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Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates
Shea Pielsticker1, Lori Whelan2, Annette O Arthur1
1University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
Insights
To reduce emergency department (ED) leave-without-being-seen (LWBS) rates, maintain DoorRoom time (patient presentation to exam room) under 20 minutes. Longer intervals significantly decrease the likelihood of meeting the LWBS goal of less than 1%.
Area of Science:
- Emergency Medicine
- Healthcare Operations Research
- Health Services Research
Background:
- High leave-without-being-seen (LWBS) rates in emergency departments (EDs) lead to inefficiency, medical risks, and financial losses.
- Hospitals aim to maintain LWBS rates below 1% to ensure quality care and operational efficiency.
- The interval between patient presentation and placement in an exam room (DoorRoom time) is a critical operational metric.
Purpose of the Study:
- To assess the impact of prolonged DoorRoom times on LWBS rates in an ED.
- To identify specific DoorRoom time cutoffs that maximize the likelihood of achieving the target LWBS rate of <1%.
- To provide data-driven performance goals for ED operations.
Main Methods:
- A retrospective analysis of one year of ED operations data (annual census ~50,000).
- DoorRoom times were categorized into intervals (≤10 min to >60 min).
- Multivariate logistic regression adjusted for patient acuity and operational factors to identify significant DoorRoom cutoffs predicting LWBS rates.
Main Results:
- A DoorRoom time cutoff of 20 minutes was identified as crucial for maintaining a high likelihood (>85%) of meeting the LWBS goal.
- A secondary cutoff at 35 minutes was indicated to prevent a sharp decline in the likelihood of meeting the LWBS goal.
- Days with DoorRoom times between 21-35 minutes were 74% less likely to meet the LWBS goal compared to DoorRoom times ≤20 minutes.
Conclusions:
- Operationally relevant DoorRoom time cutoffs can be established to effectively minimize LWBS.
- Setting performance goals based on identified DoorRoom time thresholds can improve ED efficiency and patient safety.
- The study provides actionable insights for EDs striving to reduce LWBS rates.
Introduction:
Emergency department (ED) patients in the leave-without-being-seen (LWBS) group risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS to <1%. This study's goal was to assess the influence on LWBS associated with prolonging intervals between patient presentation and placement in an exam room (DoorRoom time). This study's major aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).
Methods:
We conducted the study over one year (8/13-8/14) using operations data for an ED with annual census~50,000. For each study day, the LWBS endpoint (i.e. was LWBS<1%: "yes or no") and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals starting with ≤10min and ending at >60 min. Multivariate logistic regression was used to assess for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and admission %) and operations parameters. We used predictive marginal probability to assess utility of the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio (OR) and 95% confidence intervals (CI).
Results:
Univariate results suggested a primary DoorRoom cutoff of 20', to maintain a high likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35', to prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35' to 34.4% at 40'. Predictive marginal analysis using multivariate techniques to control for operational and patient-acuity factors confirmed the 20' and 35' cutoffs as significant (p<0.001). Days with DoorRoom between 21-35' were 74% less likely to meet the LWBS goal than days with DoorRoom≤20' (OR 0.26, 95% CI [0.13-0.53]). Days with DoorRoom>35' were a further 75% less likely to meet the LWBS goal than days with DoorRoom of 21-35' (OR 0.25, 95% CI [0.15-0.41]).
Conclusion:
Operationally useful DoorRoom cutoffs can be identified, which allow for rational establishment of performance goals for the ED attempting to minimize LWBS.
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