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Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline
Brandon Kappy1, Kenneth McKinley1, James Chamberlain1
1Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia.
Insights
Pediatric emergency departments saw a significant rise in patients leaving without being seen (LWBS) after COVID-19 restrictions eased. System factors and patient arrival times were linked to increased LWBS, especially for high-acuity cases.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Patient Safety
Background:
- Left Without Being Seen (LWBS) rates are critical quality indicators in pediatric emergency departments (EDs).
- High-acuity LWBS cases pose a significant patient safety risk.
- A notable surge in LWBS occurred in our pediatric ED after the end of stringent COVID-19 quarantine measures in July 2021.
Purpose of the Study:
- To assess changes in LWBS rates in a pediatric ED across different COVID-19 phases.
- To examine the associations between system factors and patient characteristics with LWBS.
- To identify potential strategies for reducing LWBS in pediatric emergency care.
Main Methods:
- Retrospective study of all arriving patients in a large, urban pediatric ED.
- Comparison of three periods: Pre-COVID (Jan 2018-Feb 2020), Early COVID (Mar 2020-Jun 2021), and Post-COVID variants/seasonal viruses (Jul 2021-Dec 2021).
- Statistical analysis using negative binomial and logistic regression models to evaluate system and patient factors associated with LWBS.
Main Results:
- Mean daily LWBS rates increased dramatically from 1.8% (Pre-COVID) to 10.7% (Post-COVID).
- LWBS rates rose across all patient demographics and triage levels in the Post-COVID period, despite lower ED volumes.
- Significant associations with LWBS included Emergency Severity Index 2 scores, mean ED census, staff productivity, lower triage levels, and nighttime arrivals (8 pm - 4 am).
Conclusions:
- Pediatric EDs have experienced a substantial and ongoing increase in LWBS rates since July 2021, affecting even high-acuity patients.
- Identified system factors and patient characteristics offer potential targets for interventions to reduce LWBS.
- Further research is needed to develop and implement effective strategies for preventing LWBS in at-risk pediatric populations.
Background:
Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended.
Objective:
We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS.
Methods:
We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively.
Results:
Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am.
Conclusions:
LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.
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