By Stacey Kusterbeck
With long wait times and crowded waiting rooms, many EDs are seeing an uptick of patients who leave without being seen (LWBS).1,2
“There was a convergence of ‘triple-demic’ — COVID-19, influenza, and RSV — infections in 2021 and 2022, with widespread staffing shortages. This led to unprecedented rates of LWBS, not just in our hospital but across the country,” reports Brandon Kappy, MD, a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC.
Kappy and colleagues compared the pediatric ED’s LWBS rates before the pandemic (2018 to early 2020), early in the pandemic (2020-2021), and after the emergence of variants and re-emergence of seasonal viruses in the last half of 2021.3 The ED’s LWBS rates started out at 1.8%. “This rate fluctuated based on the season and year; but in general, infrequently went about 2% to 3% on a given day,” Kappy reports.
The LWBS rates decreased to 1.4% during the early pandemic, but increased sharply to 10.7% later in the pandemic. Daily ED volume during this later period decreased from what the ED was seeing before the pandemic. Despite this lower volume of patients, LWBS rates increased across every triage level. Patients with lower-acuity triage levels and those arriving between 8 p.m. and 4 a.m. were linked to higher LWBS rates.
“The general public — and even many in the healthcare community — consider pediatric EDs to be ‘separate’ entities from adult EDs, and not subject to the same boarding and crowding dynamics,” Kappy notes.
The dramatic increase in LWBS rates indicated pediatric EDs are affected by those system factors. It was unclear precisely which system factors were driving the large LWBS increases (e.g., patient acuity levels or ED volumes). “Many system factors, especially staffing and boarding, are difficult to disentangle from one another. But we are currently building patient flow simulation models to further define each factor’s contribution to overall ED crowding,” Kappy reports.
The central concern is what happens to all the children leaving the ED.
“It wasn’t only lower-acuity children leaving without treatment. Even patients triaged at a high acuity were found to be leaving without being seen,” Kappy says.
Based on this worrisome data, the ED instituted a call-back program to contact the highest-acuity children who LWBS. “We’ve had enormous success with this program,” Kappy shares.
Providers have instructed many ill children to return to the ED, and arranged follow-up care for others. The calls are made by a group of pediatric emergency medicine faculty and fellows who are trained to recognize signs and symptoms of clinical deterioration. Many times, providers subsequently contact the patient’s pediatrician, arrange subspecialty follow-up, or refer the patient back to the ED.
Recently, ED staff called a family who had brought their infant in with intermittent abnormal movements. After the call-back, staff coordinated the next steps with the neurology team and the patient’s pediatrician. The patient returned to the ED for an expedited admission to the neurology service. Staff ordered lab work and an electroencephalogram. “It’s been incredibly meaningful having conversations with many of these patients’ families who only want what is the best for their child and are very appreciative for the outreach,” Kappy adds.
Kappy recommends EDs track LWBS rates closely, and proactively think about ways to offset LWBS rates if surges are detected. The soaring LWBS rates at Children’s National did subside in summer 2023. “But we predict that they have the potential to acutely worsen as children go back to school and the viral winter season approaches,” Kappy cautions.
Although the ED’s overall daily volume has not changed drastically since before the pandemic, patient acuity has increased amid ongoing nationwide staffing shortages. “As a result, days with pre-COVID patient volumes may still have large LWBS rates,” Kappy offers.
As pediatric patients become more medically complex, inpatient pediatric beds across the country continue to consolidate, and pediatric EDs are expecting to see higher volumes of children.
“EDs need to build these considerations into their staffing and patient flow approaches if they hope to prevent LWBS in the future,” Kappy advises.
REFERENCES
1. Lazar K. Eight-hour waiting times. Patients leaving before being seen. Mass. hospital emergency departments are beyond the brink. The Boston Globe. Nov. 5, 2022.
2. Mulder JT. Syracuse emergency rooms are jammed, dirty and frustrating; waits are among worst in U.S. Syracuse.com. Feb. 27, 2023.
3. Kappy B, McKinley K, Chamberlain J, et al. Leaving without being seen from the pediatric emergency department: A new baseline. J Emerg Med 2023;65:e237-e249.
As pediatric patients become more medically complex, inpatient pediatric beds across the country continue to consolidate, and pediatric EDs are expecting to see higher volumes of children. Healthcare leaders must build these considerations into their staffing and patient flow approaches if they hope to prevent more patients from leaving without before they are seen.
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