Emergency departments are busy places with an array of patient types. Presentations range from illnesses that are life threatening to those that are non-emergent. As patients are organized by the severity of illness and seen in the order of acuity (sickest first), wait times at busy locations can be long especially at county facilities or busy urban centers. Patients may leave without being seen or after being seen but before treatment has been completed. The Centers for Medicare & Medicaid Services (CNS) reports the number of patients leaving without being seen in the Hospital Outpatient Quality Reporting Program, and began using this measure for hospital reimbursement in 2014, setting a national goal of <2%. An understanding of the characteristics of patients who are more likely to leave without completing treatment can help a hospital focus efforts on solutions at reducing this population of patients. 

The CDC-NHAMCS survey collects some information regarding these visits and categorizes patients into three groups: 

  • Left Before Triage: This population stays long enough to be registered but leaves before having their complaint and initial vitals signs documented by a nurse (triage). 
  • Left After Triage: This population was seen by a nurse but left before seeing a provider – physician, nurse practitioner, or physician assistant. 
  • Left Against Medical Advice (AMA): This category is comprised of patients who have seen a provider and are leaving before results are available. It also includes those patients who are refusing further care (medications, observation, admission).

A number of articles have been published examining the characteristics of patients who leave without being seen, and the characteristics of facilities with higher numbers of these patients. Although CMS does not take into account hospital characteristics , there is much published data suggesting that hospitals serving primarily low income or uninsured patients may suffer from higher left without being seen percentages.

Below are two tables published by Sherry Leviner in 2015 detailing her literature review findings. She performed a data analysis of the CDC-NHAMCS data from 2007-2010 examining the same areas and validating these conclusions. The full paper is available here.

Table 1: Patient Characteristics and Relationship with Left Without Being Seen

VariablesRelationship with LWBSSource of Evidence
Age Older patients less likely to LWBS

Younger patients (18-24 years) more likely to
LWBS.
Baibergenova (2006)
Ding et al. (2006)
Johnson et al. (2009)
Pham et al. (2009)
Pines et al. (2012)
Sun et al. (2007)
Triage
Acuity
Lower triage acuity is associated with longer LOS.

Lower triage acuity is associated with higher
LWBS.
Baibergenova (2006)
Bourgeois et al. (2008)
Gilboy, Tanabe, Travers, Rosenau, and
Eitel (2011)
Gilligan et al. (2009)
Goldman et al. (2005)
Goodacre and Webster (2005)
Liao et al. (2001)
Mohsin et al. (2007)
Pham et al. (2009)
Sun et al. (2007)
Gender Disagreement in published results. No significant difference in LWBS based on gender.
Baker et al. (1991)
Bourgeois et al. (2008)
Goodacre and Webster (2005)
Johnson et al. (2009)
Mohsin et al. (2007)
Pham et al. (2009)
Sun et al. (2007)
Race Black patients had higher risk of LWBS compared
to White patients.
Bourgeois et al. (2008)
Ding et al. (2006)
Hsia, Asch, et al. (2011)
Pham et al. (2009)
Shen and Hsia (2010).
Ethnicity Hispanics have higher percentage of LWBS Pham et al. (2009)
Arrival
Time
7p-11p greatest number of LWBS.

4p-11p greatest number of LWBS.

Nights have higher LWBS
Bourgeois et al. (2008)
Kronfol et al. (2006)
Gilligan et al. (2009)
Goodacre and Webster (2005)
Liao et al. (2001)
Day of weekSunday, Saturday, Monday highest LWBS Gilligan et al. (2009)
Mohsin et al. (2007)

Table 2: Organizational Characteristics and Relationship with Left Without Being Seen

Variables Relationship with LWBSSource of Evidence
Metropolitan Statistical AreaUrban- higher LWBS Sun et al. (2007)
Bourgeois et al. (2008)
Pham et al. (2009)
Hospital OwnershipCounty-owned has higher
LWBS

Non-profit has higher LWBS

For-profit hospitals have
lower LWBS
Hsia, Asch, et al. (2011)
Stock et al. (1994)
Bourgeois et al. (2008)
Handel et al. (2013)
RegionSouth has highest percentage
of LWBS
Bourgeois et al. (2008)
Sun et al. (2007)

Tables above reproduced with permission from the author.

In the face of increasing emergency department crowding and a national trend of increasing numbers of patients leaving without being seen, efforts should be focused on improving patient flow and hospital efficiency in healthcare delivery.

If your emergency department is in need of more robust data, assistance with digesting existing data, or assistance with the next step in process improvement, please reach out to us here for a free consultation.

References:

  • Baibergenova, A. (2006). Missed opportunity: Patients who leave emergency departments without being seen. Healthcare Policy, 1, 35–42. Full Text
  • Baker, D. W., Stevens, C. D., & Brook, R. H. (1991). Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. Journal of the American Medical Association, 266, 1091–1096. PubMed
  • Bourgeois, F. T., Shannon, M. W., & Stack, A. M. (2008). “Left without being seen”: A national profile of children who leave the emergency department before evaluation. Annals of Emergency Medicine, 52, 599–605. PubMed
  • Ding, R., McCarthy, M. L., Li, G., Kirsch, T. D., Jung, J. L., & Kelen, G. D. (2006). Patients who leave without being seen: Their characteristics and history of emergency department use. Annals of Emergency Medicine, 48, 686–692. PubMed
  • Gilboy, N., Tanabe, P., Travers, D. A., Rosenau, A. M., & Eitel, D. R. (2011). Emergency Severity Index (ESI), Version 4: Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD: Agency for Healthcare Research and Quality. Full Text
  • Gilligan, P., Joseph, D., Winder, S., O’Keefe, F., Oladipo, O., Ayodele, . . . Hegarty, D. (2009). DNW—“Did not wait” or demographic needing work: A study of the profile of patients who did not wait to be seen in an Irish emergency department. Emergency Medical Journal, 26, 780–782. PubMed
  • Goldman, R. D., Macpherson, A., Schuh, S., Mulligan, C., & Pirie, J. (2005). Patients who leave the pediatric emergency department without being seen: A case-control study. Canadian Medical Association Journal, 172(1), 39–43. PubMed
  • Goodacre, S., & Webster, A. (2005). Who waits longest in the emergency department and who leaves without being seen? Emergency Medicine Journal, 22(2), 93–96. PubMed
  • Handel, D. A., Fu, R., Vu, E., Augustine, J. J., Hsia, R. Y., Shufflebarger, C. M., & Sun, B. (2013). Association of emergency department and hospital characteristics with elopements and length of stay. The Journal of Emergency Medicine, 46, 839–46. PubMed
  • Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L., Han, W., . . . Sun, B. C. (2011). Hospital determinants of emergency department left without being seen rates. Annals of Emergency Medicine, 58(1), 24–32. PubMed
  • Johnson, M., Myers, S., Wineholt, J., Pollack, M., & Jusmiesz, A. L. (2009). Patients who leave the emergency department without being seen. Journal of Emergency Nursing, 35, 105–108. PubMed
  • Kronfol, R. N., Childers, K., & Caviness, A. C. (2006). Patients who leave our emergency department without being seen: The Texas children’s hospital experience. Pediatric Emergency Care, 22(8), 550–554. PubMed
  • Liao, H. C., Liaw, S. J., Hu, P. M., Lew, K. T., Chen, C. M., & Wang, F. L. (2001). Emergency department patients who leave without being seen by a doctor: The experience of a medical center in northern Taiwan. Chang Gung Medical Journal, 25(6), 267–373. PubMed
  • Mohsin, M., Forero, R, Leraci, S., Bauman, A. E., Young, L., & Santiano, N. (2007). A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emergency Medical Journal, 24(3), 175–179. PubMed
  • Pham, J. C., Ho, G. K., Hill, P. M., McCarthy, M. L., & Pronovost, P. J. (2009). National study of patient, visit, and hospital characteristics associated with lean an emergency department without being seen: Predicting LWBS. Academic Emergency Medicine, 16, 949–955. PubMed
  • Pines, J. M., Decker, S. L., & Hu, T. (2012). Exogenous predictors of national performance measures for emergency department crowding. Annals of Emergency Medicine, 60, 293–298. PubMed
  • Stock, L. M., Bradley, G. E., Lewis, R. J., Baker, D. W., Sipsey, J., & Stevens, C. D. (1994). Patients who leave emergency departments without being seen by a physician: Magnitude of the problem in Los Angeles County. Annals of Emergency Medicine, 23, 294–298. PubMed
  • Sun, B. C., Binstadt, E. S., Pelletier, A., & Camargo, C. A. (2007). Characteristics and temporal trends of “left before being seen” visits in US emergency departments, 1995–2002. The Journal of Emergency Medicine, 32, 211–215. PubMed

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.