ORIGINAL CONTRIBUTION

Walk-out Patients In the

Hospital Emergency Department

Geoffrey Gibson, PhD Lois A. Maiman, PhD Anne M. Chase, MA Baltimore, Maryland

Four hundred twenty-six patients walked out of The Johns Hopkins Hospital Adult Emergency Department before being treated between April 1976 and March 1977. Of these, 179 were matched for sex, race, age, shift and presenting complaint with cOntrols to identify the distinguishing characteristics of walk-out patients. Walk- out patients have recent onset of symptoms, report a great deal of pain and dis- comfort at the time of initial visit, and wait a relatively short period of time before walking out. They are, however, likely to report little continuing pain or discomfort one to two weeks after followup, although they believe that they still need care. Walk-out patients do not seem to be exposed to objectively worse treatment in the emergency department but seem to have less subjective tolerance for wait- ing. Gibson G, Maiman LA, Chase MA: Walk-out patients in the hospital emergency department. JACEP 7:47-50, February 1978. emergency department, walk-out patients; walk-out patients, emergency department.

INTRODUCTION

Pat ien ts who leave the emergency depa r tmen t before t r e a tmen t place hospi- ta ls in potent ia l cl inical and legal jeopardy. In addition, the ra te and charac- ter is t ics of walk-out pa t ien ts m a y be an impor tan t moni tor ing mechan i sm for pa t i en t sat isfact ion and emergency depa r tmen t effectiveness. Despite this, the one s tudy 1 of walk-out pa t ien ts did not involve sys temat ic followup of pat ients , nor matched pa i r compar isons between walk-out and nonwalk-out pat ients . Hirsch, e t al 1 found tha t 1.1% of emergency depa r tmen t pa t ien ts a t the Arizona Medical Center left before be ing t r ea ted and repor ted on the character is t ics of 106 such pa t ien ts observed du r ing a f ive-month study.

Several impor tan t issues and quest ions are involved in any s tudy of walk- out pat ients . Have pa t ien ts who have walked out been exposed to objectively inferior aspects of t r e a t m e n t compared wi th nonwalk-out pa t ien ts? Or were walk-out pa t ien ts t rea ted s imi lar ly , but mere ly possess less tolerance and so left p remature ly? Also, can walk-out pa t ien ts be screened prospectively, accurate ly enough so that , for example, the nurse can identify on presen ta t ion those pa- t i en ts a t grea ter r i sk of l eav ing p rematu re ly and a t t empt to prevent the walk- out.

From the Health Services Research and Development Center, Depar tment of Emergency Medicine, The Johns Hopkins Medical Institutions, Baltimore, Mary- land.

Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1977.

Supported by Grant No. HS 01907 from the National Center for Health Services Research, Department of Health, Educa- tion and Welfare.

Address for reprints: Geoffrey Gibson, PhD, 624 N. Broadway, Baltimore, Mary- land 21205.

7:2 (Feb) 1978 JACEP 47/19

M e t h o d o l o g i c a l l y , t he f ac to r s t ha t cause pa t ien ts to walk out mus t be c a r e f u l l y s e p a r a t e d f rom those t h a t m e r e l y d i f f e r e n t i a t e p a t i e n t s who walk out from those who do not. Thus, whi le wa lk -ou t p a t i e n t s can be compared wi th the en t i re emer- gency d e p a r t m e n t p o p u l a t i o n , the essent ia l comparison should be wi th pa t i en t s s i m i l a r in most major re- spects except t ha t they did not walk out.

Here, comparison wi th matched controls is a quas i -exper imen ta l de- sign to at leas t pa r t i a l l y subs t i tu te for a classic exper imenta l design of random allocat ion of pa t ien ts to ex- p e r i m e n t a l ve r sus cont ro l groups . Since the ma tch ing was done on most cha rac t e r i s t i c s (age, shift , sex and presen t ing complaint) believed to be exogenously re la ted to the l ikel ihood of wa lk ing out, the observed differ- ence between walk-outs and matched controls may reasonab ly be consid- ered causa l ly re la ted to the decision to wa lk out or, a t leas t , to d i s t in - guish ing character is t ics of walk-out pat ients .

The f inal policy issue is whose " f a u l t " i t is, t h e p a t i e n t or t he emergency depar tment , tha t pa t ien ts walk out and therefore which should modify behavior to reduce the ra te of walk-out.

METHODS

The pa t ien t ser ies being repor ted here includes pa t ien ts over 18 years of age who left The Johns Hopkins Hospi ta l Adul t Emergency Depar t - m e n t be fo re t r e a t m e n t d u r i n g a one-year period, Apr i l 1976 to March 1977. A walk-out pa t i en t was defined as one who left before t r e a t m e n t be- gan. Wherever possible, each walk- ou t p a t i e n t w a s m a t c h e d w i t h a nonwalk-out pa t ien t of the same sex, race, age ca tegory and ca t egory of p r e s e n t i n g c o m p l a i n t ( t r a u m a or non t r auma ; site of t r a u m a or non- t r a u m a compla in t - - lower extremi- ty, upper ex t remi ty , chest, abdomen, face and neck, side and back; s imi la r gynecologic complaints; r e tu rn visits, and counse l i ng - - p s y c h i a t r i c , al- coholism and social services) and of ident ical imputed severi ty, and who p resen ted w i th in four hours of the walk-out pat ients . Both the walk-out pa t ien ts and the i r matches were in- t e r v i e w e d w i t h i n two weeks a f t e r the i r emergency depa r tmen t v is i t by telephone or in person.

RESULTS Between Apr i l 1976 and March

1977, 426 p a t i e n t s lef t The J o h n s

Table 1 WALK-OUT PATIENTS COMPARED TO EMERGENCY

DEPARTMENT VISIT SAMPLE

All Walk-Outs Variable No Percent

ED Visit Sample* Percent (n=9270)

Age < 18 0 0 9

18-34 277 65 48 35-45 87 20 16 46-64 58 14 18 65 4 1 9

TOTAL 426 100 1005

Sex 238 56 45 !88 44 55 '426 100 100

347 81 79 78 18 20

1 426 100~ 100~

114 27 16 92 21 40

220 52 44 426 100 100

59 14 16 57 13 14 53 12 13 43 10 13 64 15 13 98 23 15 52 12 15

426 100~ 100~

168 39 19 182 43 29 73 17 44

3 1 7 426 100 1005

Male Female

TOTAL

Race Black White Other

TOTAL

Presenting Shift 11 pm - - 7 am

7 a m - - 3 p m 3 pm - - 11 pm

TOTAL

Presenting Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday

TOTAL

Payment Status Self-pay Private insurance Medicare/Medicaid Other

TOTAL

* Data from ED surveillance sample for January-February 1977• 1" Not consistent because of "missing" data values•

_ ~ Percents do not add to 100 because of rounding.

Hopkins Hospi tal Adul t Emergency Depa r tmen t before t r e a t m e n t began, approx imate ly 1 % of the emergency depa r tmen t populat ion. If a more ex- tended defini t ion is used, t ha t is, a pa t ien t who leaves before t r e a t m e n t is completed, the ra te is 3.1% of the e m e r g e n c y d e p a r t m e n t popu la t ion . The w a l k - o u t p a t i e n t s were com- p a r e d wi th the e m e r g e n c y depar t - m e n t p o p u l a t i o n de sc r ibed by the Hospi ta l Emergency Room Survei l - lance Sys tem ~ at John Hopkins Hos- pi ta l (Table 1).

Walk-out pa t ien ts were common dur ing the evening shift (52%) and r a r e s t d u r i n g the d a y t i m e (21%).

This over represen ta t ion for the day- t ime is quite d i ss imi la r to the Hirsch, a t a l 1 p o p u l a t i o n w h i c h p e a k e d between noon and 2 pro.

Al though 45% of al l emergency depa r tmen t pa t ien ts are male, 56% of the walk-outs were male. Hirsch 's populat ion was 50% male. 1 By con- t rast , a s imi la r percentage of walk- out pa t ien ts and the ent i re popula- t ion was black, about 80%. The s tudy populat ion was at leas t 18 years of age; 65% were be tween 18 and 34 and 14% between 46 and 64 years of age. None of the walk-ou t pa t i en t s were over 65 yea r s of age. S imi lar ly , Hirsch, et aP found t ha t two th i rds of

20/48 JACEP 7:2 (Feb) 1978

their walk-outs were between 14 and 44. Compared with the emergency department population, walk-out pa- tients are much younger. They seem to be distr ibuted equally across the days of the week except for a greater number on Saturdays. Walk-out pa- t ients are much more l ikely to be without insurance than the general emergency depar tment population.

Twenty-five percent of the walk outs left wi th in 30 minutes after ar- rival and near ly two thirds wi th in one hour (Table 2). Only 9% stayed more than 1i/2 hours.

F o r t y - s e v e n pe r cen t of the walk-outs came to the emergency de- partment the same day as the onset of symptoms; one quar ter less than one hour after onset. Only one fifth waited more t h a n three days." This high proportion of walk-outs with ex- tremely recent oaset is s imilar to the findings of Hirsch et al. 1

Over half (57%) of the walk-outs reported a ~'great deal" of pain or dis- comfort at the time of the visit and only 13% reported '~none." At our follow-up i n t e r v i e w one- to two- weeks after the visit, only 12% re- ported a great deal of pain or discom- fort and half none at all. When asked why they left wi thou t be ing seen, over half (52%) reported dissatisfac- tion wi th wa i t i ng t ime. Since two thirds waited less t han one hour, this dissatisfaction may reflect a low tol- erance of any wa i t ing ra the r t han excessive wai t ing periods. Well over half (61%) of the walk-outs had not sought care subsequently; while 15% had gone i m m e d i a t e l y to ano the r emergency depa r tmen t . Never the- less, 45% felt at the t ime of the follow-up in te rv iew tha t they st i l l needed care (Table 2).

Of the 426 walk-out pa t ien ts , 179 were matched wi th an appro- priate control (Table 3). With regard to r e c e n t n e s s of onse t , a s l i gh t ly higher proportion of walk-outs (54%) than controls (47%) reported same day onset, chal lenging the image of the walk-out pa t i en t s as a nonur - gent , l o n g - d e l a y i n g " m a l i n g e r e r " without ~'real" symptoms. Similarly, n e a r l y double the p ropo r t i on of walk-outs (9% vs 5%) arrived by am- bulance.

W a l k - o u t p a t i e n t s were less likely to be marr ied (24%) than con- t rols (34%) and s o m e w h a t more likely to be never marr ied (53% vs 46%). As a result, walk-out pat ients were more l i ke ly to be accompa- nied by a friend and not a spouse than the controls. While 71% of the con- t rols spent over two hours in the

Table 2

CHARACTERISTICS OF WALK-OUT PATIENTS

No.

(n - 426)

% DAY

Monday 59 14 Tuesday 57 13 Wednesday 53 12 Thursday 43 10 Friday 64 15 Saturday 98 23 Sunday 52 12

TIME IN - - TIME OF WALK-OUT

< 1/2 hr 51 25 1/2 hr-1 hr 75 37 1 hr-11/2 hr 60 29 > 11/2 hr 19 9

ONSET

< 1 hour 84 26 1-5 hours 47 14 5-24 hours 23 7 1-2 days 19 6 2-7 days 43 13 1-4 weeks 60 18 > 1 week 49 15

SOUGHT CARE AFTER WALK-OUT

No 194 61 Another ED 47 15 Private MD 22 7 Hospital ED 32 10 Return to

JHH ED 12 4 Elsewhere 12 4

No. % DO YOU STILL NEED CARE?

No 88 4 5 Yes 107 55

HOW MUCH PAIN OR DISCOMFORT AT TIME OF ED VISIT?

None 37 12 Little 156 17 Moderate 45 14 Great Deal 182 57

HOW MUCH PAIN OR DISCOMFORT IS THERE NOW?

None 161 50 Little 85 26 Moderate 39 12 Great deal 38 12

REASON FOR WALK-OUT

Dissatisfied with 130 52 waiting time

No longer need- 26 10 ed treatment

Dissatisfied with 26 10 ED Staff

Too sick to re- 16 5 main

Monetary 12 5 Other 39 16

Table 3

CHARACTERISTICS OF MATCHED WALK-OUT PATIENTS AND CONTROLS

TIME IN ED

< 1/2 hr 1/2 hr-1 hr 1 hr-2 hr > 2 hrs

ONSET Same Day 1-2 days 2 days

Matched Walk-Outs Matched Controls

No. % No. %

21 20 0 - - 36 34 14 7 40 37 47 22 10 9 151 71

91 54 12 7 64 38

c o n t i n u e d on next p a g e

emergency depar tment , only 9% of the w a l k - o u t p a t i e n t s did so. AI- though this is reflective of the con-

85 47 18 10 76 42

trols being treated and the walk-outs not, it also conf i rms the prev ious f inding that walk-outs did not wait

7".2 (Feb) 1978 JACEP 49/21

excessively long periods before walk- ing out.

Walk-out pa t ien ts are much less l ike ly to have insu rance coverage: 39% of w a l k - o u t s were ~ 'self-pay" compared to 21% of controls.

Walk -ou t pa t i en t s and controls gave r o u g h l y s i m i l a r r e a s o n s for us ing the emergency depar tment .

In general , walk-outs were some- wha t less sa t is f ied With emergency d e p a r t m e n t p e r s o n n e l t h a n con- trols a l though both sets of pa t ien ts r e p o r t e d e x t r e m e l y h igh l eve l s of sat isfact ion.

The avai lab le evidence from this s t u d y s u g g e s t s t h a t the h e a l t h of walk-out pa t ien t s was not adverse ly affected and tha t walk-out pa t ien t s recover as well and as rapid ly as the controls on the bas is of p r e sen t ing complaint . Ten percent of the walk- outs and 8% of the controls repor ted ' 'a g rea t deal" of pa in or discomfort dur ing our followup interview. This pain or discomfort was felt "al l of the t ime" by 11% of the walk-outs com- p a r e d w i t h 8% .of t h e c o n t r o l s . Seven ty -e igh t percen t of the walk- outs reported t ha t the i r problem had cleared up or improved compared to 79% of the controls.

CONCLUSION

Since pa t ien ts who are l ike ly to l e a v e t h e e m e r g e n c y d e p a r t m e n t p rema tu re ly probably cannot be ac- cura te ly ident if ied on in i t ia l presen- ta t ion, the best s t r a t egy m a y be an in i t i a l exp lana t ion to each pa t ien t , r epea ted at 30-minute in terva ls , of the r ea son for w a i t i n g , the l i ke ly length of wa i t ing and the principles of t r i a g e . P a t i e n t a d v o c a t e s , om- budsmen, television, and ava i l ab i l i ty of ch i ld-care fac i l i t i e s for p a t i e n t s may be of potent ia l value. Periodic telephone follow-up of walk-outs and the m o n i t o r i n g of w a l k - o u t r a t e s shou ld be a n o r m a l c o m p o n e n t of

q u a l i t y assurance in an emergency depa r tmen t ' s cont inu ing a t t emp t to assess i ts performance.

REFERENCES

1. Hirsch FJ, Lindsey D, Vann PW: Para- meters of the emergency room population: Those who leave prematurely. Read before the University Association for Emergency Medicine Annual Meeting, Philadelphia, Pennsylvania, May, 1976.

2. Kaszuba AL, Gibson G: Hospital emer- gency department surveillance system: A data base for patient care, management, research and teaching. JACEP 6:304- 307, 1977.

Table 3 continued Matched Walk-Outs

No. % MARITAL STATUS

Never Married 112 53 Separated 23 11 Divorced 16 7 Widowed 9 4 Married 52 24

MEANS OF ARRIVAL

Walked 52 26 Car 85 43 Ambulance 19 9 Taxi/Bus 35 18 Other 8 4

ACCOMPANIED BY

No one 99 48 Spouse 12 6 Other Relative 38 18 Friend 57 27

PAYMENT STATUS

Self Pay 83 39 Blue Cross/Blue Shield & 91 43

Private Inst. Medicare/Medicaid 37 17

REASON FOR USING ED

Needed immediate care 51 31 ED is appropriate place 18 11 No other place available 41 25 Used ED before 22 13 Other 33 20

SINCE ED VISIT, HOW MUCH PAIN OR DISCOMFORT

None 86 53 Little 41 25 Moderate 18 11 Great deal 17 10

SINCE ED VISIT HOW FREQUENT PAIN OR DISCOMFORT

Never 36 25 Sometimes 67 39 Half the t ime 23 16 Most of the time 17 8 All of the time 16 11

SINCE ED VISIT PROBLEM HAS

Cleared up 32 20 Gotten better 94 58 Not changed 30 18 Gotten worse 7 4

SATISFIED WITH

Front desk nurse 123 84 Registrar/Clerk 113 82 Patient advocate 27 90 Other patients 34 87 Police in ED 27 79 Security guards 37 82

Matched Controls

No. %

98 46 29 14

7 3 6 3

72 34

51 25 90 44 10 5 47 23

8 4

107 51 23 11 46 20 34 16

44 21 136 64

32 15

53 30 26 15 41 23 29 16 29 16

98 55 50 28 1 6 9 14 8

43 24 81 45 18 10 21 12 15 8

34 19 107 60

29 16 7 4

159 ~97 154 96

50 98 63 89 46 90 44 90

22/50 JACEP 7:2 (Feb) 1978