title: Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates.
abstract: BACKGROUND
  Emergency department (ED) patients in the leave-without-being-seen (LWBS) group risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS to <1%. This study's goal was to assess the influence on LWBS associated with prolonging intervals between patient presentation and placement in an exam room (DoorRoom time). This study's major aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).
  
  
  METHODS
  We conducted the study over one year (8/13-8/14) using operations data for an ED with annual census~50,000. For each study day, the LWBS endpoint (i.e. was LWBS<1%: "yes or no") and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals starting with ≤10min and ending at >60 min. Multivariate logistic regression was used to assess for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and admission %) and operations parameters. We used predictive marginal probability to assess utility of the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio (OR) and 95% confidence intervals (CI).
  
  
  RESULTS
  Univariate results suggested a primary DoorRoom cutoff of 20', to maintain a high likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35', to prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35' to 34.4% at 40'. Predictive marginal analysis using multivariate techniques to control for operational and patient-acuity factors confirmed the 20' and 35' cutoffs as significant (p<0.001). Days with DoorRoom between 21-35' were 74% less likely to meet the LWBS goal than days with DoorRoom≤20' (OR 0.26, 95% CI [0.13-0.53]). Days with DoorRoom>35' were a further 75% less likely to meet the LWBS goal than days with DoorRoom of 21-35' (OR 0.25, 95% CI [0.15-0.41]).
  
  
  CONCLUSIONS
  Operationally useful DoorRoom cutoffs can be identified, which allow for rational establishment of performance goals for the ED attempting to minimize LWBS.
authors.affiliation: University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
authors.forename: Shea
authors.initials: S
authors.lastname: Pielsticker
authors.affiliation: University of Oklahoma College of Medicine, Department of Emergency Medicine, Oklahoma City, Oklahoma.
authors.forename: Lori
authors.initials: L
authors.lastname: Whelan
authors.affiliation: University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
authors.forename: Annette O
authors.initials: AO
authors.lastname: Arthur
authors.affiliation: Hamad General Hospital, Department of Emergency Medicine, Doha, Qatar.
authors.forename: Stephen
authors.initials: S
authors.lastname: Thomas
mesh_terms: D017598:Efficiency, Organizational / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D009937:Organizational Objectives; D012189:Retrospective Studies; D013997:Time Factors