the influence of various parameters, including insurance status and race. The questionnaire elicited answers to questions about pain, overall health, quality of life, physical limitations, mental health, and social factors. Patients were rated for their acuity using a four-level system (see table) based on the triage nurse's assessment and a retrospective physician acuity-rating system. Patients with abnormal vital signs were designated as needing immediate medical attention, and were given a level 1 acuity rating. Of the 2,259 patients who came to the ED during the study period, 8.2 percent (168 patients) left without being seen by a physician. Of the patients who left without being seen, 46 percent were judged to need prompt medical evaluation because they met the level 1 acuity criteria. Almost 30 percent needed attention within 24 to 48 hours based on the acuity scale. Therefore, an amazing 76 percent had a real medical problem to substantiate their ED visit. Only two percent of the patients were judged to have no significant medical problems (vague chief complaint, general physical examination request, medication refills, return to work note, etc). When comparing the characteristics of patients who left without being seen with patients who waited, there was a minimal preponderance of male patients who left prematurely, but no age difference (mean 35–36 years), no racial difference, and no insurance qualifiers. Interestingly, the chief complaints (noted in the table) did not differ significantly between the two groups. Of those who left without being seen, the average wait stated by the patient was 6.4 hours. Those who stayed reported an average wait to see a physician of 6.2 hours. In reality, the waits were slightly less, about six hours for those who left. Those who stayed waited an average of about four hours. Most subgroups over-estimated the time it took them to be seen by a physician. The overwhelming reason for leaving was dissatisfaction with prolonged waits. Interestingly, about half of the patients stated that they felt too sick to wait any longer. Other sundry reasons for leaving included child care duties, transportation problems, and work schedule conflicts. About half of the patients who left without being seen were able to visit a physician within the one-week follow-up period. About a third returned to the same ED; others were seen in a variety of office or clinic settings. Of those who left and encountered the medical system again, 11 percent were hospitalized when first seen at the subsequent visit. About three-quarters of those were hospitalized within 24 hours and most within two days. About 40 percent of patients made no further attempts to see a physician, and almost half of those were in the two highest acuity levels. The main reason for not seeking additional follow-up was cost. About a quarter of those who left no longer thought that they needed to see a physician, and about the same number did not know where to get any other treatment.Table: Overview of 186 Patients Who Left Without Being SeenThe authors highlight the large number of seriously ill patients who initially sought medical care in the emergency department and then left without being seen. Those who left did not always have trivial medical problems. Essentially, patients who left had the same need for medical care as those who stayed. The authors highlight that 11 percent of patients who left were hospitalized within the one-week follow-up period. However, it was unclear whether patients who left without being seen had adverse consequences because of the delay in hospitalization. The main frustration for these patients was the long wait. Most of those who left still believed that they needed to be seen by a physician, but circumstances would not allow them to wait any longer. The authors had no solution to this problem, but they did conclude that overcrowding in the ED restricts access of the poor and uninsured to medical care that is legitimate and required. A significant number of patients who left without being seen were sick enough to be hospitalized within one week. Comment: If you ask any emergency physician or nurse to comment on the characteristics of patients who leave without being seen, you will usually get the same response. The first response is that the ED is consistently overwhelmed and busy enough treating patients who have made it to the back room. Most clinicians think they have little ability to monitor the waiting room, to decrease waits, or to address other throughput problems not under their control. I would agree with that conclusion, but many physicians also erroneously believe that patients who leave are probably not sick enough to be there in the first place, are looking for free medical care, find the ED more convenient, or don't bother getting an appointment with their doctor. There is nothing “convenient” about an ED visit these days, and most patients even dread the concept. The last thing my sick friends want to do is go to the ED, and wait, and wait, and wait. The results of this study, and those of many others, put to rest the notion that patients who leave untreated do not have serious medical problems, nor are they only the uninsured, indigent, unemployed individuals. Patients with real diseases and real medical problems, many with the ability to pay, leave the ED for a variety of reasons. But mostly it's long waits. Every study looking at this issue blamed overcrowding as the primary reason for patients who leave without being seen — this is not rocket science. (Ann Emerg Med 2005;23[3]:288; Acad Emerg Med 2005;12[3]:232; Am J Emerg Med 2000;18[7]:767.) The American public has little tolerance for waiting, be it at an expensive restaurant, fast food restaurant, Lexus dealership, or Target. No one wants to wait for anything, and medical care is no exception. Although you may not need that Lexus today or that second quarter-pounder, this study would suggest that you do need to see the doctor. These patients do have jobs, insurance, and kids at home that they worry about. A number of years ago, Dershewitz et al (Ann Emerg Med 1986;15[5]:717) reported slightly different statistics in a pediatric emergency department. Their data seemed to correlate with the then-prevailing impressions of physicians. Most of their walkouts were between 4 p.m. and midnight (clearly a busy time), and half had either no insurance or no other source of health care. The wait was less than three hours. In their series, four percent had emergent or urgent medical problems. Only about three percent were eventually hospitalized. About half did not seek health care at another destination. You only have to work a single shift today to realize that times have certainly changed. Actual sick people leave the waiting room, not just the homeless woman looking for a free meal and a warm bed. Patients who leave without being seen are a universal problem, not limited to the U.S. Citing the Toronto quaternary care hospital experience of universal health care, Fernandes et al, (Ann Emerg Med 1994;24[6]:1092) reported that most adult patients who left their ED waiting room (1.4% of registrants) had a low acuity rating. As expected, they left because of prolonged waits. The Canadians apparently have even less patience than Americans because most left between 30 minutes and two hours. It takes that long to get registered in many U.S. hospitals. Curiously, 28 percent of patients who left without being seen had “perceived difficulties with the hospital staff,” suggesting a modicum of friction with the doctor, nurse, or clerk. Almost 30 percent had “pressing commitments elsewhere.” In this Canadian system, half of the patients who left without being seen sought subsequent medical care through their personal physician or another ED. Not waiting to see the doctor is also a European phenomenon. In the U.K., the mean wait before leaving the ED in 1999 was 2.44 hours. (Eur J Emerg Med 1999;6[3]:233.)Table: A Questionnaire for Patients Who Left Without Being SeenThe amazing conclusion by the authors of that study was that the British themselves were able to gauge the severity of their symptoms and safely defer medical consultation, and if you believe that, I have some swampland in Florida for you! Perhaps the best care in the world (as measured by walkouts) is in Taiwan. Liao et al (Chanh Gung Med J 2002:25[6]:367) found an amazing rate of patients who left without being seen: only 0.1 percent (77 of 74,485 patients), with a 97 percent low acuity rate for the walkouts. Of course, the main reason for leaving in Taiwan — long waits. No hospital has solved this problem. Although statistics vary, most hospitals report a rate of between one percent and four percent. If you can match these figures, you are doing well. Hospital administrators love to use these data to compare their physicians with other hospitals and hospitals within the same organization. There may be a slight difference in the rate of patients who leave without being seen when one compares “public” hospitals with “private” hospitals. In 1994, the rates for public vs. private hospitals in Los Angeles were 7.3 percent vs. 2.4 percent respectively. (Ann Emerg Med 1994;23[2]:294.) This suggests that private hospitals with more staff are more efficient or simply treat patients better. I have not seen post-EMTALA numbers, but I would venture a guess that the EMTALA law may have evened things out, and geography no longer has such a great influence. In addition to prolonged waits and being uninsured, another factor that has been associated with more patients leaving without being seen is residency training programs. I don't think emergency physicians can do much to alter the numbers when they are actually working a shift. It's usually a systems problem, and doctors generally can't work much faster than they already do. If there is no place to see the patient or no nurse to bring them back, the best efforts will result in walkouts. The physician in charge should, however, keep an ear to the ground, and be vigilant for patients who intend to leave. Like the patient who leaves against medical advice, the patient who leaves without being seen is a bad outcome by mere definition.Table: Acuity Measure of ED PatientsIt would be a good idea to have some sort of system where all patients who are about to leave report to a triage nurse, security guard, or somehow make it known that they leaving. Sometimes you can alter their departure plans by offering to see them sooner or by providing other sorts of creature comforts or interventions. Most of my walkouts leave unnoticed, but if the event is still being hatched, I prefer to know and to speak with them to gauge their acuity. Usually, however, they are so mad that they don't tell anybody; they just leave. A rude clerk or nurse will sabotage your best efforts even before you get a chance to screw things up yourself. The attitude of your ancillary staff reflects on the doctor and hospital, so these individuals should be under as much scrutiny as the clinicians. Patients who leave without being seen present a high-risk group for risk management. Most patients rate their satisfaction with health care on their waits and often not on more important real issues such as outcome or thoroughness of their evaluation. The patient whose cold was “cured by antibiotics” will probably remember prolonged waits more than he will remember the accuracy of his diagnosis. Most patients don't know whether they had a good doctor, but they all know how long they waited. In the public's opinion, “good” hospitals see patients more quickly than “bad” hospitals. Although the medical disasters from patients who leave without being seen is probably very small, the public relations disasters are many. A patient advocate in the waiting room probably helps solve some of the problems, and at least it lets the patients know you didn't lose their charts and that you know they are waiting. A few reassurances about the acuity of the ED and the fact that their complaints will be addressed are good business tactics. In these days of nursing shortages and overcrowding, this perk has been left by the wayside in many places. Finally, alternatives to ED care should be explored. Fast tracks are obviously the easiest quick fix. No ED can function efficiently without one these days. However, few EDs have solved this issue. EMTALA aside, some hospitals are now providing a screening examination and then alternatives to ED treatment. In an area where clinics, private offices, and other walk-in health centers are available, such a tactic may solve some of the problems, but it's not a popular alternative with anyone. If reasonable alternatives to ED health care were available, the patients probably would not be in the ED in the first place. Patients Who Leave the Pediatric Emergency Department Without Being Seen: A Case-Control Study Goldman R, et al Can Med Assoc J 2005;172(1):1503 The problem of pediatric patients who leave without being seen persists in every country, including at the Hospital for Sick Children in Toronto. As recently as 2005 the rate of patients who left without being seen was three percent. Like in most studies, the majority of patients had lower acuity problems. In the universal access system of Canada, the majority of children were taken elsewhere for treatment. U.S. hospitals do not have this luxury, and patients remain captive to the local ED system. In this Canadian tertiary care children's hospital where they see 50,000 visits a year, the problem of leaving without being seen was again related to well known variables: waits, difficulty communicating with the staff, other commitments, or resolution of symptoms. Only one of the 289 patients who left without being seen required admission to the hospital for the presenting problem, even though 15 percent were classified as urgent by the triage process. The volume between midnight and 4 a.m. increased the odds of leaving by almost six times. The authors note that the rate of premature departure from EDs in Australia is even higher, in the five percent to six percent range. Comment: It's one thing if an adult leaves the hospital without being seen, but it's another if the parent removes his child because of perceived inattention. This is terrible public relations, and the scenario gives any hospital administrator angina. While the incidence of ED visits for drug, alcohol, and psychiatric problems are on the rise in the United States, one would not expect children leaving without being seen to be a problem. And any untoward outcome for a child is likely to prompt serious questioning or litigation at a rate higher than for an adult. I have not found any relevant literature concerning litigation risks for patients who leave the ED without telling anyone. Once they arrive in the ED, however, they are your patients, even before they register. If a patient must leave, I suggest you grab the triage chart or make one on the spot if you can. Document the patient's mental capacity to make important medical decisions, and carefully look at the chief complaint and vital signs. If they signed in with dizziness and a pulse of 130 bpm, try to make them a priority in the ED proper. Likewise, when a patient has a medical problem in the waiting room prior to being seen, it is generally considered that the ED is at fault for inappropriate triage or observation. It would be nice to have all patients sign out AMA when they leave before being seen, but this is probably asking too much from our already broken system. When a patient leaves without being seen, the hospital, the physician, the patient, and their families all lose. This issue, perhaps more than any other, is a discouraging comment on the status of health care in this country.