Patients leaving the ED without being seen by a physician: Is same-day follow-up indicated?,

A prospective study was performed to determine acuity levels, waiting times, and reasons why patients who sought care in an emergency department (ED) left without being seen by a physician, and to evaluate whether timed telephone follow-up improved their health outcomes. A comparison and follow-up survey was conducted on all patients who registered for care in the ED at the Naval Medical Center, San Diego, CA, and left without being seen (n = 32) and a 20% systematic sampling of patients who waited until they were seen (n = 170) during a one-week period in Spring, 1993. Baseline demographics and health statuses on reporting to the ED were gathered on all patients waiting to be seen that agreed to participate in the study (n = 533). Demographics for those seen versus those who left without being seen (LWBS) were similar (mean age 23.9 v 23.2, not significant [NS]; percent male 50.5% v 50.0%, NS). Seen versus LWBS had a similar proportion of patients triaged urgent (15% v 6%, NS), and nonurgent (85% v 69%, NS). Twenty-five percent of LWBS left before triage. Acuity levels were compared for patients seen versus LWBS for level I (1.5% v 3%, NS), level II (75% v 78%, NS), and level III (23.5% v 19%, NS). For the 25% that left before triage, level I was 9%, level II was 64%, and level III was 27%. Sixty-nine percent of patients who LWBS were seen for evaluation within 48 hours, 9% in an ED and 60% in a clinic. One patient was admitted with a diagnosis of possible lithium toxicity and remained hospitalized for 7 days. Fifty-one percent of those seen received further care within one week, 3% in an ED and 48% in a clinic, with 80% being status checks rather than care because the patients said they felt worse. Mean waiting time of patients seen was 1.17 hours versus 1.78 hours for patients LWBS (significant at .05). The primary reason for a patient to LWBS was waiting time (69%). On follow-up, patients rated how they felt on a scale of 1 to 6, with 1 being much worse, and 6 being 100% better. Seen versus LWBS ratings were 5.10, much better (seen) versus 4.28, somewhat better (LWBS), significant at .01. When asked if they felt better as a direct result of their care/phone call, seen versus LWBS ratings were 5.1, to a large degree (seen) versus 4.0, to some degree (LWBS), significant at .01. The one acuity level I patient who LWBS said that her phone follow-up directly improved her health outcome (5, to a large degree). It was concluded that ED patients who LWBS have similar acuity levels to those who remain to be seen. The primary reason they leave is waiting time. Waiting time is directly related to limited access to primary care facilities after hours. This ultimately leads to ED overcrowding and increases the number of patients who LWBS, which potentially leads to poor health outcomes. Call-backs to patients who LWBS affects and, in certain cases, may improve health outcomes for this population.