The article by James Roberts, MD, in the November EMN (“Patients Who Leave the ED Without Being Seen,” 2005;27:18) is not wholly accurate. Patients leave the ER without being seen even after gaining entry into the treatment area. Signing out against medical advice is intertwined with the walkout concept. The former is used if you get a signature prior to walking out.
“Feeling better,” “have to meet the school bus,” or “didn't think it would take this long” are often used expressions. Patients have become savvy in ways to beat the system. Ambulances are abused by many as a means of gaining automatic entry into the ER and beating the wait to register. Attempts to triage back to the waiting room or fast track are met with hostility or threats of legal action, public relations nightmares. This affects waiting time, overcrowding, and walkouts.
Unfortunately, the status quo remains because “volume does count,” and innovative approaches to speed delivery of care may reduce the annual statistics. Insurance coverage is immaterial and a fake argument in the issue of waiting, walkouts, and overcrowding. Every patient has to be seen regardless of the ability to pay. Every hospital has its own anecdotal contribution to prolonged waiting or inappropriate ER usage.
Secondary triage can take place on waiting and registered patients. A resident can walk around asking, “What's your problem?” giving reassurance and attention. Some can be x-rayed ahead of time or have UCGs performed, all with chart documentation. Doing something is better than doing nothing. Each innovation needs to be honed for the hospitals involved. Dealing with admitted patients on stretchers is another issue requiring a different set of initiatives.
The American public does have a tolerance for waiting when it's of interest to the individual. A recent sale by clothes designers in New York City had women lining up at 3 a.m. Tickets for concerts, ballgames, and famous clubs and restaurants have people waiting for hours or days, with no walkouts or impatience shown. Managing by having a resident walking around or following a Sir William Osler truism — clinical judgment comes before lab testing or disposition — can reducing waiting time. Unfortunately, residents need oversight; bedside teaching; instruction in lab, x-ray, and EKG interpretation; and duplication of effort as part of the education process. What's a mother to do?!
Donald Forester, MD
North Babylon, NY