As ER Wait Times Grow, More Patients Leave Against Medical Advice

CALAAEM News Service at
Thu May 23 17:42:43 PDT 2019


May 23, 2019


As ER Wait Times Grow, More Patients Leave Against Medical Advice


ents-leave-against-medical-advice/> California Healthline


By Phillip Reese


May 16, 2019


Emergency room patients increasingly leave California hospitals against
medical advice, and experts say crowded ERs are likely to blame.


About 352,000 California ER visits in 2017 ended when patients left after
seeing a doctor but before their medical care was complete. That’s up by
57%, or 128,000 incidents, from 2012, according to data from the Office of
Statewide Health Planning and Development.


Another 322,000 would-be patients left the emergency room without seeing a
doctor, up from 315,000 such episodes in 2012.


Several hospital administrators said overcrowding is a likely culprit for
the trend. California emergency room trips grew by almost 20%, or 2.4
million, from 2012 to 2017.


Moreover, ER wait times also increased for many during that time period: In
2017, the median ER wait time for patients before admission as inpatients to
California hospitals was 336 minutes — or more than 5½ hours. That is up 15
minutes from 2012, according to the federal Centers for Medicare & Medicaid
Services. The median wait time for those discharged without admission to the
hospital dropped 12 minutes over that period, but still clocked in at more
than 2½ hours in 2017.


California wait times remain higher than the national average. In 2017, the
median length of a stay in the ER before inpatient admission nationwide was
80 minutes shorter than the median stay in California. Four states —
Maryland, New York, New Jersey and Delaware — had even longer median wait


The growth in patients leaving California ERs prematurely was faster than
the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended
with patients leaving the ER against medical advice or abruptly
discontinuing care after seeing a doctor, compared with 1.8% in 2012.


“Most patients are sick but not critically ill,” said Dr. Steven Polevoi,
medical director of the emergency department at UCSF Helen Diller Medical
Center at Parnassus Heights. “Emergency care doesn’t equal fast care all of
the time.”


When a patient leaves the ER after seeing a doctor but before the doctor
clears them to leave, the Office of Statewide Health Planning and
Development classifies that encounter as “leaving against medical advice or
discontinued care.” The definition includes encounters in which a doctor
carefully explains the risks to the patient and has the patient sign a form,
but also instances in which the patient simply discontinues care and bolts
out the door.


Patients leaving the emergency room too soon “are deliberately putting
themselves at more risk for morbidity and even mortality,” Polevoi said — a
point echoed by other physicians.


Dr. Veronica Vasquez-Montez, emergency room medical director at Good
Samaritan Hospital in Los Angeles, said she sometimes finds herself having
“tough conversations” with sick patients intent on leaving the ER, often
citing pressing responsibilities.


“If you die from this,” she tells them, “you are good to no one you are
caring for.”


One of her recent patients was at high risk for a major stroke but insisted
he needed to leave the ER to take care of his pet.


“Guess what he came back for? A major stroke,” said Vasquez-Montez, also a
clinical assistant professor at the University of Southern California’s Keck
School of Medicine.


Compared with all ER patients, those leaving against medical advice were
more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal,
the government insurance program for the poor, state figures show. They were
also more likely to complain primarily of non-specific symptoms such as
chest pain or a cough.


Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the
highest proportion of ER encounters in 2017 that ended with patients leaving
against medical advice or abruptly discontinuing care. Each of those
counties recorded more than 4% of ER patients leaving too soon, state
figures show.


>From 2012 to 2017, the number of emergency room encounters in Fresno County
increased by almost 95,000, or 37%. At Fresno’s Community Regional Medical
Center, about 9% of ER encounters ended with a patient leaving too soon,
more than three times the statewide rate.


Community Regional Medical Center is one of the busiest hospitals in the
state. It recently instituted a “Provider at Triage” program that puts
caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the
hospital’s chief medical and quality officer. The hospital’s internal data
now show fewer than 2% of patients leaving against medical advice or
abruptly discontinuing care.


“When patients bring themselves into the ED, they are seen in about 5
minutes by a qualified registered nurse and, on average, are seen by a
provider within 30 minutes of arrival,” Thomas said in a statement.


When a sick patient is about to leave the emergency room, doctors should
determine why he or she wants to go, make sure the patient is capable of
making a sound decision, involve friends and family, explain the course of
treatment and, if nothing works, arrange for speedy follow-up care, said Dr.
Jay Brenner, emergency department medical director at Upstate University
Hospital-Community Campus in New York and co-author of several studies about
patients leaving against medical advice.


“When someone requests to leave,” Brenner said, “it needs to be a priority
that ranks just below a cardiac arrest.”


Phillip Reese is a data reporting specialist and an assistant professor of
journalism at California State University-Sacramento.




Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service


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