title: Who are the children leaving the emergency department without being seen by a physician?
abstract: BACKGROUND
  Waiting times to see a physician in emergency departments (EDs) are growing, and a greater number of patients are leaving the ED without being seen by a physician (LWBS).
  
  
  OBJECTIVE
  The objective was to assess the characteristics of the children who left a pediatric ED without being seen by a physician.
  
  
  METHODS
  This retrospective case-control study was performed using the computerized database of a tertiary care pediatric ED. All children aged less than 19 years old presenting to the ED between April 1, 2008, and March 31, 2009, were included. Cases were all triaged children who LWBS. Controls were all triaged children seen by a physician. Independent variables concerning the patient, the illness, and the period of consultation were assessed. A stepwise logistic regression model was constructed using significant variables identified through univariate analysis to select characteristics most predictive of patients who LWBS. The minimum sample size needed to evaluate 10 risk factors is 100 patients who LWBS. We estimated that evaluating all patients visiting the ED for 1 year would minimize seasonal variation and generate more than 10,000 patients who LWBS.
  
  
  RESULTS
  During the study period, 60,525 patients presented to the ED. A total of 10,037 (16.6%) patients were triaged, but LWBS. On multiple logistic regression, referral by a physician (odds ratio [OR] = 0.1, 95% confidence interval [CI] = 0.08 to 0.12); summer or fall consultation (OR = 0.46, 95% CI = 0.43 to 0.45; and OR 0.42, 95% CI = 0.39 to 0.45, respectively, compared to winter); and higher acuity triage level were associated with a lower risk of patients who LWBS. Evening arrivals (OR = 2.1, 95% CI = 1.9 to 2.2, compared to night), ages between 3 months and 11 years (OR varying from 1.3 to 1.8 compared to more than 11 years of age), and living close to the hospital (OR = 1.2, 95% CI = 1.1 to 1.3) were risk factors for LWBS. The most important predictor of LWBS was triage level with rates of 0, 0, 1.5, 23, and 49% for Levels 1 to 5 according to the Canadian Triage and Acuity Scale (CTAS).
  
  
  CONCLUSIONS
  This study shows that children who LWBS have a lower triage acuity, are less often referred by a physician, and are largely in the 3-month to 11-year-old age range. Environmental factors, such as the timing of the consultation and the proximity of patients' homes, are also associated with LWBS.
authors.affiliation: Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Québec, Canada.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Gaucher
authors.forename: Benoit
authors.initials: B
authors.lastname: Bailey
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Gravel
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D003441:Crowding; D016208:Databases, Factual; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007902:Length of Stay; D016015:Logistic Models; D010372:Pediatrics; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012307:Risk Factors; D012621:Seasons; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D014218:Triage / Q000706:statistics & numerical data*; D014850:Waiting Lists