Return visit characteristics among patients who leave without being seen from a pediatric ED

Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
The American journal of emergency medicine (Impact Factor: 1.27). 10/2011; 30(7):1019-24. DOI: 10.1016/j.ajem.2011.06.017
Source: PubMed


The primary aim of this study was to evaluate for differences in acuity level and rate of admission on return visit between patients who leave without being seen (LWBS) and those who are initially evaluated by a physician. Our secondary aim was as well as to identify predictors of which LWBS patients will return to the ED with high acuity or require admission.
A cross-sectional study using an administrative database at an academic tertiary-care pediatric hospital in the United States from January 1, 2006, to December 31, 2008 was done.
There were 3525 patients who LWBS during the study period (1.2% of total ED visits). Of these, 87% were triaged as nonurgent, and 13% as urgent at their initial visit. Two hundred eighty-nine (8%) of LWBS patients returned to the ED within 48 hours. Compared with the population who returned to the ED after previous evaluation, patients who LWBS from their initial visit and returned had significantly lower odds of urgent acuity at time of return visit (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.15-0.32) and of being admitted (OR, 0.58; 95% CI, 0.40-0.84). Urgent acuity at initial visit (OR, 2.86; 95% CI, 1.35-6.04) and number of ED visits in last 6 months (OR, 1.24; 95% CI, 1.02-1.52) were significant predictors of admission at return visit among the LWBS population.
Generally, patients who LWBS from a pediatric ED were unlikely to return for ED care, and those who did were unlikely to either be triaged as urgent or require hospital admission. This study showed that urgent acuity during the initial visit and number of previous ED visits were significant predictors of admission on return. Identification of these predictors may allow a targeted intervention to ensure follow-up of patients who meet these criteria after they LWBS from the pediatric ED.

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    • "This could be assessed by the percentage of subsequent return visit in the ED after leaving. The return visits in our study are found to be 3.6% much higher than the internationally reported numbers (1.2%) in a USA study with 1.5% requiring hospital admission subsequently [38]. "
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    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.
    Full-text · Article · Jan 2013 · BMC Emergency Medicine
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    ABSTRACT: Background Emergency Department (ED) crowding has become more common and perceptions of crowding vary among different healthcare providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings. Objective Determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high volume ED and assess the reliability and consistency of different providers’ perceptions of ED crowding. Material and Methods This was a two-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay (LOS) and number of patients that left without being seen (LWBS) were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The inter-rater and intra-rater agreements of ED crowding were tested. Results In phase 1, the subject ED was determined to be overcrowded > 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average LOS and the number of LWBS patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between healthcare providers was reached (k = 0.5402, p < 0.0001). Test-retest reliability among providers was high (r = 0.8833, p = 0.0007). The strength of agreement between study groups and the NEDOCS was weak (k = 0.3695, p < 0.001). Conclusion Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high volume ED setting.
    No preview · Article · Oct 2014 · American Journal of Emergency Medicine