Pandemic brought increases in the number of patients leaving the ED without being seen

Hospitals and health systems should tackle the problem at the organizational level rather than viewing it as an issue for ED clinical and operational staff to solve, researchers say.

By one metric, deferred care appeared to become more widespread in the emergency department (ED) amid the COVID-19 pandemic.

As published Sept. 30 in JAMA Network Open, clinical researchers with Yale and the University of Michigan examined the rate at which patients left the ED without being seen during a period spanning 2017 through 2021.

Among hospitals that reported benchmarking data through Epic — a pool that expanded from 365 in January 2017 to 1,769 in December 2021 — the median rate at which patients left the ED without being seen nearly doubled, from 1.1% to 2.1%, during the study period.

Among the 5% of hospitals that performed the worst in the metric, rates were 4.3% in 2017 and 4.4% in early 2020 before surging to 10% in late 2021.

Key considerations

“Findings from this cross-sectional study demonstrate the failure of the emergency care system to maintain broad access in the context of pandemic demands, suggesting that existing regulatory and financial incentives may be inadequate to meet challenges of future pandemic waves and other disasters,” the researchers wrote.

They noted that traditionally, organizations have viewed the issue as ED-specific rather than a problem to be dealt with at the hospital or health system level.

“Thus, most solutions to date have relied on intradepartmental operational fixes to mitigate ED crowding; for example, doctor-in-triage or split-flow models offer more rapid medical screening evaluations, effectively bypassing traditional triage processes,” they wrote. “These processes promote rapid but limited physician evaluations, often in the waiting room. Amid the current crisis, these ED-focused operational efforts may be inadequate to stem this growing problem.”

Constraints in the methodology

Because of “limitations of available data fields,” the researchers noted, the findings could not be parsed based on specific hospital characteristics or local COVID-19 infection rates.

“We hypothesize that system strain would be associated with increased differences in rates … for hospitals serving low-income and underinsured patient populations,” they wrote.

They concluded, “Access to emergency care cannot be considered universal until all patients presenting to EDs receive high-quality treatment for time-sensitive conditions. Given contributing system constraints, [patients leaving without being seen] should be viewed as a failure to offer equitable access to acute care, understood in the context of other measures of care access.”