ACEP News 
July 2009

By Bruce Jancin
Elsevier Global Medical News

NEW ORLEANS -- 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.

Audience member Dr. Arthur L. Kellermann congratulated Dr. Schull on what he hailed as "a masterful work." But he cautioned that some hospital administrators might find a way to distort the findings.

"I do worry somewhat, not about the science, but about how this [information] might be used. ... Those hospital CEOs in this country who are aggressively turning patients away from the ED or limiting access by design might see from this study a rationale for why that's okay," said Dr. Kellermann, professor of emergency medicine at Emory University, Atlanta.

"We'll be writing this up carefully," Dr. Schull promised.

Other audience members wondered whether adverse events were more frequent among LWBS patients who presented at hospitals with double-digit LWBS rates. There were only a few such hospitals, Dr. Schull replied, and adverse event rates were indeed higher there--but that's because those hospitals also had on average older and sicker patients.