Continuous Improvement Decreases Emergency Department Patients Leaving Before Treatment Complete Rates

In hospital-based emergency departments, the national average of left before treatment complete was 2%. In addition, patients may leave without being seen or against medical advice and elope after arriving to the emergency department. When events occurred, they were associated with an increased length of stay for patients who were admitted to the hospital and decreased patient satisfaction.

In a 24-bed emergency department within a small rural hospital that is part of a large quaternary care health care system, a multidisciplinary team used a continuous improvement model and nursing and medical caregivers to implement a clustered intervention to decrease the frequency of patients leaving before treatment was completed. After completing summary statistics, logistic regression was performed to assess left before treatment complete rates in 2021 and 2022. Sensitivity analysis was performed using Poisson log-linear regression.

Of 45,814 emergency visits (July to December 2021, 15,600; January to December 2022, 30,214), 3097 patients (6.76%) left before treatment complete, left before being seen, left against medical advice, or eloped. When comparing rates before and after countermeasures were introduced, the odds of leaving before a final disposition was made was 354% higher pre- vs postcountermeasure implementation (odds ratio [95% confidence interval], 4.54 [4.2-4.91], P < .001). In sensitivity analyses that regressed the rate of left before treatment complete over the 2 years, the odds ratio was similar (4.07 [2.92-5.67], P < .001).

Using a continuous improvement framework and nursing caregiver-based countermeasures, the rate of leaving before final disposition was dramatically reduced. Team involvement in action planning and change processes was critical to successful outcomes.