3 Ways to Lower LWBS Rates in the ED

Patient Walking Away Donovan & Partners

There can be profound consequences for patients, emergency departments and the healthcare industry as a whole when patients leave an ED before they receive treatment. For patients, delayed treatment can mean sustained illness, pain and even death. For hospitals, high rates of patients leaving without being seen (LWBS) signify a loss of revenue. And for the healthcare industry, when patients seek treatment but don’t receive it, questions regarding appropriate access to care arise.   

The rate at which patients will leave an ED without being seen varies sharply from one hospital to another. In one report published in 2011, researchers looked at patient-visit data from 262 hospitals and found LWBS rates as low as .1 percent and as high as 20.3 percent — a tremendous variation. (The median rate was 2.6 percent.)

The reasons why one hospital may see upwards of one fifth of their patients leave without receiving treatment while another is able to treat almost all of the patients that enter its doors is just as varied. These same researchers offer a few explanations as to why there may be high walkout rates:

  • Hospital restructuring and market factors, including the increased number of EDs that have closed their doors.
  • The possibility that hospitals in lower-income areas may be closing at a higher rate, causing more vulnerable populations to have less access to care.
  • Increased wait times and ED crowding.

It’s important to mention that this study noted hospitals that served a high proportion of low-income and poorly insured patients had disproportionately higher LWBS rates. (Researchers found that the odds of a patient leaving without being seen fell by a factor of .86 for each $10,000 increase in household income.)

With this in mind, what can a hospital do to lower LWBS rates within its ED?

To lower LWBS rates, ED leadership must first identify the reasons why LWBS rates are increasing. Is it because of overcrowding or inefficient patient flow? Did a nearby ED recently close and now you’re seeing an influx of patients? Is your ED properly staffed? Once you identify the causes then you can tailor a plan of action.

Here are a three examples of what EDs have done to curb rising LWBS rates:  

1. Triage is a process, not a location.

In 2011, Illinois’ Elmhurst Hospital moved to a new campus four miles west of its former location. As a result, nearby Gottlieb Memorial Hospital in Melrose Park became the closest hospital for many patients and ambulances in the area. Naturally, due to Elmhurst’s move Gottlieb experienced a surge in average monthly volume — from 1,800 to 2,100 patients — and with that, a 10 percent LWBS rate.

To combat such a high LWBS rate, hospital leaders at Gottlieb implemented a “pull till full model,” redefining triage as a process rather than a location. Nurses were instructed to immediately lead patients to empty rooms and conduct the triage process at bedside. Six months later, Gottlieb’s LWBS rate plummeted to just below four percent thanks to the strategy and other sound initiatives, such as the evaluation of staffing patterns among its nurses and physicians.

2. Communicate with other departments.

In 1999, the ED at Miami Children’s Hospital had a LWBS rate of 5 percent. Its average throughput time was 3.5 hours and patient satisfaction scores were dismal. Over the course of four years, through a series of innovative changes implemented by ED leadership, the ED’s LWBS rate dropped to 1 percent with a nearly one-hour decrease in average throughput time. (Its patient satisfaction scores went from being in the 35th percentile to the 90th percentile.)

How did they do it?

One way was by working with staff from radiology, laboratory, registration and administration to expand capacity and improve flow. By communicating with other departments the ED was able to identify extra space adjacent to their ED to expand into, and then brought on additional physicians and nurses.

They also streamlined the registration process by taking basic information during triage, and pressed hospital leadership to start discharging in-patients in the morning, as opposed to the afternoon. Additionally, housekeeping was requested to clean rooms in a timelier manner.  

3. Keep it simple.

In 2001, Annie T. Sadosty, MD, an attending physician in the department of emergency medicine at Mayo Clinic, and assistant professor at Mayo Medical School, studied the reasons patients leave an ED without being seen. During her research, Sadosty and her colleagues were also able to glean what would cause patients to wait. The results were interesting.

She found that patients would be more likely to wait if they were offered immediate treatment for minor ailments, such as Tylenol for a headache, or ice packs and temporary bandages for injuries. Sadosty also found that by simplyannouncing wait times, patients said they would be more willing to stick around. Providing entertainment for children — think coloring books and toys — would also help, patients told Sadosty.

As you can see, the factors that lead to high LWBS rates are just as varied as the solutions. If you find that your patients are leaving without being seen, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to lower your LWBS rate. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.


Renee Y. Hsia, MD, MSc, Steven M. Asch, MD, MPH, Robert E. Weiss, PhD, David Zingmond, MD, PhD, Li-Jung Liang, PhD, Weijuan Han, MS, Heather McCreath, PhD, and Benjamin C. Sun, MD, MPP: “Hospital Determinants of Emergency Department Left Without Being Seen Rates”

GMH ED Staff, Sylwia Wright, RN, MSN, Mark Cichon, DO: “Decreasing Left Without Being Seen”

Urgent Matters: “Reducing the Left Without Being Seen (LWBS) Rate and Throughput Time Miami Children’s Hospital”

Arendt KW, Sadosty AT, Weaver AL, Brent CR, Boie ET: “The left-without-being-seen patients: what would keep them from leaving?”

AHC Media: “Want to drastically cut LWBS numbers? Try ice packs and adding a fast track”