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Emergency Medicine Australasia (2014) 26, 145–152
doi: 10.1111/1742-6723.12223
ORIGINAL RESEARCH
‘Did not waits’: A regional Australian emergency department experience Denise F BLAKE,1,2 Dananjaya B DISSANAYAKE,1 Robyn M HAY1 and Lawrence H BROWN3 1 Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia, 2School of Marine and Tropical Biology, James Cook University, Townsville, Queensland, Australia, and 3School of Public Health, Tropical Medicine and Rehabilitation Services, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Describe the characteristics, reasons for leaving and outcomes of patients who did not wait (DNW) to be seen by a health practitioner in a regional Australian ED. Methods: Prospective observational study of a convenience sample of ED DNW patients presenting to The Townsville Hospital between June 2011 and July 2012. Seven days from each month were selected, and DNW patients presenting on those days were enrolled. An investigator attempted to contact every DNW patient by telephone in the following week to elicit reasons for leaving, subsequent health contacts, outcomes and suggestions for system improvements. Additional outcome information was obtained from hospital electronic medical records. Results: Nearly 15 000 patients presented on the study days, with 648 (4.3%) DNWs: 415 (64.0%) adults, 193 (29.8%) children (1–16 years old) and 40 (6.2%) infants. Thirty-eight (5.9%) patients who DNW were Australasian Triage Scale (ATS) category 3, 546 (84.3%) were ATS category 4 and 64 (9.9%) were ATS category 5. Most DNW patients presented on Sundays and between 1600 and 2359. Just over half of the patients who
DNW (52.9%) sought additional medical treatment, with 4.9% requiring subsequent hospital admission. Three psychiatric patients who DNW required urgent mental health interventions organised by the investigators. Frustration with perceived waiting times was the most common reason for leaving without being seen. Conclusions: Regional Australia ED patients who DNW often still require medical care, with approximately 1 in 20 requiring subsequent hospital admission. Patients with psychiatric conditions who DNW might be at particular risk. Key words: did not wait, emergency department, mental health, outcome, waiting time.
Introduction In Australia, like most developed countries, many ED patients present with apparently minor injuries and illnesses. Critically ill or injured patients are seen as a priority, whereas those with less severe or chronic problems are often left waiting. Prolonged waiting times are viewed as a failure of access to, and quality of, care1 and have implications for patient safety, waiting room congestion, ED violence and patient and staff satisfac-
Key findings • Nearly 5% of patients who DNW subsequently require hospital admission. • Psychiatric patients who DNW are particularly vulnerable. • Parents believe pediatric patients should be given higher priority.
tion.2 ED overcrowding additionally contributes to long waiting times, ambulance offload delays, increased public dissatisfaction, decreased physician productivity and increased medical staff frustration.2 Long waiting times and overcrowding also contribute to some patients deciding to leave the ED before they see a healthcare practitioner,3,4 and some of these patients have adverse outcomes.5–7 Most research into the outcome of patients who do not wait (DNW) has been completed in large urban centres8–10 so it is unknown whether similar patterns and outcomes occur outside that setting. The present study describes the characteristics, reasons for leaving, subsequent health system contacts and outcomes of DNW patients in a regional Australian ED.
Methods Correspondence: Dr Denise F Blake, Emergency Department, The Townsville Hospital, IMB 23, 100 Angus Smith Drive, Douglas, QLD 4814, Australia. Email: denise.blake@ health.qld.gov.au Denise F Blake, BN, MD, FRCPC, FACEM, PG Dip Med Sci (D&HM), Staff Specialist, Adjunct Senior Lecturer; Dananjaya B Dissanayake, MBBS, Emergency Medicine Registrar; Robyn M Hay, RN, RM, BNursSci, Grad Cert Critical Care, Clinical Nurse; Lawrence H Brown, PhD, MPH&TM, Senior Principal Research Officer. Accepted 27 January 2014
Setting The present study was conducted at The Townsville Hospital (TTH), a 650bed public tertiary referral and teaching hospital in regional Queensland, Australia. Townsville has a population of 180 000 and services a catchment area of approximately 650 000.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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TABLE 1.
DF BLAKE ET AL.
Australasian Triage Scale Maximum waiting time
Category 1 Category 2 Category 3 Category 4 Category 5
Seen immediately Seen within 10 min Seen within 30 min Seen within 60 min Seen within 120 min
TTH has the only ED in the city, seeing approximately 65 000–70 000 patients annually. The current ED opened 19 July 2011 with 34 acute beds, two mental health rooms, six consult rooms and eight short stay beds. Certified emergency physicians staff the ED from 08.00 hours to 23.00 hours, with overnight coverage by ED registrars with an on call emergency physician. Two nurse practitioners are also employed, primarily working weekday shifts.
Study design, study period and participants This prospective study of DNW patients who were not seen by a healthcare professional (doctor, nurse practitioner or the mental health Acute Care Team [ACT]) commenced 26 June 2011 and was completed 21 July 2012. A convenient 2-week period was prospectively selected for each calendar month, and DNW patients were identified every second day of the 2-week period so that each weekday was included. The ED clinical staff was blinded to the selected data collection period. The Emergency Department Information System (EDIS) was checked daily to ensure correct coding of patient’s departure destination, the variable used by Queensland Health to report DNW data. Patients who received nurse initiated care but left before assessment by a health professional were coded as ‘left after treatment commenced’ and excluded from the present study. DNW patient data abstracted from EDIS included age, sex, date and time of presentation, Australasian Triage Scale (ATS) category (Table 1), presenting problem, alcohol or drug use, mode of arrival, (if appropriate) treatment provided by
Performance indicator threshold (%) 100 80 75 70 70
Queensland Ambulance Service and waiting time. DNW patient contact details were entered onto a previously developed, scripted questionnaire, modified and used with permission11 (Appendix S1). Where contact details were incomplete or inaccurate, the Hospital Based Corporate Information System, the patient’s medical record, next of kin and subsequent ED visits were all used as secondary sources to obtain contact details. Up to six attempts to contact each patient (parent for paediatric patients) were made 1 week after their initial ED presentation. Once the patient was contacted, verbal informed consent was obtained. Patients were excluded from follow-up interviews if consent was unobtainable, if they had difficulty communicating in English, or if phone contact was deemed potentially detrimental (such as in cases of domestic violence), but these patients’ demographic data and other information available from EDIS were retained and included in the study. Contacted patients who consented to be interviewed were asked about any presentations for medical care since their initial ED visit; reason(s) for leaving the ED before seeing a doctor; their present state of health; and suggestions for improving ED services. All data were collected by two investigators: RMH and DFB. Data were initially entered into a structured Excel (Microsoft, Redmond, WA, USA) spread sheet by one researcher (RMH) and subsequently reviewed and verified by a second investigator (DFB). At least 1 month after initial presentation, EDIS was rechecked to identify any further ED presentations relating to the original DNW presentation. The data were
then imported into spss 20 (IBM Corporation Software Group, Somers, NY, USA) for analysis. To evaluate non-response bias, χ2test and t-test were used as appropriate to compare the demographic characteristics of DNW patients who participated in the follow-up interviews with those who did not participate. Otherwise only descriptive statistics are reported. The Townsville Health Service District Human Research Ethics Committee approved the present study.
Results During the study period, 72 555 patients presented to the ED with 3669 (5.1%) not waiting to see a healthcare professional. On the enrolment days included in the present study, there were 14 920 patient presentations and 648 (4.3%) patients who DNW. During the study some patients who presented to triage but who left before registering with the administration officer were simply being deleted from EDIS. Once discovered, this practice was changed, but some patients who should have been classified as DNW are missing from our data.
Demographics Demographic data are shown in Table 2. Four hundred and fifteen (64%) DNW patients were adults (>16 years old) and 40 (6.2%) were less than 1 year old; 48.8% were male. No DNW patients were designated ATS category 1 or 2; only 38 (5.9%) were ATS category 3. Six category 3 patients were children; three of whom were less than 1 year old. Laceration/ contusion (26.5%) and abdominal pain (20.2%) were the most common presenting complaints among adult DNW patients; laceration/contusion (18.9%) and cardio/respiratory (18.0%) were the most common complaints among children who DNW. Twenty-one per cent of adult DNW patients had current alcohol or drug use mentioned in their chart. DNW patients disproportionately presented on Sundays, and between the hours of 16.00 hours and 23.59 hours (Table 3).
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TABLE 2.
Characteristics of did not wait (DNW) patients compared with the total ED population
Age Mean (SD) Sex Female Male Triage category 1 2 3 4 5 Day presented Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time presented 00.00–07.59 hours 08.00–15.59 hours 16.00–23.59 hours Arrived via ambulance Yes Complaint General Laceration/contusion Abdominal pain Neurological Cardiorespiratory OB-GYN Psychiatric EENT Other Alcohol/drug use Yes Sought additional treatment† Yes
Adult (n = 415)
Paediatric (n = 233)
Total DNW† (n = 648)
All patients‡ (n = 14 920)
35.2 (15.3)
4.7 (4.8)
24.2 (19.3)
35.9 (23.9)
52.3% 47.7%
49.4% 50.6%
51.2% 48.8%
49.7% 50.3%
0.0% 0.0% 7.7% 81.0% 11.3%
0.0% 0.0% 2.6% 90.1% 7.3%
0.0% 0.0% 5.9% 84.3% 9.9%
1.1% 11.5% 39.4% 44.7% 3.3%
15.2% 14.9% 13.0% 14.0% 11.6% 10.8% 20.5%
13.7% 19.7% 8.6% 9.4% 12.0% 14.2% 22.3%
14.7% 16.7% 11.4% 12.3% 11.7% 12.0% 21.1%
15.4% 14.5% 14.1% 13.9% 14.3% 12.1% 15.7%
22.4% 23.9% 53.7%
13.3% 17.6% 69.1%
19.1% 21.6% 59.3%
16.2% 43.5% 40.3%
33.7%
8.6%
24.7%
35.4%
6.5% 26.5% 20.2% 5.3% 4.1% 4.8% 9.2% 6.5% 16.9%
15.9% 18.9% 11.6% 5.2% 18.0% 1.3% 0.0% 10.3% 18.9%
9.9% 23.8% 17.1% 5.2% 9.1% 3.5% 5.9% 7.9% 17.6%
NA NA NA NA NA NA NA NA NA
21.7%
1.7%
14.5%
NA
52.8%
53.2%
52.9%
NA
†Adult and paediatric combined. Includes patients who did not participate. ‡All patients who presented during study days. NA, not available for patients not enrolled in the study.
Follow-up interviews One hundred and sixteen (18%) DNW patients were unreachable and another 43 were excluded; 489 DNW patients were contacted and 457 (70.5%) agreed to be interviewed (Fig. 1). The only significant differences between participants and non-participants were that non-participating adult DNW patients were more likely to have arrived
by ambulance (46.4% vs 26.5%, P ≤ 0.001) and more likely to have had alcohol or drug use documented in their ED record (32.5% vs 15.5%, P ≤ 0.001). Also, although not statistically significant, more than half (52.6%, n = 20) of the 38 DNW patients who presented with a psychiatric complaint were in the non-participant group including 12 (31.6%) who could not be contacted after their ED visit.
Outcomes Just over half (52.9%) of all patients who DNW sought additional medical treatment, including patients who were not contactable but who re-presented to the ED and were identified via EDIS. Of the 457 patients participating in the telephone interviews, 290 (63.5%) sought additional medical care (Table 4). Most patients presented to
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Number of ED presentations 26 June 2011 to 21 July 2012 (n = 72 555)
TABLE 3. Did not wait (DNW) rates by triage category and time/ day of presentation DNW rate (%) Triage category 1 2 3 4 5 Day presented Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time presented 00.00–07.59 hours 08.00–15.59 hours 16.00–23.59 hours
Number of ED presentations during study days (n = 14 920)
0.0 0.0 0.65 8.2 13.0
Coded ‘Did Not Wait’ during study days (n = 716)
4.1 5.0 3.5 3.9 3.6 4.3 5.8
Excluded: Coding error (n = 68)
True Did Not Waits
5.1 2.2 6.4
their general practitioner (GP) (adults: 66.9%; children: 83.5%) but a substantial number re-presented to the ED (adults: 25.4%; children: 12.4%). Most patients presented for followup care within 1 day of their initial ED visit. Overall, 4.1% of DNW patients who sought further treatment required hospital admission (Table 4), but 15.8% of ATS category 3 DNW patients who sought additional treatment were admitted to hospital. The majority of patients (71.6%) reported they were ‘much better’ when contacted for follow up. Only 9.2% of adult DNW patients presented with a psychiatric complaint, but half of those patients could not be contacted for follow-up interviews, a substantially higher lost to follow-up rate than in other patient presentation groups. Three DNW patients with psychiatric conditions required urgent mental health interventions organised by the investigators. One patient was triaged ATS category 5, had no contact details, was homeless and recently had his involuntary treatment order cancelled. Fortunately, contact details for a family member were available, and the mental health ACT arranged care for the
(n = 648)
Excluded (n = 43; 6.6%) -No contact details (n = 30; 4.6%) -Language barriers (n = 10; 1.5%) -Domestic violence (n = 2; 0.3%) -Disruptive patient (n = 1; 0.2%)
Unreachable (n = 116; 17.9%) Refused interview (n = 32; 4.9%)
Agreed to interview (n = 457; 70.5%)
Figure 1.
Did not wait patient enrolment flow chart.
patient. Another patient was ATS category 4 and suicidal. Again, investigators contacted the mental health ACT who arranged appropriate follow up. The third patient presented and DNW twice in 24 h. The patient was triaged category 4 on the original visit and category 3 on re-presentation. The triage nurse flagged this patient to one of the researchers, who arranged follow-up care outside of the study protocol.
Reasons patients DNW The majority of DNW patients left because they were ‘fed up’ with
waiting, but 19% left because they felt better (Table 5). ‘Other reasons’ for leaving were grouped into major themes with social issues, such as having to pick up children or needing to go to work, being the largest. The waiting room environment was another major theme, with patients expressing the need to lie down, being unable to sit any longer and being cold and hungry as reasons for leaving. Some patients left because they felt reassured by the triage nurse assessment or advice and others left because they were made aware of long waiting times. Some left because they were
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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TABLE 4.
Outcomes of patients who agreed to participate Adult (n = 264)
Paediatric (n = 193)
Total (n = 457)
36.0% 39.0% 14.4% 10.2% 0.4%
37.3% 47.7% 11.4% 3.1% 0.5%
36.5% 42.7% 13.1% 7.2% 0.4%
1 1 0–10
1 1 0–10
1 1 0–10
66.9% 3.6% 25.4% 4.1%
83.5% 3.3% 12.4% 0.8%
73.8% 3.4% 20.0% 2.8%
27.8% 11.8% 53.3% 4.7% 2.4%
47.9% 5.8% 43.0% 3.3% 0.0%
36.3% 9.3% 49.0% 4.1% 1.4%
0.4% 1.5% 13.3% 18.6% 66.3%
0.0% 2.1% 6.8% 12.0% 79.2%
0.2% 1.8% 10.5% 15.8% 71.6%
Sought additional treatment No Once Twice Three times Four times Delay to additional treatment Days (median) 75th percentile Range Place of 1st additional visit GP Specialist ED Other 1st additional visit outcome No additional testing or treatment Testing only Testing, script Admitted DNW Status at follow up Much worse A little worse The same A little better Much better
TABLE 5.
Reasons for DNW Adult (n = 264) (%)
Reason(s) given† Felt better Fed up Other appointment Went elsewhere Waiting room full Offensive Staff Other‡ Most important reason Felt better Fed up Other appointment Went elsewhere Waiting room full Offensive staff Other‡ No single reason
Paediatric (n = 193) (%)
Total (n = 457) (%)
15.2 52.7 2.3 4.9 10.2 6.4 51.1
24.4 55.4 1.6 5.7 14.5 6.7 48.7
19.0 53.8 2.0 5.3 12.0 6.6 50.1
10.2 43.2 2.3 2.3 5.7 4.2 31.4 0.8
15.0 45.1 1.0 1.6 3.1 2.6 30.1 1.6
12.3 44.0 1.8 2.0 4.6 3.5 30.9 1.1
†Multiple reasons could be given. ‡See description in Results.
frustrated with lack of knowledge about waiting times and the perception that other patients were being called before them, particularly those patients asked to wait in the waiting room after arriving by ambulance. Few stated that they realised their problem was not urgent.
Waiting times Some patients left the ED immediately after registering their complaint, whereas others remained for hours (Table 6). Approximately 20% of the ATS 3, 33% of ATS 4 and over 50% of the ATS 5 patients left within their recommended waiting time. ATS 3 patients were discovered to have left sooner than the other triage categories. Mean waiting times were considerably longer in the DNW group than in the group see by a clinician.
Suggestions for improvement Some patients offered suggestions for avoiding DNWs. These included increasing the number of staff and decreasing waiting times; keeping patients informed about waiting times; having the triage nurse perform an in-depth assessment; and providing more care and more empathy. Parents felt small children should be prioritised and seen quicker. Table 7 presents some examples of patient suggestions.
Discussion As ED utilisation increases and ED overcrowding worsens, a rise in DNW rates seems inevitable.12 One American ED reported their DNW rate more than doubled once their patient volume exceeded 100% of planned capacity.13 It has been suggested that DNW patients are a particularly vulnerable group, and EDs should have a goal of a 1% or lower DNW rate.14 The DNW rate in our regional Australian ED is approximately 5% overall, and 4.3% using our more stringent study definition of DNW. This is consistent with DNW rates reported by other, more urban Australian EDs,8,9,15,16 and in the low-middle of the
Emergency Medicine Australasia (2014) 26, 145–152
doi: 10.1111/1742-6723.12223
ORIGINAL RESEARCH
‘Did not waits’: A regional Australian emergency department experience Denise F BLAKE,1,2 Dananjaya B DISSANAYAKE,1 Robyn M HAY1 and Lawrence H BROWN3 1 Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia, 2School of Marine and Tropical Biology, James Cook University, Townsville, Queensland, Australia, and 3School of Public Health, Tropical Medicine and Rehabilitation Services, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Describe the characteristics, reasons for leaving and outcomes of patients who did not wait (DNW) to be seen by a health practitioner in a regional Australian ED. Methods: Prospective observational study of a convenience sample of ED DNW patients presenting to The Townsville Hospital between June 2011 and July 2012. Seven days from each month were selected, and DNW patients presenting on those days were enrolled. An investigator attempted to contact every DNW patient by telephone in the following week to elicit reasons for leaving, subsequent health contacts, outcomes and suggestions for system improvements. Additional outcome information was obtained from hospital electronic medical records. Results: Nearly 15 000 patients presented on the study days, with 648 (4.3%) DNWs: 415 (64.0%) adults, 193 (29.8%) children (1–16 years old) and 40 (6.2%) infants. Thirty-eight (5.9%) patients who DNW were Australasian Triage Scale (ATS) category 3, 546 (84.3%) were ATS category 4 and 64 (9.9%) were ATS category 5. Most DNW patients presented on Sundays and between 1600 and 2359. Just over half of the patients who
DNW (52.9%) sought additional medical treatment, with 4.9% requiring subsequent hospital admission. Three psychiatric patients who DNW required urgent mental health interventions organised by the investigators. Frustration with perceived waiting times was the most common reason for leaving without being seen. Conclusions: Regional Australia ED patients who DNW often still require medical care, with approximately 1 in 20 requiring subsequent hospital admission. Patients with psychiatric conditions who DNW might be at particular risk. Key words: did not wait, emergency department, mental health, outcome, waiting time.
Introduction In Australia, like most developed countries, many ED patients present with apparently minor injuries and illnesses. Critically ill or injured patients are seen as a priority, whereas those with less severe or chronic problems are often left waiting. Prolonged waiting times are viewed as a failure of access to, and quality of, care1 and have implications for patient safety, waiting room congestion, ED violence and patient and staff satisfac-
Key findings • Nearly 5% of patients who DNW subsequently require hospital admission. • Psychiatric patients who DNW are particularly vulnerable. • Parents believe pediatric patients should be given higher priority.
tion.2 ED overcrowding additionally contributes to long waiting times, ambulance offload delays, increased public dissatisfaction, decreased physician productivity and increased medical staff frustration.2 Long waiting times and overcrowding also contribute to some patients deciding to leave the ED before they see a healthcare practitioner,3,4 and some of these patients have adverse outcomes.5–7 Most research into the outcome of patients who do not wait (DNW) has been completed in large urban centres8–10 so it is unknown whether similar patterns and outcomes occur outside that setting. The present study describes the characteristics, reasons for leaving, subsequent health system contacts and outcomes of DNW patients in a regional Australian ED.
Methods Correspondence: Dr Denise F Blake, Emergency Department, The Townsville Hospital, IMB 23, 100 Angus Smith Drive, Douglas, QLD 4814, Australia. Email: denise.blake@ health.qld.gov.au Denise F Blake, BN, MD, FRCPC, FACEM, PG Dip Med Sci (D&HM), Staff Specialist, Adjunct Senior Lecturer; Dananjaya B Dissanayake, MBBS, Emergency Medicine Registrar; Robyn M Hay, RN, RM, BNursSci, Grad Cert Critical Care, Clinical Nurse; Lawrence H Brown, PhD, MPH&TM, Senior Principal Research Officer. Accepted 27 January 2014
Setting The present study was conducted at The Townsville Hospital (TTH), a 650bed public tertiary referral and teaching hospital in regional Queensland, Australia. Townsville has a population of 180 000 and services a catchment area of approximately 650 000.
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TABLE 1.
DF BLAKE ET AL.
Australasian Triage Scale Maximum waiting time
Category 1 Category 2 Category 3 Category 4 Category 5
Seen immediately Seen within 10 min Seen within 30 min Seen within 60 min Seen within 120 min
TTH has the only ED in the city, seeing approximately 65 000–70 000 patients annually. The current ED opened 19 July 2011 with 34 acute beds, two mental health rooms, six consult rooms and eight short stay beds. Certified emergency physicians staff the ED from 08.00 hours to 23.00 hours, with overnight coverage by ED registrars with an on call emergency physician. Two nurse practitioners are also employed, primarily working weekday shifts.
Study design, study period and participants This prospective study of DNW patients who were not seen by a healthcare professional (doctor, nurse practitioner or the mental health Acute Care Team [ACT]) commenced 26 June 2011 and was completed 21 July 2012. A convenient 2-week period was prospectively selected for each calendar month, and DNW patients were identified every second day of the 2-week period so that each weekday was included. The ED clinical staff was blinded to the selected data collection period. The Emergency Department Information System (EDIS) was checked daily to ensure correct coding of patient’s departure destination, the variable used by Queensland Health to report DNW data. Patients who received nurse initiated care but left before assessment by a health professional were coded as ‘left after treatment commenced’ and excluded from the present study. DNW patient data abstracted from EDIS included age, sex, date and time of presentation, Australasian Triage Scale (ATS) category (Table 1), presenting problem, alcohol or drug use, mode of arrival, (if appropriate) treatment provided by
Performance indicator threshold (%) 100 80 75 70 70
Queensland Ambulance Service and waiting time. DNW patient contact details were entered onto a previously developed, scripted questionnaire, modified and used with permission11 (Appendix S1). Where contact details were incomplete or inaccurate, the Hospital Based Corporate Information System, the patient’s medical record, next of kin and subsequent ED visits were all used as secondary sources to obtain contact details. Up to six attempts to contact each patient (parent for paediatric patients) were made 1 week after their initial ED presentation. Once the patient was contacted, verbal informed consent was obtained. Patients were excluded from follow-up interviews if consent was unobtainable, if they had difficulty communicating in English, or if phone contact was deemed potentially detrimental (such as in cases of domestic violence), but these patients’ demographic data and other information available from EDIS were retained and included in the study. Contacted patients who consented to be interviewed were asked about any presentations for medical care since their initial ED visit; reason(s) for leaving the ED before seeing a doctor; their present state of health; and suggestions for improving ED services. All data were collected by two investigators: RMH and DFB. Data were initially entered into a structured Excel (Microsoft, Redmond, WA, USA) spread sheet by one researcher (RMH) and subsequently reviewed and verified by a second investigator (DFB). At least 1 month after initial presentation, EDIS was rechecked to identify any further ED presentations relating to the original DNW presentation. The data were
then imported into spss 20 (IBM Corporation Software Group, Somers, NY, USA) for analysis. To evaluate non-response bias, χ2test and t-test were used as appropriate to compare the demographic characteristics of DNW patients who participated in the follow-up interviews with those who did not participate. Otherwise only descriptive statistics are reported. The Townsville Health Service District Human Research Ethics Committee approved the present study.
Results During the study period, 72 555 patients presented to the ED with 3669 (5.1%) not waiting to see a healthcare professional. On the enrolment days included in the present study, there were 14 920 patient presentations and 648 (4.3%) patients who DNW. During the study some patients who presented to triage but who left before registering with the administration officer were simply being deleted from EDIS. Once discovered, this practice was changed, but some patients who should have been classified as DNW are missing from our data.
Demographics Demographic data are shown in Table 2. Four hundred and fifteen (64%) DNW patients were adults (>16 years old) and 40 (6.2%) were less than 1 year old; 48.8% were male. No DNW patients were designated ATS category 1 or 2; only 38 (5.9%) were ATS category 3. Six category 3 patients were children; three of whom were less than 1 year old. Laceration/ contusion (26.5%) and abdominal pain (20.2%) were the most common presenting complaints among adult DNW patients; laceration/contusion (18.9%) and cardio/respiratory (18.0%) were the most common complaints among children who DNW. Twenty-one per cent of adult DNW patients had current alcohol or drug use mentioned in their chart. DNW patients disproportionately presented on Sundays, and between the hours of 16.00 hours and 23.59 hours (Table 3).
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TABLE 2.
Characteristics of did not wait (DNW) patients compared with the total ED population
Age Mean (SD) Sex Female Male Triage category 1 2 3 4 5 Day presented Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time presented 00.00–07.59 hours 08.00–15.59 hours 16.00–23.59 hours Arrived via ambulance Yes Complaint General Laceration/contusion Abdominal pain Neurological Cardiorespiratory OB-GYN Psychiatric EENT Other Alcohol/drug use Yes Sought additional treatment† Yes
Adult (n = 415)
Paediatric (n = 233)
Total DNW† (n = 648)
All patients‡ (n = 14 920)
35.2 (15.3)
4.7 (4.8)
24.2 (19.3)
35.9 (23.9)
52.3% 47.7%
49.4% 50.6%
51.2% 48.8%
49.7% 50.3%
0.0% 0.0% 7.7% 81.0% 11.3%
0.0% 0.0% 2.6% 90.1% 7.3%
0.0% 0.0% 5.9% 84.3% 9.9%
1.1% 11.5% 39.4% 44.7% 3.3%
15.2% 14.9% 13.0% 14.0% 11.6% 10.8% 20.5%
13.7% 19.7% 8.6% 9.4% 12.0% 14.2% 22.3%
14.7% 16.7% 11.4% 12.3% 11.7% 12.0% 21.1%
15.4% 14.5% 14.1% 13.9% 14.3% 12.1% 15.7%
22.4% 23.9% 53.7%
13.3% 17.6% 69.1%
19.1% 21.6% 59.3%
16.2% 43.5% 40.3%
33.7%
8.6%
24.7%
35.4%
6.5% 26.5% 20.2% 5.3% 4.1% 4.8% 9.2% 6.5% 16.9%
15.9% 18.9% 11.6% 5.2% 18.0% 1.3% 0.0% 10.3% 18.9%
9.9% 23.8% 17.1% 5.2% 9.1% 3.5% 5.9% 7.9% 17.6%
NA NA NA NA NA NA NA NA NA
21.7%
1.7%
14.5%
NA
52.8%
53.2%
52.9%
NA
†Adult and paediatric combined. Includes patients who did not participate. ‡All patients who presented during study days. NA, not available for patients not enrolled in the study.
Follow-up interviews One hundred and sixteen (18%) DNW patients were unreachable and another 43 were excluded; 489 DNW patients were contacted and 457 (70.5%) agreed to be interviewed (Fig. 1). The only significant differences between participants and non-participants were that non-participating adult DNW patients were more likely to have arrived
by ambulance (46.4% vs 26.5%, P ≤ 0.001) and more likely to have had alcohol or drug use documented in their ED record (32.5% vs 15.5%, P ≤ 0.001). Also, although not statistically significant, more than half (52.6%, n = 20) of the 38 DNW patients who presented with a psychiatric complaint were in the non-participant group including 12 (31.6%) who could not be contacted after their ED visit.
Outcomes Just over half (52.9%) of all patients who DNW sought additional medical treatment, including patients who were not contactable but who re-presented to the ED and were identified via EDIS. Of the 457 patients participating in the telephone interviews, 290 (63.5%) sought additional medical care (Table 4). Most patients presented to
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DF BLAKE ET AL.
Number of ED presentations 26 June 2011 to 21 July 2012 (n = 72 555)
TABLE 3. Did not wait (DNW) rates by triage category and time/ day of presentation DNW rate (%) Triage category 1 2 3 4 5 Day presented Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time presented 00.00–07.59 hours 08.00–15.59 hours 16.00–23.59 hours
Number of ED presentations during study days (n = 14 920)
0.0 0.0 0.65 8.2 13.0
Coded ‘Did Not Wait’ during study days (n = 716)
4.1 5.0 3.5 3.9 3.6 4.3 5.8
Excluded: Coding error (n = 68)
True Did Not Waits
5.1 2.2 6.4
their general practitioner (GP) (adults: 66.9%; children: 83.5%) but a substantial number re-presented to the ED (adults: 25.4%; children: 12.4%). Most patients presented for followup care within 1 day of their initial ED visit. Overall, 4.1% of DNW patients who sought further treatment required hospital admission (Table 4), but 15.8% of ATS category 3 DNW patients who sought additional treatment were admitted to hospital. The majority of patients (71.6%) reported they were ‘much better’ when contacted for follow up. Only 9.2% of adult DNW patients presented with a psychiatric complaint, but half of those patients could not be contacted for follow-up interviews, a substantially higher lost to follow-up rate than in other patient presentation groups. Three DNW patients with psychiatric conditions required urgent mental health interventions organised by the investigators. One patient was triaged ATS category 5, had no contact details, was homeless and recently had his involuntary treatment order cancelled. Fortunately, contact details for a family member were available, and the mental health ACT arranged care for the
(n = 648)
Excluded (n = 43; 6.6%) -No contact details (n = 30; 4.6%) -Language barriers (n = 10; 1.5%) -Domestic violence (n = 2; 0.3%) -Disruptive patient (n = 1; 0.2%)
Unreachable (n = 116; 17.9%) Refused interview (n = 32; 4.9%)
Agreed to interview (n = 457; 70.5%)
Figure 1.
Did not wait patient enrolment flow chart.
patient. Another patient was ATS category 4 and suicidal. Again, investigators contacted the mental health ACT who arranged appropriate follow up. The third patient presented and DNW twice in 24 h. The patient was triaged category 4 on the original visit and category 3 on re-presentation. The triage nurse flagged this patient to one of the researchers, who arranged follow-up care outside of the study protocol.
Reasons patients DNW The majority of DNW patients left because they were ‘fed up’ with
waiting, but 19% left because they felt better (Table 5). ‘Other reasons’ for leaving were grouped into major themes with social issues, such as having to pick up children or needing to go to work, being the largest. The waiting room environment was another major theme, with patients expressing the need to lie down, being unable to sit any longer and being cold and hungry as reasons for leaving. Some patients left because they felt reassured by the triage nurse assessment or advice and others left because they were made aware of long waiting times. Some left because they were
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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DID NOT WAITS
TABLE 4.
Outcomes of patients who agreed to participate Adult (n = 264)
Paediatric (n = 193)
Total (n = 457)
36.0% 39.0% 14.4% 10.2% 0.4%
37.3% 47.7% 11.4% 3.1% 0.5%
36.5% 42.7% 13.1% 7.2% 0.4%
1 1 0–10
1 1 0–10
1 1 0–10
66.9% 3.6% 25.4% 4.1%
83.5% 3.3% 12.4% 0.8%
73.8% 3.4% 20.0% 2.8%
27.8% 11.8% 53.3% 4.7% 2.4%
47.9% 5.8% 43.0% 3.3% 0.0%
36.3% 9.3% 49.0% 4.1% 1.4%
0.4% 1.5% 13.3% 18.6% 66.3%
0.0% 2.1% 6.8% 12.0% 79.2%
0.2% 1.8% 10.5% 15.8% 71.6%
Sought additional treatment No Once Twice Three times Four times Delay to additional treatment Days (median) 75th percentile Range Place of 1st additional visit GP Specialist ED Other 1st additional visit outcome No additional testing or treatment Testing only Testing, script Admitted DNW Status at follow up Much worse A little worse The same A little better Much better
TABLE 5.
Reasons for DNW Adult (n = 264) (%)
Reason(s) given† Felt better Fed up Other appointment Went elsewhere Waiting room full Offensive Staff Other‡ Most important reason Felt better Fed up Other appointment Went elsewhere Waiting room full Offensive staff Other‡ No single reason
Paediatric (n = 193) (%)
Total (n = 457) (%)
15.2 52.7 2.3 4.9 10.2 6.4 51.1
24.4 55.4 1.6 5.7 14.5 6.7 48.7
19.0 53.8 2.0 5.3 12.0 6.6 50.1
10.2 43.2 2.3 2.3 5.7 4.2 31.4 0.8
15.0 45.1 1.0 1.6 3.1 2.6 30.1 1.6
12.3 44.0 1.8 2.0 4.6 3.5 30.9 1.1
†Multiple reasons could be given. ‡See description in Results.
frustrated with lack of knowledge about waiting times and the perception that other patients were being called before them, particularly those patients asked to wait in the waiting room after arriving by ambulance. Few stated that they realised their problem was not urgent.
Waiting times Some patients left the ED immediately after registering their complaint, whereas others remained for hours (Table 6). Approximately 20% of the ATS 3, 33% of ATS 4 and over 50% of the ATS 5 patients left within their recommended waiting time. ATS 3 patients were discovered to have left sooner than the other triage categories. Mean waiting times were considerably longer in the DNW group than in the group see by a clinician.
Suggestions for improvement Some patients offered suggestions for avoiding DNWs. These included increasing the number of staff and decreasing waiting times; keeping patients informed about waiting times; having the triage nurse perform an in-depth assessment; and providing more care and more empathy. Parents felt small children should be prioritised and seen quicker. Table 7 presents some examples of patient suggestions.
Discussion As ED utilisation increases and ED overcrowding worsens, a rise in DNW rates seems inevitable.12 One American ED reported their DNW rate more than doubled once their patient volume exceeded 100% of planned capacity.13 It has been suggested that DNW patients are a particularly vulnerable group, and EDs should have a goal of a 1% or lower DNW rate.14 The DNW rate in our regional Australian ED is approximately 5% overall, and 4.3% using our more stringent study definition of DNW. This is consistent with DNW rates reported by other, more urban Australian EDs,8,9,15,16 and in the low-middle of the
