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Objective Improve left without being seen (LWBS) in our high volume, tertiary care trauma center. Prior to intervention, our LWBS rate was 4.4%. Including a direct bedding strategy, we successfully reduced our LWBS to <1%. Design and method We utilized a retrospective before and after model. We hired a clinical documentation specialist and tracked several metrics. These included daily census, admission rates, and door to provider, door to room, average boarding, and door to disposition times. Data were collected and disseminated daily. Reports were shared at organization quality meetings. Simultaneously, we implemented the direct bedding initiative in conjunction with quick registration. To accommodate higher numbers of patients and expediate movement to care spaces, all patient spaces were clearly designated and labeled. Results Direct bedding began in September 2015 and our LWBS was 4.4%. One-year post-intervention, our LWBS was <2%. Within four years, it was <0.5%. The LWBS rate for each year, 2016 to 2019, was significantly lower than the control period (p < 0.01) (2015 up to September). Improvement was also seen in door-to-provider time and with patient experience scores. Conclusion Our multifactorial approach was associated with a profound and sustained reduction in LWBS over a short time period.

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INTRODUCTION: Emergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact. METHODS: A retrospective chart review was conducted on patient's presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage. RESULTS: A total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%. DISCUSSION: The addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.

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Objectives: One of the endpoints for assessing the emergency department (ED) performance is the left-without-being-seen (LWBS) proportion. This study aimed to evaluate the impact of increasing proportions of on-duty emergency medicine (EM) trainees on LWBS rates in clinical shifts. Methods: The study was conducted at an urban-academic-ED (annual census: 452,757) over a period of one year. We employed multivariate linear regression (p < 0.05) defining significance to identify and adjust for multiple LWBS influencers related to patient care. Results: After analyzing over 1098 shifts, the median LWBS rate was 8.9% (interquartile range 5.3% to 13.5%). The increasing number of EM trainees in the ED did not adversely impact the LWBS; the opposite was noted. In univariate analysis, the increasing proportion of on-duty EM trainee physicians was significantly (p < 0.001) associated with a decrease in the LWBS rates. The multivariate model adjusted for the statistically significant and confounding LWBS influencers, with an absolute increase of 1% in trainees' proportion of overall on-duty physician coverage, was associated with an absolute decrease of 2.1% in LWBS rates (95% confidence interval 0.43% to 3.8%, p = 0.014). Conclusions: At the study site, there was a statistically and operationally significant improvement in LWBS associated with partial replacement of board-certified specialist-grade EM physicians with EM residents and fellow trainees.

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OBJECTIVE: The objective of this study was to develop a US-representative prediction model identifying factors with a greater likelihood of patients leaving without being seen. METHODS: We conducted a retrospective cohort analysis using a 2016 nationwide emergency department (ED) sample. Patient factors considered for analysis were the following: age, sex, acuity, chronic diseases, weekend visit, quarter of presentation, median household income quartile for patient's zip code, primary/secondary insurance, total charges for the visit, and urban/rural household. Hospital factors considered were urban/rural location, trauma center/teaching hospital, and annual ED volume. Multivariable logistic regression was used to find significant predictors and their interactions. A random forest algorithm was used to determine the order of importance of factors. RESULTS: A total of 32,680,232 hospital-based ED visits with 466,047 incidences of leaving without being seen were included. The cohort comprised 55.5% females, with a median (IQR) age of 37 (21-58) years. Positively associating factors were male sex (odds ratio [OR], 1.22; 99% confidence interval [CI], 1.17-1.26), lower acuity (P < 0.001), and annual ED visits ≥60,000 (OR, 1.44; 99% CI, 1.21-1.7) versus <20,000. Negatively associating factors were primary insurance being Medicare/Tricare or private insurance (P < 0.001); weekend presentations (OR, 0.87; 99% CI, 0.85-0.89); age >64 or <18 years (P < 0.001); and higher median household income for patient's zip code second (OR, 0.86; 99% CI, 0.77-0.97), third (OR, 0.8; 99% CI, 0.7-0.91), and fourth (OR, 0.7; 99% CI, 0.6-0.8) quartiles versus the first quartile. Significant interactions existed between age, acuity, primary insurance, and chronic conditions. Primary insurance was the most predictive. CONCLUSION: Our derivation model reiterated several modifiable and non-modifiable risk factors for leaving without being seen established previously while rejecting the importance of others.

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BACKGROUND: The January 1, 2018 closure of Memorial Hospital of RI (MHRI) has anecdotally resulted in operational strain for the area's remaining EDs. This study seeks to evaluate the impact on neighboring facilities. METHODS: An interrupted time-series analysis was conducted to compare operational outcomes and demographics pre- and post-MHRI closure. Three hospitals were selected from the same health system: Miriam Hospital, Rhode Island Hospital, and Newport Hospital. RESULTS: In the first 12 months following MHRI's closure, there were significant increases in monthly ED volume, length of stay, and left without being seen rates at two area hospitals. There was also a significant diversification of the patient population at these sites. The most substantial impact was noted at Miriam Hospital, the closest remaining facility. CONCLUSION: This study demonstrates operational strain and an evolving patient population at neighboring EDs following MHRI's closure. These findings suggest the need for additional resource allocation to support clinical care and logistics.

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BACKGROUND: Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital's emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States. OBJECTIVE: This study describes the LWBS population at a multi-hospital academic health system. METHODS: This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed. RESULTS: During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7 days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period. CONCLUSIONS: LWBS patients are high ED utilizers who may be effectively targeted by "hotspotting." Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.

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BACKGROUND: Left without being seen (LWBS) rates have become a key metric of emergency department (ED) flow, and high rates have been associated with poor patient outcomes, especially at busy urban, academic hospitals. OBJECTIVE: To assess a triage intervention's impact on LWBS rates among Emergency Severity Index (ESI) level 2 patients especially at risk for adverse outcomes. METHODS: We conducted a retrospective review at an urban academic center of LWBS rates prior to and after a "direct bedding" intervention, which directed patients triaged to ESI level 2 to be immediately placed in any available ED area, including those typically reserved for lower-acuity complaints. Our primary analysis employs an adjusted difference-in-difference-in-difference (DDD) approach using controls from the previous year and a nearby affiliate community hospital that did not participate in the intervention. RESULTS: Mean daily patient volume increased from 275 to 298 arrivals after the intervention. In the primary DDD analysis, odds of LWBS were lower after the intervention (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.45-0.70, p < 0.001). LWBS was higher in the unadjusted analysis (unadjusted OR 1.39, 95% CI 1.31-1.49, p < 0.001), but still lower among ESI 1 or 2 patients targeted by the intervention (unadjusted OR 0.56, 95% CI 0.43-0.74, p < 0.001). CONCLUSIONS: "Direct bedding" of ESI 2 patients may expedite care for the sickest patients, reducing potential harm to patients who might otherwise LWBS, without compromising care for patients triaged to less acute ESI levels.

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The objective of this study was to develop an agent based modeling (ABM) framework to simulate the behavior of patients who leave a public hospital emergency department (ED) without being seen (LWBS). In doing so, the study complements computer modeling and cellular automata (CA) techniques to simulate the behavior of patients in an ED. After verifying and validating the model by comparing it with data from a real case study, the significance of four preventive policies including increasing number of triage nurses, fast-track treatment, increasing the waiting room capacity and reducing treatment time were investigated by utilizing ordinary least squares regression. After applying the preventing policies in ED, an average of 42.14% reduction in the number of patients who leave without being seen and 6.05% reduction in the average length of stay (LOS) of patients was reported. This study is the first to apply CA in an ED simulation. Comparing the average LOS before and after applying CA with actual times from emergency department information system showed an 11% improvement. The simulation results indicated that the most effective approach to reduce the rate of LWBS is applying fast-track treatment. The ABM approach represents a flexible tool that can be constructed to reflect any given environment. It is also a support system for decision-makers to assess the relative impact of control strategies.

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OBJECTIVE: The emergency department (ED) left-without-being-seen (LWBS) rate is a performance indicator, although there is limited knowledge about why people leave, or whether they seek alternate care. We studied characteristics of ED LWBS patients to determine factors associated with LWBS. METHODS: We collected demographic data on LWBS patients at two urban hospitals. Sequential LWBS patients were contacted and surveyed using a standardized telephone survey. A matched group of patients who did not leave were also surveyed. Data were analysed using the Fisher exact test, chi-square test, and student t-test. RESULTS: The LWBS group (n=1508) and control group (n=1504) were matched for sex, triage category, recorded wait times, employment and education, and having a family physician. LWBS patients were younger, more likely to present in the evening or at night, and lived closer to the hospital. A long wait time was the most cited reason for leaving (79%); concern about medical condition was the most common reason for staying (96%). Top responses for improved likelihood of waiting were shorter wait times (LWBS, 66%; control, 31%) and more information on wait times (41%; 23%). A majority in both groups felt that their condition was a true emergency (63%; 72%). LWBS patients were more likely to seek further health care (63% v. 28%; p<0.001) and sooner (median time 1 day v. 2-4 days; p=0.002). Among patients who felt that their condition was not a true emergency, the top reason for ED attendance was the inability to see their family doctor (62% in both groups). CONCLUSION: LWBS patients had similar opinions, experiences, and expectations as control patients. The main reason for LWBS was waiting longer than expected. LWBS patients were more likely to seek further health care, and did so sooner. Patients wait because of concern about their health problem. Shorter wait times and improved communication may reduce the LWBS rate.

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INTRODUCTION: At our urban academic medical center, efforts to alleviate ED overcrowding have included the implementation of a "fast track" area, increasing the ED size, using hallway beds, and ambulance diversion. In October 2012, we began the first steps of a process that created a system in which the admission process involves equal amounts of pushing and pulling to achieve the balance necessary to accomplish optimal outcomes. The foundation of the initiative was based on the use of a BSN-educated emergency nurse as a flow coordinator; a position specifically empowered to affect patient throughput in the emergency department. METHODS: A determination of quality improvement was obtained by the local institutional review board for a retrospective analysis of all ED patient encounters 1 year before and 1 year after the implementation of the ED flow coordinator position. All patient encounters were included for consideration and calculation; no encounters were excluded. RESULTS: The flow coordinator program decreased length of stay by 87.6 minutes (P=.001) and lowered LWBS rate by 1.5% (P=.002). Monthly hospital diversion decreased from 93 hours to 43.3 hours (P=.008). DISCUSSION: Investing in a flow coordinator program can generate improvements to patient flow and can yield significant financial returns for the hospital. A decrease in diversion by an average of 49.8 hours per month translates to an annual decrease of nearly $20 million in lost potential charges. A decrease in the LWBS rate by 1.5% (31% relative decrease) per month translates to an annual decrease in lost potential charges of more than $5 million. Our research shows that an ED flow coordinator, when supported by departmental and hospital leadership, can yield significant results in a large academic medical center and that the program is able to produce an effective return on investment.

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