Left Without Being Seen
Patients who leave without being seen and how to reduce risks with follow-up programs.
1. What are the ways to reduce risks of patients who leave the ED without being seen?
Your waiting room should be treated as an extension of your ED. Consider this area as a room assignment when making out your daily staffing assignments as a room, because there are sick patients in it. They have been triaged and have come for their “Medical Screening Exam (MSE)” and the federal law protects those patients who show up on your hospital property seeking medical attention. Since every patient who presents seeking emergency care is entitled to a MSE a hospital could violate the patient anti-dumping law if it routinely keeps patients waiting so long that they leave without being seen, particularly if the hospital does not attempt to determine and document why the patient is leaving, and reiterate to them that you are prepared to see them in a timely fashion. My experience has taught me to keep statistics and QA on wait times and benchmark against other ED’s similar in size and volume. When JCAHO arrives you will be able to demonstrate that this is an area that is of high risk, high volume and problem prone. JCAHO may ask you to show evidence of how you have addressed it, therefore relieving yourself of any recommendations and violations.
On the ED record there is usually an area where you check off the disposition of the patient, if not have it inserted when re ordering your new ED records and make the changes. i.e.: admitted, expired, D/C AMA and LWBS, remember LWBS must be calculated into your ED volume as nurses have triaged them and that relates to FTE’s. If you do not calculate those numbers when budget time comes, your ED does not get the credit for that time spent triaging and FTE’s may be cut, leaving lots of work without enough staffing.
I have managed to have the charge RN and Triage RN to oversee the ED waiting room. This means having them update patients on wait times. I had portable headphones for the triage RN, Charge RN and registration so lines of communication are kept open on the ED bed status since we did not have a bed tracking system. These updates are communicated on going as the shift progresses and patients may then make a decision to leave and tell the staff, making documentation easier.
Have a policy in place for LWBS patients and discuss ongoing at staff meetings as staff changes. Many policies incorporate AMA’s with LWBS, they are two different situations, they both need separate policies and QA, reviewed and discussed.
2. What are the effective ways to follow up with these patients?
Telephone before the shift ends if possible to get them back, if there is no phone or the number is wrong we send a certified letter, many times the address is incorrect. Our department secretary assists with all letters. An attempt needs to be made and documented. Now where you document this is a matter of controversy as it has been suggested by legal that it should be on the original record. I agree, however, it may not happen, leaving you open to serious legal implications.
I have every LWBS chart copied and placed on my desk for the following morning. As the Director I liked to look at the chief complaint, the time of arrival, and time they left (if the nurse knows) she is instructed to document this on the front of the medical record. I look at the census and discuss all LWBS in monthly staff meetings. We also keep a logbook at triage that has room for Name, MR#, time registered, time triaged, time left if known and patients phone number. There is another column for documentation of the follow up as some patients may have then gone to another ED or their Primary Care Physician or even felt better and now don’t want to come in.
3. How should telephone follow-up be handled?
The next day the triage nurse or charge RN calls back every LWBS and documents it in the log and asks the patient if they would like to return. Every effort is made to have those patients seen quickly if they return; they are given the name of the nurse to ask for so she will expect them. The nurse communicates this to the ED physician and they work as a team to expedite the visit and provide the necessary treatment if needed. We attempt three times to call the patients then a letter would be sent.
4. Examples of cases
A 42/F walked into triage with her husband and registered as “ wanting admission” the nurse told them there was a wait to be seen by the M.D. The family offered no other information as we all know there are patients who won’t tell the triage nurse exactly what is wrong. The nurse assessment did not reveal anything in her documentation that would lead you to believe she needed an emergent screening. The patient and husband left and went to another ED where she was admitted for suicidal ideation. These are high-risk patients and overcrowded ED’s are faced with these situations daily. They are in your waiting room like a tome bomb.
Pediatric cases are also risky, as I have seen toddlers triaged, even given a room in the ED and the wait may be lengthy for the physician to see the patient so the family leaves. Toddlers who are coughing and parents say my child developed a cold need to be assessed further for possible foreign body obstruction. Parents may not have ever seen their child swallow something and think it is just a cold when in fact it may be a serious situation.
Another high-risk case is when a 70/M was triaged for cough, chest x-ray was ordered and done and he waited over an hour to be seen and left without ever seeing the physician. The next day the radiologist reading came back and he was on our list to call, however, he had a huge mass indicative of a tumor, never saw the physician and we have an x-ray that needed attention. We had him come back the next day; he was very reluctant and was not planning on any follow up. The ED physician explained to him his x-ray, the patient was admitted and schedule for surgery the next day. We of course did not charge him from the ED.
Death could happen to any one of these cases that is why it is so important to make attempts to prevent the walkouts.
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.