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Left Without Being Seen in the ER: An Important Indicator of Access to Care

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Last year, the Winnipeg press reported that the number of patients leaving local emergency departments had significantly increased.

The CBC reported that “in the past year, 10.7 per cent of patients who sought care at the Health Sciences Centre’s emergency room left without being seen — up 23 per cent from 2009-10 — according to numbers from the Winnipeg Regional Health Authority (WRHA).

About 8.8 per cent of people left St. Boniface General Hospital’s emergency room without seeing a doctor in 2011-12. That’s up 44 per cent from 2009-10, when it was 6.1 per cent.”

“Left without being seen” or LWBS refers to patients who register in the emergency department but leave before they have seen a clinician.

The prevalence of such an event is a marker of ED crowding and is a signal that access to care issues are prevalent.

A study by Hsia published in the Annals of Emergency Medicine in 2011 noted that:

“a cross-sectional analysis of 262 acute-care hospitals involving more than 9 million ED visits to hospitals in California that operated an ED in 2007 to assess patient-level and hospital-level characteristics associated with LWBS. It found that the percentage of LWBS varied greatly, ranging from about 0.1% in some locations to a startling 20.3% in one hospital. The median percentage of LWBS was 2.6%. “While on the surface this figure may seem small, it’s important to note that national estimates of LWBS in the recent past were reported to be about 1.0%,” Dr. Hsia says. “These findings suggest that the phenomenon of LWBS is worsening.”

Factors associated with LWBS were reviewed in a 2006 Canadian study: “Missed Opportunity: Patients who leave the emergency department without being seen” by Baibergenova (CIHI).

Using National Ambulatory Care Reporting System data the authors looked at 4.3 million ED visits in Ontario between 2003-2004 and found a LWBS rate of 3.1%.

Factors associated with leaving included: patients aged 15-35 years, those with less acute conditions, and facilities that handle large volume of patients such as teaching hospitals and those with an annual census greater than 30,000 patients. The median time that patients waited before leaving was 103 minutes.

A Canadian study by Friedman published in the Canadian Journal of Emergency Medicine in 2005 revealed that:

“LWBS patients comprise a subgroup of ED patients who are socially disenfranchised and at high risk for loss to follow-up. They often lack stable housing and, in this study, were almost 6 times as likely to have no valid telephone number. In addition, they were less likely to have a family physician and more likely to attend other EDs or urgent care clinics after leaving the ED. These findings may reflect barriers to primary health care, including a limited ability to receive telephone messages, or accommodate scheduled appointments, or travel to a doctor’s office, and sometimes also the inability to furnish a valid health insurance card. They may also reflect LWBS patient perceptions that EDs and clinics are more receptive to them than traditional office-based environments. For individuals who lack a regular source of health care, access to health services is often difficult and, in many cases, the ED may be the most practical care option, even when their problem is non-urgent.”

This study performed in a teaching hospital in downtown Toronto showed a LWBS rate of 3.7%.

Though the is a general perception that those who LWBS are more likely to have nonurgent illness, there have been studies that have demonstrated complications from such a course of action including life threatening events from delayed diagnosis or treatment and liability risks to providers.

This may not be as significant as once thought.

Michael Schull of ICES reported in 2009 that “Patients who present to the emergency department but leave without being seen do not have a higher rate of adverse events than do those who wait to be seen and discharged, according to a large population-based Canadian study.

In our opinion, the conclusion from this study is that leaving without being seen does not represent an important patient safety issue. When you look at the number of patients who leave without being seen, it’s clear that this does represent an important patient access issue: A lot of patients coming to the hospital are not getting care when they feel they need it. But this is not a patient safety issue,” Dr. Michael J. Schull said at the annual meeting of the Society for Academic Emergency Medicine.

An important health policy implication is that hospital safety programs that track patients who leave without being seen (LWBS) are of limited utility.

Some hospitals phone every patient who leaves without being seen to get them back in, at substantial effort and cost. “We would suggest that this practice is not supported by our results,” said Dr. Schull of the Institute for Clinical Evaluative Sciences, Toronto.

He presented an analysis of the nearly 25 million patient visits to higher-volume EDs in Ontario during 2005-2008. After exclusion of visits that resulted in hospital admission, transfer, or death in the ED, 3.5% of the remainder, or nearly 780,000 ED visits, involved patients who left without being seen.

LWBS patients and those seen by a physician and discharged were demographically and socioeconomically similar. They also had a similar number of ED visits in the prior year. They presented with similar chief complaints as well, the top three in both groups being abdominal/pelvic pain, chest pain, and fever. However, urban hospitals had far higher numbers of LWBS patients than did rural hospitals.

In the 7 days following the index ED visit, LWBS patients had a 2.0% inpatient admission rate and a 0.04% mortality, while those seen and discharged had a 2.3% admission rate and 0.1% mortality.

After adjustment for numerous potential confounders in a multivariate analysis, including age, triage acuity status, chief complaint, and hospital factors, LWBS patients had a 2% greater risk of death or inpatient admission in the next 7 days, compared with those seen and discharged. This translated into an absolute 0.04% increase in risk. Although this was statistically significant because of the enormous patient numbers involved, “we do not think this represents a clinically important difference,” stressed Dr. Schull, an emergency physician at Sunnybrook Health Sciences Centre, Toronto.

Nevertheless, the proportion of those who LWBS is an important marker of how an emergency health care system (as opposed to an institution) is failing to mmeet the access needs of a vulnerable population.

Futhermore low risk is not no risk and meeting ED Length of Stay targets is associated with significant risk reduction.

Winnipeg has a clear problem as indicated by their significant rates of LWBS.
The emergency access to care needs of those in Winnipeg are clearly not being met and are significantly above the national average.

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