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Emergency Medicine Australasia (2014) 26, 243–248
doi: 10.1111/1742-6723.12167
ORIGINAL RESEARCH
Characteristics of patients who leave the emergency department without being seen: The first report in China Sihuan LIU,1 Hu NIE,1 Wenxia HUANG,1 Xiang LIU,2 Li LUO,3 Wayne Bond LAU4 and Yu CAO1 1 Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China, 2Department of Health Statistics, School of Public Health, Sichuan University, Chengdu, China, 3Business School, Sichuan University, Chengdu, China, and 4Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
Abstract Objective: The incidence of patients who leave without being seen (LWBS) by a doctor in the ED in China has not been reported. The purpose of this study is to identify the prevalence and characteristics of the LWBS patient population as well as predictors of LWBS in the ED of a tertiary hospital of China. Methods: We conducted a retrospective cohort study of all ED patients from November 2011 to October 2012 in our hospital. Patient age, sex, nationality, time of day, day of week and month of patient presentation, mode of arrival, and triage category were examined as potential predictors of LWBS. Multivariate logistic regression was performed to identify independent predictors of LWBS patients. Results: The prevalence of LWBS patients was 10.7%. LWBS patients were nearly equally divided between men and women (52.8% men, 47.2% women). The average age of LWBS patients was significantly younger than non-LWBS patients (P < 0.001). The majority of LWBS patients (82.2%) arrived on foot, and very few LWBS patients (0.3%) were non-Chinese. The majority of LWBS patients (94.6%) were assigned to Emergency Severity
Index level 3 or 4. Independent predictors of LWBS included paediatric age, lower triage acuity, arrival on foot, time of the day, day of the week and month of presentation. Conclusions: Independent LWBS predictors include paediatric patients arriving on foot in the evening with lower acuity problems. Potential risk management strategies should be implemented to decrease or eliminate the LWBS population by improving communication and providing increased comfort measures. Key words: age, emergency department, triage category.
Introduction Patients who present and subsequently leave without being seen (LWBS) by a doctor represent an almost universal problem in emergency medicine.1,2 This category of patients who do not receive the care desired in the ED is an important marker of the quality of emergency care in terms of both access to and the process of care.3 Previous studies suggest that a non-trivial proportion of LWBS patients are seriously ill, require immediate evaluation and are at risk of poorer outcomes.4,5 The recognised potential consequences of
Correspondence: Professor Yu Cao, Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu 610041, China. Email: [email protected] Sihuan Liu, MD, Associate Professor; Hu Nie, MD, Associate Professor; Wenxia Huang, MD, Associate Professor; Xiang Liu, PhD, Associate Professor; Li Luo, PhD, Professor; Wayne Bond Lau, MD, Professor; Yu Cao, MD, Professor. Accepted 20 November 2013
Key findings • The prevalence of patients who left without being seen was 10.7%. • Patient characteristics are similar to but also distinguishable from previous studies.
LWBS include detrimental patient health, medico-legal risk for the hospital and damaged hospital public relations.6 Any strategies employed to minimise these risks must counter specific factors contributing to a patient’s decision to LWBS. However, LWBS patient prevalence and sociodemographic characteristics in China have not previously been reported. Determining the characteristics of the LWBS patient population as well as predictors of LWBS in the ED is an important measure quantifying potential clinical risks from the absence or delay of care. Such a study might also yield insight regarding preventative measures reducing the LWBS population in Chinese hospitals. West China Hospital of Sichuan University is a major national tertiary medical centre serving both local patients and those referred from southwestern China. The ED is a crucial gateway to our institution’s wards. In recent years, there has been a growing risk of potential medical and legal issues related to patients’ perception of the timeliness, efficiency, safety and patient-centred care in our ED, as well as those elsewhere in China and the world.7,8 The aims of this study are to
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
244
S LIU ET AL.
(i) define the LWBS patient demographic, and (ii) assess predictive factors of LWBS.
Methods
been used in the ED, and all the triage process, medical records and medical prescriptions were recorded in the computerised system.
Methods and measurements
Setting and participants We conducted a retrospective cohort study of all ED patients from November 2011 to October 2012 in West China Hospital of Sichuan University. West China Hospital is an urban and public level III hospital in Chengdu of Sichuan Province and currently the largest hospital in China, with 4300 inpatient beds, serving as the major referral centre for complex health problems for southwestern China. The ED deals with internal and emergency medicine; surgery (including paediatric surgery); eye, ear, nose and throat emergency; and major trauma. For historical reasons, there is no dentistry, obstetrical, gynaecological or internal paediatric service in our ED. Emergency mental health service is provided in another campus of our hospital, which is not included in this study. Generally, the ED evaluates over 10 000 patients monthly, and is staffed by 12 attending emergency physicians each shift. In the ED, self-pay is the most common source of payment, although around 20% of the patients have public insurance to cover some small parts of ED payment. On arrival in the ED triage area, all the patients complete an information form with their name, chief complaint, contact phone number and time of arrival, which are all recorded in the ED computerised medical record system. Patients are subsequently interviewed by the triage nurse and then wait for an available ED room. We include patients whose ED visit resulted in being either seen by a doctor, admitted to the hospital, discharged from the hospital (all termed nonLWBS patients) or LWBS. LWBS includes all patients who leave after triage by a nurse but before further assessment by a physician; it excludes those who left after seeing a physician either without treatment or against medical advice. We also exclude those patients with incomplete data or brought in dead. Since 2008, a computerised medical record system has
The following variables were collected: patient age, gender, nationality, time of day, day of week and month of presentation, mode of arrival (assisted transport such as arrival by ambulance service vs on foot), triage category, and time of physician assessment. According to the Emergency Severity Index (ESI) version 4, triage category was assigned to each patient by a senior triage nurse on initial patient arrival.9 Patients were categorised into five levels, dependent on urgency of illness requiring physician treatment, including: immediate (I), emergent (II), urgent (III), semi-urgent (IV) and non-urgent (V).10 Time of presentation in ED was divided into morning (08.00–11.59 hours), afternoon (12.00–15.59 hours), early evening (16.00–19.59 hours), late evening (20.00–23.59 hours), early night (00.00–03.59 hours) and late night (04.00–07.59 hours). For the purpose of this study, Chinese patients refer to those who come from mainland China as well as Taiwan, Hong Kong and Macau, and nonChinese patients refer to those who come from other nations. All data were extracted from the ED computerised medical record system. This study is approved by the research ethics review board of West China Hospital, Sichuan University.
Statistical analysis Categorical data were summarised using percentages. Continuous data were summarised as the mean and standard deviation. χ2 tests were used to compare categorical data. Continuous variables were compared via twosample t-tests. Multivariate analysis was performed using logistic regression to predict LWBS likelihood. For the regression model, LWBS was the dependent variable, and several independent variables were used to develop the model. All variables that demonstrated statistically significant differences of P < 0.05 between groups in the univariate analysis were included
in the models as they were considered potentially significant to outcomes of interest. The category determined by univariate analysis to have least LWBS possibility was selected to be the reference category. All analyses were performed by spss software for Windows, version 18 (SPSS, Chicago, IL, USA). A P-value
Emergency Medicine Australasia (2014) 26, 243–248
doi: 10.1111/1742-6723.12167
ORIGINAL RESEARCH
Characteristics of patients who leave the emergency department without being seen: The first report in China Sihuan LIU,1 Hu NIE,1 Wenxia HUANG,1 Xiang LIU,2 Li LUO,3 Wayne Bond LAU4 and Yu CAO1 1 Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China, 2Department of Health Statistics, School of Public Health, Sichuan University, Chengdu, China, 3Business School, Sichuan University, Chengdu, China, and 4Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
Abstract Objective: The incidence of patients who leave without being seen (LWBS) by a doctor in the ED in China has not been reported. The purpose of this study is to identify the prevalence and characteristics of the LWBS patient population as well as predictors of LWBS in the ED of a tertiary hospital of China. Methods: We conducted a retrospective cohort study of all ED patients from November 2011 to October 2012 in our hospital. Patient age, sex, nationality, time of day, day of week and month of patient presentation, mode of arrival, and triage category were examined as potential predictors of LWBS. Multivariate logistic regression was performed to identify independent predictors of LWBS patients. Results: The prevalence of LWBS patients was 10.7%. LWBS patients were nearly equally divided between men and women (52.8% men, 47.2% women). The average age of LWBS patients was significantly younger than non-LWBS patients (P < 0.001). The majority of LWBS patients (82.2%) arrived on foot, and very few LWBS patients (0.3%) were non-Chinese. The majority of LWBS patients (94.6%) were assigned to Emergency Severity
Index level 3 or 4. Independent predictors of LWBS included paediatric age, lower triage acuity, arrival on foot, time of the day, day of the week and month of presentation. Conclusions: Independent LWBS predictors include paediatric patients arriving on foot in the evening with lower acuity problems. Potential risk management strategies should be implemented to decrease or eliminate the LWBS population by improving communication and providing increased comfort measures. Key words: age, emergency department, triage category.
Introduction Patients who present and subsequently leave without being seen (LWBS) by a doctor represent an almost universal problem in emergency medicine.1,2 This category of patients who do not receive the care desired in the ED is an important marker of the quality of emergency care in terms of both access to and the process of care.3 Previous studies suggest that a non-trivial proportion of LWBS patients are seriously ill, require immediate evaluation and are at risk of poorer outcomes.4,5 The recognised potential consequences of
Correspondence: Professor Yu Cao, Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu 610041, China. Email: [email protected] Sihuan Liu, MD, Associate Professor; Hu Nie, MD, Associate Professor; Wenxia Huang, MD, Associate Professor; Xiang Liu, PhD, Associate Professor; Li Luo, PhD, Professor; Wayne Bond Lau, MD, Professor; Yu Cao, MD, Professor. Accepted 20 November 2013
Key findings • The prevalence of patients who left without being seen was 10.7%. • Patient characteristics are similar to but also distinguishable from previous studies.
LWBS include detrimental patient health, medico-legal risk for the hospital and damaged hospital public relations.6 Any strategies employed to minimise these risks must counter specific factors contributing to a patient’s decision to LWBS. However, LWBS patient prevalence and sociodemographic characteristics in China have not previously been reported. Determining the characteristics of the LWBS patient population as well as predictors of LWBS in the ED is an important measure quantifying potential clinical risks from the absence or delay of care. Such a study might also yield insight regarding preventative measures reducing the LWBS population in Chinese hospitals. West China Hospital of Sichuan University is a major national tertiary medical centre serving both local patients and those referred from southwestern China. The ED is a crucial gateway to our institution’s wards. In recent years, there has been a growing risk of potential medical and legal issues related to patients’ perception of the timeliness, efficiency, safety and patient-centred care in our ED, as well as those elsewhere in China and the world.7,8 The aims of this study are to
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
244
S LIU ET AL.
(i) define the LWBS patient demographic, and (ii) assess predictive factors of LWBS.
Methods
been used in the ED, and all the triage process, medical records and medical prescriptions were recorded in the computerised system.
Methods and measurements
Setting and participants We conducted a retrospective cohort study of all ED patients from November 2011 to October 2012 in West China Hospital of Sichuan University. West China Hospital is an urban and public level III hospital in Chengdu of Sichuan Province and currently the largest hospital in China, with 4300 inpatient beds, serving as the major referral centre for complex health problems for southwestern China. The ED deals with internal and emergency medicine; surgery (including paediatric surgery); eye, ear, nose and throat emergency; and major trauma. For historical reasons, there is no dentistry, obstetrical, gynaecological or internal paediatric service in our ED. Emergency mental health service is provided in another campus of our hospital, which is not included in this study. Generally, the ED evaluates over 10 000 patients monthly, and is staffed by 12 attending emergency physicians each shift. In the ED, self-pay is the most common source of payment, although around 20% of the patients have public insurance to cover some small parts of ED payment. On arrival in the ED triage area, all the patients complete an information form with their name, chief complaint, contact phone number and time of arrival, which are all recorded in the ED computerised medical record system. Patients are subsequently interviewed by the triage nurse and then wait for an available ED room. We include patients whose ED visit resulted in being either seen by a doctor, admitted to the hospital, discharged from the hospital (all termed nonLWBS patients) or LWBS. LWBS includes all patients who leave after triage by a nurse but before further assessment by a physician; it excludes those who left after seeing a physician either without treatment or against medical advice. We also exclude those patients with incomplete data or brought in dead. Since 2008, a computerised medical record system has
The following variables were collected: patient age, gender, nationality, time of day, day of week and month of presentation, mode of arrival (assisted transport such as arrival by ambulance service vs on foot), triage category, and time of physician assessment. According to the Emergency Severity Index (ESI) version 4, triage category was assigned to each patient by a senior triage nurse on initial patient arrival.9 Patients were categorised into five levels, dependent on urgency of illness requiring physician treatment, including: immediate (I), emergent (II), urgent (III), semi-urgent (IV) and non-urgent (V).10 Time of presentation in ED was divided into morning (08.00–11.59 hours), afternoon (12.00–15.59 hours), early evening (16.00–19.59 hours), late evening (20.00–23.59 hours), early night (00.00–03.59 hours) and late night (04.00–07.59 hours). For the purpose of this study, Chinese patients refer to those who come from mainland China as well as Taiwan, Hong Kong and Macau, and nonChinese patients refer to those who come from other nations. All data were extracted from the ED computerised medical record system. This study is approved by the research ethics review board of West China Hospital, Sichuan University.
Statistical analysis Categorical data were summarised using percentages. Continuous data were summarised as the mean and standard deviation. χ2 tests were used to compare categorical data. Continuous variables were compared via twosample t-tests. Multivariate analysis was performed using logistic regression to predict LWBS likelihood. For the regression model, LWBS was the dependent variable, and several independent variables were used to develop the model. All variables that demonstrated statistically significant differences of P < 0.05 between groups in the univariate analysis were included
in the models as they were considered potentially significant to outcomes of interest. The category determined by univariate analysis to have least LWBS possibility was selected to be the reference category. All analyses were performed by spss software for Windows, version 18 (SPSS, Chicago, IL, USA). A P-value
