Patients who leave the pediatric emergency department without being seen: a case-control study

Ran D Goldman, Alison Macpherson, Suzanne Schuh, Crystal Mulligan, Jonathan Pirie
Canadian Medical Association Journal: CMAJ 2005 January 4, 172 (1): 39-43

BACKGROUND: Children who visit pediatric emergency departments (EDs) and leave before being seen by a physician may present with particular health problems and may be at risk for preventable health outcomes. We compared children who left without being seen with those who stayed and were seen by a pediatrician, and followed all of the study subjects after they left the ED.

METHODS: We asked all parents of children who visited the ED between July 1 and Oct. 31, 2002, to participate. Parents were interviewed by a trained ED research assistant. We abstracted data from the ED medical records. We used the Canadian Emergency Department Triage and Acuity Scale (CTAS) to measure the acuity of the illness or injury. Each child who left without being seen was matched with 2 children who had been seen by selecting the next patients on an alphabetical list by day, sex and age (within 1 year). We did follow-up interviews with parents within 96 hours of the visit to determine the reason for leaving and any treatment and diagnoses received subsequent to the ED visit.

RESULTS: Of the 11 087 children seen in the ED during the study period, 289 (3%) left without being seen. Of the 289, the families of 158 (56%) consented to participate in the study and met the study criteria. The case and control groups thus consisted of 158 and 316 children respectively. Of the children who left without being seen, 24 (15%) were triaged as "urgent," and none had a CTAS score of less than 3. A total of 99 children (63%) who left were taken by their families elsewhere for further medical care, compared with 89 (28%) of those who stayed. Waiting too long and resolution of symptoms accounted for 92 (58%) and 59 (37%) of the premature departures respectively. One child who left without being seen was subsequently admitted to hospital. Multivariate analysis showed that, after adjustment for time of arrival and time to reach the ED, children who left without being seen had lower acuity than those who stayed (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.2-7.2) and were more likely to register in the ED between midnight and 4 am (OR 5.9, 95% CI 2.8- 12.5). Children in the premature departure group were also more likely to be taken elsewhere for follow-up care (unadjusted OR 4.3, 95% CI 2.9-6.4).

INTERPRETATION: Children who left the ED without being seen had lower acuity levels and were more likely to be taken elsewhere for follow-up care than children who stayed. Most of those who left did so because the wait was too long or their symptoms resolved.

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