Patients who leave Emergency Department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short term outcomes

Abstract

Background and AimsPatients who leave Emergency Department before physician’s visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients.MethodsThis is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients.ResultsThe cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician’s visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5–4.7; OR = 2.89, 95%CI 2.8–2.9; LDT: OR = 3.12, 95%CI 3–3.2; OR = 2.25, 95%CI2.2–2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4–3.9; OR = 2.25, 95%CI 2.1–2.4; LDT: OR = 3.96, 95%CI 3.6–4.3; OR = 2.62, 95%CI 2.4–2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6–4.2; OR = 1.7, 95%CI 1.3–2.2 within 2 and 7 days respectively).ConclusionsDeterminants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study

“…Findings of higher rates of FN patients leaving without being seen and leaving against medical advice are similar to earlier US findings for American Indian populations [ 22 , 70 ], for FN Chronic Obstructive Pulmonary Disorder patients in Alberta emergency departments [ 21 ], and for FN abdominal pain patients in a Saskatchewan emergency department [ 20 ]. Patients who leave emergency care without completing treatment may be at risk of returning to emergency facilities [ 71 ] and admissions to hospital [ 71 , 72 ]. To our knowledge, no studies have examined outcomes for FN patients who leave without completing treatment.…”

Evaluation of Patient Flow and Waiting Time for the First Physician Visit in an Overcrowded Emergency Department

“…Long waiting time results in undesirable services, reduced quality of care, adverse effects for patients with critical illnesses, and the increased number of patients leaving the hospital before receiving medical services. In this regard, Mataloni et al, reported that 8.9% of patients left ED before physician visits and 4.3% during treatment (23). Studies in Australia, North America, Canada, the United Kingdom, and Hong Kong indicated that the most important reason for emergency escape is the prolongation of waiting time.…”

Development and validation of a scoring system for mortality prediction and application of standardized W statistics to assess the performance of emergency departments

“…Outcome indicators have many advantages, such as being valid, stable and concrete, so policymakers and patients have shown greater interest in outcome measures [ 1 , 2 ]. In-hospital mortality or short-term mortality are commonly used outcome indicators to evaluate the outcome of emergency department (ED) treatment [ 3 , 4 ]. However, crude mortality has limitations, as it is difficult to interpret the results when differences in severity are not considered.…”

“…Therefore, scoring systems based on physiological variables were developed and have been used to measure the severity of illness or injury [ 5 – 7 ]. The impact of ED process indicators such as ED length of stay or leaving without being seen are evaluated against outcome indicators such as hospital mortality [ 3 , 8 ]. However, mortality without consideration of severity can lead to misleading or inconclusive results.…”