The left-without-being-seen patients: What would keep them from leaving?

T H E P R A C T I C E O F E M E R G E N C Y M E D I C I N E /O R I G I N A L R E S E A R C H

Katherine W. Arendt, MDAnnie T. Sadosty, MDAmy L. Weaver, MSChristopher R. Brent, MHAEric T. Boie, MD

From the Department ofAnesthesiology, Mayo GraduateSchool of Medicine, Rochester,MN (Arendt); the Departmentof Emergency Medicine, MayoMedical School, Rochester, MN(Sadosty, Boie); and theDepartments of Biostatistics(Weaver) and Administration(Brent), Mayo Medical Center,Rochester, MN.

Copyright © 2003 by the AmericanCollege of Emergency Physicians.

0196-0644/2003/$30.00 + 0doi:10.1067/mem.2003.277

The Left-Without-Being-Seen Patients:

What Would Keep Them From Leaving?

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Study objective: We determine which services, if any, an emergency department(ED) could provide to help a patient who left the ED without being seen by a physi-cian wait longer to see a physician.

Methods: In this retrospective observational study, patients who had left the SaintMarys Hospital ED without being seen by a physician were surveyed by telephone.The Saint Marys Hospital ED is a 43-bed facility with an annual patient volume of77,600 located in a city of 82,000. Responders were questioned regarding 15 specificservices the Saint Marys Hospital ED could provide to help them wait longer. Eligibleparticipants included willing adults, parents accompanying patients younger than 18years of age, and patients between the ages of 13 and 18 years whose parentsgranted permission. Participants were excluded if they denied research authoriza-tion, did not speak English, refused to participate, or were unable to be contacted.

Results: Between April 9, 2001, and July 17, 2001, 20,494 patients registered, 172patients left without being seen, and 152 patients approved research authorization;we attempted to contact these patients. In total, 97 patients, their parents, or theircaretakers completed the entire interview (56.4% of those who left without beingseen, 63.8% of those with whom contact was attempted). Nearly 85% of respondersretrospectively identified “more frequent updates on wait time” and 70.1% identified“the availability of immediate temporary treatments” as services that would havehelped them wait longer. Other waiting room services were identified by fewer thanhalf of the responders as potentially helpful in allowing them to wait longer.

Conclusion: Communication of estimated waiting time and the availability of imme-diate treatments for minor injuries or symptoms might increase the time patients arewilling to wait and therefore might decrease an ED’s rate of patients leaving withoutbeing seen.[Ann Emerg Med. 2003;42:317-323.]

T H E U N S E E N P A T I E N TArendt et al

I N T R O D U C T I O N

Patients come to emergency departments (EDs) seekingmedical care, yet some leave without being seen by aphysician. Such patients pose potential problems.Patients who leave without being seen might not be get-ting the health care they need. Furthermore, the left-without-being-seen population exposes an ED toincreased liability exposure, threatens an ED’s publicrelations, and is a potential lost source of revenue forhospitals.

The frequency of patients leaving without being seenand their medical severity have been shown to varytremendously. A study in Los Angeles County foundthat 7.3% of public hospital patients leave withoutbeing seen, and 2.4% of private hospital patients leavewithout being seen.1 A study at an urban ED in LosAngeles found that of the patients who leave withoutbeing seen, 46% needed immediate medical attention,29% needed care within 24 to 48 hours, and 8.2% werehospitalized within 1 week.2 By contrast, other studieshave indicated that patients who leave without beingseen have lower severity rates, as evidenced by datashowing hospital admission rates of 1.7% to 4.0% afterED departure.3-5 No matter which of the studies indi-cates the more accurate severity of patients who leavewithout being seen, it is clear that some sick patients donot receive services from EDs because they leave pre-maturely.

Prior studies attempted to identify means of decreas-ing the rate of patients leaving without being seen. In a1991 study of patients waiting at a city teaching hospital,Bindman et al3 showed that the left-without-being-seenrate decreases when patient waiting time is decreased.Prior studies show that ED staffing and reorganizationmeasures designed to decrease ED waiting times mightdecrease the left-without-being-seen rate.6-8 However,few other interventions have been identified as a meansof reducing the proportion of patients who leave with-out being seen. We could identify no study that hasdirectly asked patients who have left without being seenwhat ED service, if any, might have kept them from leav-ing.

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In this study, a telephone questionnaire was adminis-tered to patients who left the Saint Marys Hospital EDwithout being seen by a physician (Appendix availableat www.mosby.com/AnnEmergMed). The participantswere asked a series of questions regarding specific ser-vices the ED could provide to help them wait longer tosee a physician. This study is the first step toward a trialof implementing services to determine how the ED inthis study and EDs in general could better serve patientsand thereby reduce the number of patients who leavewithout being seen.

M A T E R I A L S A N D M E T H O D S

The study site was the Mayo Clinic Saint Marys HospitalED. The Saint Marys Hospital ED is a 43-bed facilitylocated in a city of 82,000 persons surrounded by smallagricultural communities in southeastern Minnesota.The Saint Marys Hospital ED serves an average of71,600 patients per year. There is a geographically sepa-rate urgent care center that serves an additional 50,000patients per year. The urgent care center is run by theinternal medicine and family medicine departmentsand was not included in this study. The obstetrics andgynecology departments are located at a separate hospi-tal 8 blocks away from the Saint Marys Hospital ED. TheSaint Marys Hospital ED services women who walk inwith gynecologic complaints, although laboringwomen are instructed to present to the patient receivingunit at this separate hospital.

For this study, the investigators used a database ofpatients who had left without being seen that was main-tained by the Saint Marys Hospital ED staff to obtaineach patient’s registration number, Saint Marys HospitalED chart, home telephone number, and date of ED visit.The completeness of the database was ensured by SaintMarys Hospital ED staff, who review all ED records toensure a physician saw the patient. The accuracy of thedatabase was confirmed when the individuals werecalled and asked whether they did, in fact, leave with-out being seen. The Mayo Foundation InstitutionalReview Board approved this study. A scripted question-naire was developed through discussion among the

http://www.mosby.com/AnnEmergMed


rate was calculated, and the reasons for lack of partici-pation were reported. The age and sex distributions ofpatients who did participate versus those who did notparticipate in the survey were compared, and 95% CIswere reported. The responses to each survey questionwere summarized with frequencies and percentages.Statistical analyses were performed by using the SASsoftware package (SAS Institute, Inc., Cary, NC).

R E S U L T S

Between April 9, 2001, and July 17, 2001, the percent-age of patients who left without being seen as a percent-age of total registered patients was 0.84% (95% CI0.71% to 0.96%). A total of 20,494 patients registered,and 172 patients left without being seen.

Table 1 summarizes the level of participation of these172 patients in the follow-up telephone interview.Among the 172 patients, 9 male and 11 female patients(mean age 25.9 years; range 4 months to 66 years)denied research authorization and thus were not con-tacted. Among the remaining 152 patients who werecalled, 97 (63.8%) patients, their parents, or their care-takers completed the entire telephone interview. Of the55 nonresponders to the interview, 23 (41.8% of nonre-sponders, 13.4% of all patients who left without beingseen) were unreachable because of the absence of aworking telephone number on record. An additional 5

authors, including major input from the statistician.This questionnaire was not tested for internal consis-tency or for its clarity to a telephone listener. This ques-tionnaire was used to administer the telephone inter-view to consecutive eligible patients who left withoutbeing seen between 3 days and 3 weeks after the patientleft the ED. Given the descriptive nature of this study, itwas not deemed necessary to establish power, and theinvestigators chose a sample size of 100 that was consis-tent with investigator time constraints.

A single investigator made all calls and strictly fol-lowed the language of the scripted questionnaire.Participants eligible to answer the telephone question-naire included consenting adults older than 18 years ofage who came to the Saint Marys Hospital ED betweenthe dates of April 9, 2001, and July 17, 2001, as well asparents accompanying patients younger than 18 yearsof age. If a participant was an adolescent between theages of 13 and 18 years, verbal permission over the tele-phone was obtained from the participant’s parent orguardian before the questionnaire was administered. Ifa participant was unable to answer the questionnaire,then a resident at the site of the same telephone numberwho accompanied the participant to the ED during thevisit when they left without being seen was eligible toanswer the questionnaire. If the participant was hospi-talized, his or her inpatient nurse was called and askedto approach the patient regarding his or her willingnessto answer the questionnaire. If the patient was intu-bated or otherwise unable to speak on the telephoneaccording to the nurse, then the participant was ex-cluded from the study. Participants were also excludedfrom the study if they denied authorization for therelease of information for research purposes, did notspeak English, simply refused participation, did nothave a working telephone number, or were otherwiseunable to be contacted.

The study was designed to be descriptive. The pro-portion of patients who left without being seen duringthe time period of this study was estimated along with a95% confidence interval (CI) by using the total numberof Saint Marys Hospital ED visits during this timeperiod as the denominator. The survey participation


Table 1. Summary of the level of response of the 172 patients to thetelephone interview.

Level of Response No. (%)

Completed the entire questionnaire 97 (56.4)Denied research authorization 20 (11.6)Unable to contact after numerous attempts* 17 (9.9)No telephone number available, telephone 23 (13.4)

disconnected, patient moved, or wrong numberCompleted a portion of the questionnaire 5 (2.9)Chose not to participate 5 (2.9)Did not speak English 4 (2.3)In hospital and too sick to communicate 1 (0.6)*All patients had a minimum of 5 attempts to contact by telephone.


patients who completed a portion of the interview didnot, however, complete the section of the interviewregarding the helpfulness of additional services, andtherefore, they were excluded from further analysis.Compared with the nonresponders, responders withcompleted telephone interviews (n=97) were slightlyyounger (95% CI for difference in mean age –10.2 to 3.2years) and more likely to be female (95% CI for differ-ence in the proportion female –11.7% to 21.3%). Amongthe 97 responders with completed telephone inter-views, the mean±SD age of the patient was 32.3±20.8years (range 8 months to 82 years), and 55.7% werefemale. Among the 55 patients who did not participatein the complete telephone interview, the mean±SD agewas 35.8±18.9 years (range 1 to 81 years), and 50.9%were female.

The results reported herein are based on the 97responders with completed interviews. The interviewswere conducted, on average, 9±4.2 days (range 3 to 22days) after patients were in the ED. A mean number of 2.8attempts per responder (range 1 to 9 attempts) were madebefore the interview was complete. Four or more attemptsto contact were necessary for 30% of the responders. Themean length of each completed telephone interview was8.8±4.4 minutes (range 3 to 22 minutes). Twenty-two ofthe responders were younger than 18 years of age, and aparent or grandparent completed the interview in all but 3of these interviews (verbal permission from a parent wasgranted for these 3). For the 75 patients who were 18years of age or older, the interview was completed by thepatient in all but 2 interviews, in which case a caretakeraccompanying the patient to the ED completed the ques-tionnaire. English was the primary language for themajority (94.8%) of the responders.

Responders were asked an open-ended question as towhy they left without being seen. The reasons for leav-ing the ED before seeing a physician are listed in Table2. Many responders provided multiple reasons. Overall,67.0% left the ED either because they believed they hadalready waited too long or they believed that the waitlooked like it was going to be too long. Twenty-five per-cent believed their symptoms had improved or did notworsen, and approximately 19% believed they weretreated poorly by the ED workers. Fourteen percent had


a mode of transportation that would not wait, and 14%stated that they were too sick, scared, or tired or in toomuch pain to wait in the waiting room.

The length of time that the responders estimated thatthey waited averaged 84±70.1 minutes (median 60 min-utes). The length of time that the responders said theyanticipated waiting when deciding to go to the ED aver-aged 61 minutes (median 60 minutes). Among the 92responders who provided estimates of the length oftime they waited and the length of time that they antici-pated waiting, the wait time was less than what theyanticipated for 26 (28.3%) responders, equal for 7(7.6%) responders, and longer for 59 (64.1%) respond-ers. Most of the patients who left before the length oftime they anticipated waiting did not leave because they“waited too long” but instead left for other reasons, aslisted in Table 2.

The majority of the responders considered them-selves patient persons, with 25 (25.8%) indicating thatthey are always patient, 59 (60.8%) most of the time, 8(8.2%) sometimes, 3 (3.1%) rarely, and 2 (2.1%) never.Twenty-five of the responders had a child or grandchildwith them while they were waiting, and the child (<17years of age) was the patient waiting to be seen in 19 ofthese instances. When asked if they thought a stressfulsituation in their life led to their leaving without being

Table 2. Summary of the reasons why the patient left the ED beforeseeing a physician for the 97 patients who completed the tele-phone interview.

Reason for Leaving No. (%)

Waited too long 46 (47.4)Wait looked like it was going to be too long 37 (38.1)Symptoms improved or did not worsen 24 (24.7)Treated poorly by ED workers 18 (18.6)Family member, mode of transportation, or 14 (14.4)

work that could not waitFelt too sick, scared, or tired or in too much 14 (14.4)

pain to wait in waiting roomFinancial reasons 8 (8.2)Redirected by personal physician (by telephone) 5 (5.2)

to seek care elsewhereReassured by nurse 4 (4.1)Other 4 (4.1)


longer. The endorsement of each of these services issummarized in Table 3. The services most often identi-fied by responders as enabling them to wait longerincluded “more frequent updates on wait time” and“the availability of immediate temporary treatments ofyour symptoms, such as an ice pack for an injury or ban-dage for minor cut,” with 84.5% and 70.1% of respond-ers, respectively, believing that the services “probablywould” or “definitely would” help them wait longer.The least helpful services included “greater privacy inthe waiting room” and “a quieter waiting room,” with77.3% and 78.4% of responders, respectively, believingthat the services “probably would not” or “definitelywould not” help them wait longer. The 12 other servicesqueried were identified as helpful by 20% to 40% ofresponders.

D I S C U S S I O N

This study shows that patients who leave without beingseen believe that communication of estimated waitingtime and the availability of immediate treatments forminor injuries or symptoms might increase the timepatients are willing to wait. Furthermore, poor commu-nication with patients by the ED staff leads patients to

seen, 18 (18.6%) of the responders indicated yes.Sixteen of the 18 responders specified the source of thestressful situation as being a domestic dispute (43.8%),family illness (43.8%), or psychiatric reason (12.5%).Among those reporting a stressful situation, 3 to 4responded that had either a trained psychiatric nurse(n=4), social worker (n=4), chaplain (n=3), or volun-teer (n=3) been with them while they waited, it wouldhave assisted them in managing their emotional stressand allowed them to wait longer.

Nineteen (19.6%) responders were missing workwhile they waited, and 5 believed it would have beenhelpful for an ED employee to call and inform their bosswhere they were. Seven (7.2%) responders reportedleaving a dependent, such as a young child or elderlyperson, at home alone while they were at the ED, butnone believed it would have been helpful for police per-sonnel to visit the home. More than half (56.7%) of theresponders were aware that a telephone was availablefor them to make necessary calls (both local and longdistance) for free; however, only 5 believed this servicewould have helped them wait longer.

The interview included a section that asked aboutwhether the availability of 15 different services mighthave been helpful by enabling the responder to wait


Table 3. Endorsement of services as to whether their availability would have been helpful by enabling the patient to wait longer.

Definitely Probably Probably DefinitelyWould, Would, Unsure, Would Not, Would Not,

Service % % % % %

More frequent updates on wait time 43.3 41.2 4.1 4.1 7.2Food or coffee available 12.4 15.5 16.5 25.8 29.9More comfortable chairs 17.5 14.4 3.1 28.9 36.1Greater privacy in waiting room 8.2 12.4 2.1 36.1 41.2Quieter waiting room 9.3 7.2 5.2 33.0 45.4Portion of waiting room with dimmed lights 12.4 22.7 5.2 18.6 41.2Ability to watch chosen television channel 14.4 15.5 6.2 18.6 45.4Availability of over-the-counter pain medications 21.6 13.4 8.2 32.0 24.7Availability of immediate temporary treatments (eg, ice pack, band aid) 46.4 23.7 8.2 9.3 12.4Better play area for children 23.7 8.2 22.7 10.3 35.1Availability of children’s movies 24.7 14.4 20.6 6.2 34.0Availability of lactation room 11.3 6.2 34.0 3.1 45.4On-site day care for a minimal charge 11.3 10.3 19.6 13.4 45.4On-site day care for free 16.5 10.3 18.6 10.3 44.3Fewer children in waiting room 12.4 9.3 9.3 13.4 55.7


leave without being seen. Perhaps surprisingly, lack ofwaiting room comfort measures, such as a television,coffee, or comfortable chairs, generally do not causepatients to leave without being seen.

Nearly 85% of responders retrospectively identified“more frequent updates on wait time” as possibly help-ful in increasing waiting time. The 1995 study byLombardi et al9 also found that frequent announcementof waiting times decreases patient walkouts. Whetherby formal announcements or by the triage nurses’ will-ingness to make estimates, patients appreciate an esti-mate as to how long they will probably wait. Such anestimate, some believed, would have allowed them tostep outside the hospital for a minute to use their cellu-lar telephone or to run to their car to get a book, toy, orfood for themselves or a child.

Nearly 70% of responders identified “immediatetemporary treatments for their symptoms, such as anice pack for an injury or a bandage for a cut” as poten-tially helping them wait longer. Currently, Saint MarysHospital ED and most other EDs provide such a ser-vice, and the most obvious patients (ie, those bleedingor those with facial bruising) probably get the immedi-ate attention they need. This result indicates, however,that a statement from the triage nurse that asks, “Isthere anything I can get for you while you wait?,”might be helpful for less obvious needs: a mother witha feverish child or a migraine sufferer desiring a coolcompress.

It was found that 18.6% of responders left becausethey were “treated poorly by ED workers.” Specific com-plaints ranged from “nurses were rude enough to be talk-ing and laughing behind the counter while I was in pain”to “doctors/nurses were purposefully ignoring me” tospecific inconsiderate comments made by the triage deskstaff. The staff ’s patience and polite communication andtheir availability to the patients before formal physicianconsultation is clearly important to patients.

Most responders indicated that comfort measures inthe waiting room would “probably not” or “definitelynot” help them wait longer. About 78% believed quiet-ness would “probably not” or “definitely not” helpthem wait longer. Likewise, about 77% of responders


believed privacy, about 65% believed more comfortablechairs, about 60% believed dimmed lights, and about56% believed available food or coffee would “probablynot” or “definitely not” help them wait longer. Thisimplies that the waiting room facility itself does notexacerbate impatience for most patients. Therefore,funding to increase patient satisfaction might be betterspent on increasing ED personnel and their educationin customer service than spent on waiting room struc-tural improvements.

Approximately 32% and 40% of responders believedthat “a better play area for children” and “the availabil-ity of children’s movies” would have helped them waitlonger. However, only 26% of responders had a childwith them. Among the responders with a child present,64% and 76% of responders, respectively, believed thateach of these services would have helped them waitlonger. Likely, patients without children would havepreferred the children in the waiting room to be moreoccupied and less fussy or responders were remember-ing back to a previous time they left without being seenbecause of an impatient child. “On-site day care forfree” or “for a minimal charge” would have helped someresponders wait longer (26.8% and 21.6%, respec-tively). Among those with a child present, 40% believedeach of these services would have helped them waitlonger.

Only 17.5% of responders believed that the availabil-ity of a lactation room would have helped them waitlonger. This number might be different for EDs thatserve a different population because the obstetricsdepartment for the Mayo Clinic, Rochester, MN, islocated at a separate hospital. Postpartum patients whodelivered their baby at this separate facility are in-structed to return to that hospital’s patient receivingunit with postpartum complaints, thus reducing thenumber of breast-feeding patients who might seek careat the Saint Marys Hospital ED. Therefore, other EDsmight likely have a higher population of breast-feedingpatients and find a lactation room to be identified bymore patients as helpful in allowing them to waitlonger. Among the 32 (33%) responders who werefemale and between the ages of 18 and 45 years, 21.9%


Author contributions: ATS, ETB, and KWA conceived the study.KWA, ATS, ETB, and ALW designed the study. KWA, ATS, ETB, andCRB obtained funding. All authors contributed to the developmentof the telephone questionnaire. KWA administered the telephonequestionnaire. ATS supervised KWA in the conduct of the trial anddata collection. ALW provided statistical advice on study designand analyzed the data. KWA drafted the manuscript, with all authorscontributing substantially to its revision. KWA takes responsibilityfor the paper as a whole.

Received for publication July 28, 2002. Revisions received December2, 2002, and February 13, 2003. Accepted for publication March 2,2003.

Presented at the Mayo Medical School Class of 2002 ResearchSymposium, Rochester, MN, March 15, 2002.

Supported by the Mayo Clinic Rochester, Department of EmergencyMedicine and Mayo Medical School, Rochester, MN.

Reprints not available from the authors.

Address for correspondence: Katherine W. Arendt, MD, Departmentof Anesthesiology, Mayo Graduate School of Medicine, Saint MarysHospital, 1216 2nd Street SW, Rochester, MN 55902; 507-529-1196;E-mail [email protected].

R E F E R E N C E S1. Stock LM, Bradley GE, Lewis RJ, et al. Patients who leave emergency departmentswithout being seen by a physician: magnitude of the problem in Los Angeles County.Ann Emerg Med. 1994;23:294-298.

2. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergencydepartment without being seen by a physician: causes and consequences. JAMA.1991;299:1085-1090.

3. Bindman AB, Grumbach K, Keane D, et al. Consequences of queuing for care at apublic hospital emergency department. JAMA. 1991;266:1091-1096.

4. Dershewitz RA, Paichel W. Patients who leave a pediatric emergency departmentwithout treatment. Ann Emerg Med. 1999;15:717-720.

5. Dos Santos LM, Stewart G, Rosenberg NM. Pediatric emergency department walk-outs. Pediatr Emerg Care. 1994;10:76-78.

6. Hobbs D, Kunzman SC, Tandberg D, et al. Hospital factors associated with emer-gency center patients leaving without being seen. Am J Emerg Med. 2000;18:767-772.

7. Fernandes CMB, Price A, Christenson JM. Does reduced length of stay decreasethe number of emergency department patients who leave without seeing a physician?J Emerg Med. 1996;15:397-399.

8. Howell JM, Torma MJ, Teneyck R. The impact of dedicated physician staffing onpatient flow and quality assurance parameters in an Air Force emergency department.Mil Med. 1990;155:30-33.

9. Lombardi G, Elsner N, Gennis P, et al. Effect of periodic waiting time announce-ments on patient walk-outs in a municipal hospital ED. Presented at: Society forAcademic Emergency Medicine annual meeting; May 21-24, 1995; San Antonio, TX.

believed the availability of a lactation room would havehelped them wait longer.

It is important to note that one of the limitations ofthis study is that patients were asked their opinions offactors that affected their willingness to wait, whichmight not be the actual factors that determine theirwillingness to wait while in the ED. They were alsoasked to retrospectively rate the helpfulness of servicesin enabling them to wait longer. They were not asked toidentify a single service that would have resulted inthem not leaving without being seen, and they were alsoto consider other times they had waited in the ED andleft without being seen. In other words, we cannot con-clude that because 84.5% of responders identified“more frequent updates on wait time” as helpful, theremight be a roughly 80% drop in the rate of patients leav-ing without being seen with the implementation ofwait-time announcements.

Further limitations of this study include the biasesassociated with survey research in general. The nonre-sponse bias in the study is significant because we wereable to completely survey 97 (63.8%) of the 152 eligiblepatients who left without being seen. Of the 55 nonre-sponders, 23 (41.8% of nonresponders, 13.4% of allpatients who left without being seen) were unreachablebecause of the absence of a working telephone numberon record. Perhaps these ED customers are more likelyto have an ED as their only source of health care, and wewere unable to include this important population in ourresults. Ten (5.8% of patients who left without beingseen) patients chose not to participate or completedonly a portion of the interview. These patients were gen-erally those who were too angry or impatient and thusunable to answer the questions. Clearly, this populationmight frequently leave without being seen from EDs,and they too were not included in the results.

The findings of this study might not be applicable toEDs with different demographic characteristics, staff,and practices. That being said, our study suggests thatcommunication with patients regarding estimates ofwait times and the immediate treatment of their symp-toms or minor injuries, when possible, might increasethe time patients are willing to wait.


mailto:[email protected]


A P P E N D I XTelephone questionnaire administered to patients who left without being seen.

Investigators: Drs. A. Sadosty, E. Boie, and Katherine White Study numberStatistician: Amy Weaver Card number 01

April 17, 2001PATIENTS WHO LEAVE SMH’S EMERGENCY DEPARTMENT WITHOUT BEING SEEN BY A PHYSICIAN

Name _________________________________________________________ Phone number _______________- PHONE SCRIPT -

Column Item1-7 __ - __ __ __ - __ __ __ Mayo Clinic number8 __ Gender: 1 = Male, 2 = Female9-16 __ __ - __ __ - __ __ __ __ Date of birth (MM/DD/YYYY)17-24 __ __ - __ __ - __ __ __ __ Date seen in ED (MM/DD/YYYY)25 __ Time of day seen: 1 = 7 AM - Noon

2 = Noon - 5 PM3 = 5 PM - 9 PM4 = 9 PM - 7 AM

26 __ Number of attempts to contact27-34 __ __ - __ __ - __ __ __ __ Date contacted (MM/DD/YYYY)35-38 __ __ : __ __ Start time (24 hr clock)39-42 __ __ : __ __ End time (24 hr clock)43 __ Level of participation:

1 = Completed entire interview2 = Completed a portion of the interview3 = Denied research authorization4 = Deceased5 = No phone number6 = Didn’t speak English7 = Refused to participate8 = Unable to contact after numerous attempts9 = Other ____________________________________

“My name is Katherine White and I am working on a research project to improve emergency department services at Saint Marys. On ___________ date youwent to Saint Marys Emergency Department to see a doctor. However, you did not see a doctor before you left. I am wondering if you would be willing toanswer a few questions?”“This will take less than ten minutes. Please understand that your future and present care will not be affected if you decide not to participate.”44 __ Who completed the survey: 1 = Patient

2 = Spouse3 = Parent4 = Grandparent5 = Caregiver

45 __ Is English your primary language?: 0 = No, 1 = YesIf NO, what is your primary language? _________________

We recorded that you came to the ED with the complaint of ___________________________________. Is this correct?If NO, why did you come to the ED? __________________________________________________

46-47 __ __ ED complaint on record (see codes)48-49 __ __ ED complaint, if different from above (see codes)

Why did you leave before seeing a doctor? (See codes)50-51 __ __ ________________________________________________________________52-53 __ __ ________________________________________________________________54-55 __ __ ________________________________________________________________56-57 __ __ ________________________________________________________________58-59 __ __ ________________________________________________________________60-62 __ __ __ How long do you estimate that you waited before leaving? (minutes)63-65 __ __ __ When deciding to go to the ED, how long did you anticipate waiting? (minutes)66 __ Did you go to another health provider for this problem after leaving the ED:

0 = No, 1 = Yes67-68 __ __ If yes, who did you see and where? _______________________________69 __ Do you consider yourself a patient person?

1 = never, 2 = rarely, 3 = sometimes, 4 = most of the time, 5 = always70 __ Did you have a child or grandchild with you while you were waiting?

0 = No, 1 = Yes

Date Time called__/__/ __ ___________/__/ __ ___________/__/ __ ___________/__/ __ ___________/__/ __ _________


71 __ Do you think that a stressful situation in your life led to your leaving without being seen? 0 = No, 1 = Yes72-73 __ __ If yes, what was the situation? (see codes)

__________________________________________________________________________________________________________________________________

If YES, then would the immediate availability of any of the following have assisted you in managing your emotional stress and allowed you to wait longer?1 = Definitely would2 = Probably would3 = Unsure4 = Probably would not5 = Definitely would not

74 __ Trained psychiatric nurse75 __ Social worker76 __ Chaplain services77 __ A volunteer to be with you during the wait78 __ Were you missing work while waiting? 0 = No, 1 = Yes79 __ - If YES, would it have helped for an ED employee to call and inform your boss where you were? 0 = No, 1 = Yes80 __ Were you leaving a dependent such as a young child or elderly person home alone while you were at the ED? 0 = No, 1 = Yes81 __ - If YES, would it have helped for a police person to visit your home to make sure they were okay? 0 = No, 1 = Yes82 __ Did you know that a phone was available for you to make necessary phone calls both local and long distance for free? 0 = No, 1 = Yes83 __ - If NO, then would this service have helped you to wait longer? 0 = No, 1 = Yes

The following section asks about services that you might have found helpful if provided. Please indicate whether each of these services would have beenhelpful by enabling you to wait longer.

1 = Definitely would2 = Probably would3 = Unsure4 = Probably would not5 = Definitely would not

84 __ More frequent updates as to how much longer you will most likely be waiting85 __ Food or coffee available86 __ More comfortable chairs87 __ A greater sense of privacy in the waiting room88 __ A quieter waiting room89 __ A portion of the waiting room with dimmed lights90 __ The ability to watch the TV channel you choose91 __ Availability of over-the-counter pain medications, such as Tylenol, Advil, or aspirin at a minimal cost92 __ Availability of immediate temporary treatments of your symptoms, such as an ice pack for an injury, Band-Aids for minor cuts, etc.93 __ A better play area for children94 __ Availability of children’s movies95 __ Availability of a lactation room96 __ On-site daycare for a minimal charge97 __ On-site daycare for free98 __ Fewer children in the waiting room99-101 0 1 Card number102 1 Section number103-106 Study number

Documents

The left-without-being-seen patients: What would keep them from leaving?