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BMC Emergency Medicine

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Open Access 01-12-2013 | Research article

Missing the boat: odds for the patients who leave ED without being seen

Authors: Jabeen Fayyaz, Munawar Khursheed, Mohammed Umer Mir, Amber Mehmood

Published in: BMC Emergency Medicine | Issue 1/2013

Abstract

Background

A patient left without being seen is a well-recognized indicator of Emergency Department overcrowding. The aim of this study was to define the characteristics of LWBS patients, their rates and associated factors from a tertiary care hospital of Pakistan.

Methods

A retrospective patient record review was undertaken. All patients presenting to the Aga Khan University Hospital, Karachi, between April and December of the year 2010, were included in the study. Information was collected on age, sex, presenting complaints, ED capacity, month, time, shift, day of the week, and waiting times in the ED. A basic descriptive analysis was made and the rates of LWBS patients were determined among the patient subgroups. Logistic regression analysis was used to assess the risk factors associated with a patient not being seen in the ED.

Results

A total of 38,762 patients visited ED during the study period. Among them 5,086 (13%) patients left without being seen. Percentage of leaving was highest in the night shift (20%). The percentage was twice as high when the ED was on diversion (19.8%) compared to regular periods of operation (9.8%). Mean waiting time before leaving the ED in pediatric patients was 154 minutes while for adults it was 171 minutes. More than 32% of patients had waited for more than 180 minutes before they left without being seen, compared to the patients who were seen in ED. Important predictors for LWBS included; Triage category P4 i.e. walk –in-patients had an OR of 13.62(8.72-21.3), Diversion status, OR 1.49(1.26-1.76), night shift , OR 2.44(1.95-3.05) and Pediatric age, OR 0.57(0.48-0.66).

Conclusions

Our study elucidates the LWBS population characteristics and identifies the risk factors for this phenomenon. Targeted interventions should be planned and implemented to decrease the waiting time and alternate services should be provided for high-risk patients (for LWBS) to minimize their number.

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McPheeters RA: Counter-point: frequent users of the emergency department: meeting society’s needs. West J Emergen Med. 2009, 10 (3): 195-

Derlet RW, Richards JR, Kravitz RL: Frequent overcrowding in US emergency departments. Acad Emerg Med. 2001, 8 (2): 151-155. 10.1111/j.1553-2712.2001.tb01280.x.CrossRefPubMed

Rowe BH, Channan P, Bullard M, Blitz S, Saunders LD, Rosychuk RJ, Lari H, Craig WR, Holroyd BR: Characteristics of patients who leave emergency departments without being seen. Acad Emerg Med. 2006, 13 (8): 848-852. 10.1111/j.1553-2712.2006.tb01735.x.CrossRefPubMed

McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J, Aronsky D: Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med. 2009, 54 (4): 492-503. 10.1016/j.annemergmed.2009.03.006. e494CrossRefPubMed

Trzeciak S, Rivers E: Emergency department overcrowding in the united states: an emerging threat to patient safety and public health. Emerg Med J. 2003, 20 (5): 402-10.1136/emj.20.5.402.CrossRefPubMedPubMedCentral

Hoot NR, Aronsky D: Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008, 52 (2): 126-136. 10.1016/j.annemergmed.2008.03.014. e121CrossRefPubMed

Weiss SJ, Ernst AA, Derlet R, King R, Bair A, Nick TG: Relationship between the national ED overcrowding scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005, 23 (3): 288-294. 10.1016/j.ajem.2005.02.034.CrossRefPubMed

Polevoi SK, Quinn JV, Kramer NR: Factors associated with patients who leave without being seen. Acad Emerg Med. 2005, 12 (3): 232-236. 10.1111/j.1553-2712.2005.tb00874.x.CrossRefPubMed

Pines JM: The left without being seen rate: an imperfect measure of emergency department crowding. Acad Emerg Med. 2006, 13 (7): 807-807.CrossRefPubMed

10.

Ding R, McCarthy ML, Li G, Kirsch TD, Jung JJ, Kelen GD: Patients who leave without being seen: their characteristics and history of emergency department use. Ann Emerg Med. 2006, 48 (6): 686-693. 10.1016/j.annemergmed.2006.05.022.CrossRefPubMed

11.

Arendt KW, Sadosty AT, Weaver AL, Brent CR, Boie ET: The left-without-being-seen patients* 1: what would keep them from leaving?. Ann Emerg Med. 2003, 42 (3): 317-323. 10.1016/S0196-0644(03)00404-9.CrossRefPubMed

12.

Kelen GD, Scheulen JJ, Hill PM: Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion. Acad Emerg Med. 2001, 8 (11): 1095-1100. 10.1111/j.1553-2712.2001.tb01122.x.CrossRefPubMed

13.

Mohsin M, Young L, Ieraci S, Bauman AE: Factors associated with walkout of patients from New south Wales hospital emergency departments, Australia. Emerg Med Australas. 2005, 17 (5 6): 434-442.CrossRefPubMed

14.

Hsia RY, Asch SM, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Sun BC: Hospital determinants of emergency department left without being seen rates. Ann Emerg Med. 2011, 58 (1): 24-32. 10.1016/j.annemergmed.2011.01.009. e3CrossRefPubMedPubMedCentral

15.

Baker DW, Stevens CD, Brook RH: Patients who leave a public hospital emergency department without being seen by a physician. JAMA. 1991, 266 (8): 1085-10.1001/jama.1991.03470080055029.CrossRefPubMed

16.

Sainsbury SJ: Emergency patients who leave without being seen: are urgently ill or injured patients leaving without care?. Mil Med. 1990, 155 (10): 460-464.PubMed

17.

Pham JC, Ho GK, Hill PM, McCarthy ML, Pronovost PJ: National study of patient, visit, and hospital characteristics associated with leaving an emergency department without being seen: predicting LWBS. Acad Emerg Med. 2009, 16 (10): 949-955. 10.1111/j.1553-2712.2009.00515.x.CrossRefPubMed

18.

Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, John McConnell K, Pines JM, Rathlev N: The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2008, 16 (1): 1-10.CrossRefPubMed

19.

Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA: Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. Brit Med J. 2011, 342: D2983-10.1136/bmj.d2983.CrossRefPubMedPubMedCentral

20.

Liao HC, Liaw SJ, Hu PM, Lee KT, Chen CM, Wang FL: Emergency department patients who leave without being seen by a doctor: the experience of a medical center in northern Taiwan. Chang Gung Med J. 2002, 25 (6): 367-373.PubMed

21.

Vieth TL, Rhodes KV: The effect of crowding on access and quality in an academic ED. Am J Emerg Med. 2006, 24 (7): 787-794. 10.1016/j.ajem.2006.03.026.CrossRefPubMed

22.

Goodacre S, Webster A: Who waits longest in the emergency department and who leaves without being seen?. Emerg Med J. 2005, 22 (2): 93-10.1136/emj.2003.007690.CrossRefPubMedPubMedCentral

23.

Kennedy M, MacBean CE, Brand C, Sundararajan V, Mc DTD: Review article: leaving the emergency department without being seen. Emerg Med Australas. 2008, 20 (4): 306-313. 10.1111/j.1742-6723.2008.01103.x.CrossRefPubMed

24.

Johnson M, Myers S, Wineholt J, Pollack M, Kusmiesz AL: Patients who leave the emergency department without being seen. J Emerg Nurs. 2009, 35 (2): 105-108. 10.1016/j.jen.2008.05.006.CrossRefPubMed

25.

Burt CW, McCaig LF: Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003–04. Adv Data. 2006, 376 (376): 1-24.PubMed

26.

Kronfol RN, Childers K, Caviness AC: Patients who leave our emergency department without being seen: the Texas Children's hospital experience. Pediatr Emerg Care. 2006, 22 (8): 550-10.1097/01.pec.0000230554.01917.cb.CrossRefPubMed

27.

Baibergenova A, Leeb K, Jokovic A, Gushue S: Missed opportunity: patients who leave emergency departments without being seen. Healthc Policy. 2006, 1 (4): 35-42.PubMedPubMedCentral

28.

Hobbs D, Kunzman SC, Tandberg D, Sklar D: Hospital factors associated with emergency center patients leaving without being seen. Am J Emerg Med. 2000, 18 (7): 767-772. 10.1053/ajem.2000.18075.CrossRefPubMed

29.

Fernandes CM, Price A, Christenson JM: Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?. J Emerg Med. 1997, 15 (3): 397-399. 10.1016/S0736-4679(97)00030-9.CrossRefPubMed

30.

Mehdi IJ: Emergency medicine in Pakistan. Ann Emerg Med. 1996, 27 (1): 84-88. 10.1016/S0196-0644(96)70301-3.CrossRefPubMed

31.

Razzak JA, Ahmed A, Saleem AF, Nasrullah M: Perceived need for emergency medicine training in Pakistan: a survey of medical education leadership. Emerg Med Australas. 2009, 21 (2): 143-146. 10.1111/j.1742-6723.2008.01139.x.CrossRefPubMed

32.

Arnold JL: International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999, 33 (1): 97-103. 10.1016/S0196-0644(99)70424-5.CrossRefPubMed

33.

Derlet RW, Richards JR: Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000, 35 (1): 63-68. 10.1016/S0196-0644(00)70105-3.CrossRefPubMed

34.

Bourgeois FT, Shannon MW, Stack AM: “Left without being seen”: a national profile of children Who leave the emergency department before evaluation. Ann Emerg Med. 2008, 52 (6): 599-605. 10.1016/j.annemergmed.2008.03.012.CrossRefPubMed

35.

Dijkstra AG, Hanmer LC: Measuring socio-economic gender inequality: toward an alternative to the UNDP gender-related development index. Fem Econ. 2000, 6 (2): 41-75. 10.1080/13545700050076106.CrossRef

36.

Mumtaz Z, Salway S, Waseem M, Umer N: Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy Plann. 2003, 18: 261-269. 10.1093/heapol/czg032.CrossRef

37.

Chan TC, Killeen JP, Kelly D, Guss DA: Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen. Ann Emerg Med. 2005, 46 (6): 491-497. 10.1016/j.annemergmed.2005.06.013.CrossRefPubMed

38.

Kurowski EM, Byczkowski T, Timm N: Return visit characteristics among patients who leave without being seen from a pediatric ED. Am J Emerg Med. 2012, 30 (7): 1019-1024. 10.1016/j.ajem.2011.06.017.CrossRef

39.

Ionescu-Ittu R, McCusker J, Ciampi A, Vadeboncoeur AM, Roberge D, Larouche D, Verdon J, Pineault R: Continuity of primary care and emergency department utilization among elderly people. Can Med Assoc J. 2007, 177 (11): 1362-10.1503/cmaj.061615.CrossRef

40.

Baumann MR, Strout TD: Triage of geriatric patients in the emergency department: validity and survival with the emergency severity index. Ann Emerg Med. 2007, 49 (2): 234-240. 10.1016/j.annemergmed.2006.04.011.CrossRefPubMed

41.

Devkaran S, Parsons H, Van Dyke M, Drennan J, Rajah J: The impact of a fast track area on quality and effectiveness outcomes: a middle eastern emergency department perspective. BMC Emerg Med. 2009, 9: 11-CrossRefPubMedPubMedCentral

42.

Darrab AA, Fan J, Fernandes C, Zimmerman R, Smith R, Worster A, Smith T, O'Connor K: How does fast track affect quality of care in the emergency department?. Eur J Emerg Med. 2006, 13 (1): 32-10.1097/00063110-200602000-00008.CrossRefPubMed

43.

Monzon J, Friedman SM, Clarke C, Arenovich T: Patients who leave the emergency department without being seen by a physician: a control-matched study. CJEM. 2005, 7 (2): 107-113.PubMed

44.

Green RA, Wyer PC, Giglio J: ED walkout rate correlated with ED length of stay but not with ED volume or hospital census. Acad Emerg Med. 2002, 9 (5): 514-10.1197/aemj.9.5.514.CrossRef

45.

Lee G, Endacott R, Flett K, Bushnell R: Characteristics of patients who did not wait for treatment in the emergency department: a follow up survey. Accid Emerg Nurs. 2006, 14 (1): 56-62. 10.1016/j.aaen.2005.11.004.CrossRefPubMed

46.

Richardson DB, Bryant M: Confirmation of association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004, 11 (5): 462-

47.

Lee K, Wong T, Chan R, Lau C: A study of patients who leave without notice in an A & E department. Accid Emerg Nurs. 1998, 6 (2): 118-121. 10.1016/S0965-2302(98)90012-1.CrossRefPubMed

48.

Clarey AJ, Cooke MW: Patients who leave emergency departments without being seen: literature review and English data analysis. Emerg Med J. 2011, 29 (8): 617-621.CrossRefPubMed

49.

Lang T, Davido A, Diakité B, Agay E, Viel JF, Flicoteaux B: Using the hospital emergency department as a regular source of care. Eur J Epidemiol. 1997, 13 (2): 223-228. 10.1023/A:1007372800998.CrossRefPubMed

50.

Carret M, Fassa A, Kawachi I: Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res. 2007, 7 (1): 131-10.1186/1472-6963-7-131.CrossRefPubMedPubMedCentral

51.

Sempere-Selva T, Peiró S, Sendra-Pina P: Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons–an approach with explicit criteria. Ann Emerg Med. 2001, 37 (6): 568-579. 10.1067/mem.2001.113464.CrossRefPubMed

52.

Moineddin RMC, Agha M, Zagorski B, Glazier R: Modeling factors influencing the demand for emergency department services in Ontario: a comparison of methods. BMC Emerg Med. 2011, 11 (13):

53.

Qureshi JA, Notta NJ, Salahuddin N, Zaman V, Khan JA: An epidemic of dengue fever in Karachi–associated clinical manifestations. J Pak Med Assoc. 1997, 47 (7): 178-PubMed

54.

Ahmed S, Arif F, Yahya Y, Rehman A, Abbas K, Ashraf S, Akram DS: Dengue fever outbreak in Karachi 2006-a study of profile and outcome of children under 15 years of age. J Pak Med Assoc. 2008, 58 (1): 4-8.PubMed

55.

Khan E, Siddiqui J, Shakoor S, Mehraj V, Jamil B, Hasan R: Dengue outbreak in Karachi, Pakistan, 2006: experience at a tertiary care center. Trans R Soc Trop Med Hyg. 2007, 101 (11): 1114-1119. 10.1016/j.trstmh.2007.06.016.CrossRefPubMed

56.

Ahsan T: Dengue fever: a regular epidemic?. Epidemiology. 2005, 2: 1-

57.

Jahan F: Dengue Fever (DF) in Pakistan. Asia Pac Fam Med. 2011, 10 (1): 1-10.1186/1447-056X-10-1.CrossRefPubMedPubMedCentral

58.

Mahboob A, Iqbal Z, Javed R, Taj A, Munir A, Akhtar SM: Clinical characteristics of the patients with Dengue fever: Report of 48 patients in 2010. J Ayub Med Coll Abbottabad. 2010, 22 (4): 120-123.PubMed

The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/13/1/prepub

Title: Missing the boat: odds for the patients who leave ED without being seen
Authors: Jabeen Fayyaz
Munawar Khursheed
Mohammed Umer Mir
Amber Mehmood
Publication date: 01-12-2013
Publisher: BioMed Central
Published in: BMC Emergency Medicine / Issue 1/2013
Electronic ISSN: 1471-227X
DOI: https://doi.org/10.1186/1471-227X-13-1

At a glance: The STEP trials

Springer Medicine

Missing the boat: odds for the patients who leave ED without being seen

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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