Revisiting ‘Left Without Being Seen’ Metrics in the ED

by Gregory Jasani, MD
May 20, 2024
 
The “left without being seen” (LWBS) metric hangs around the neck of every emergency department (ED). Among the many numbers and metrics that impact our day-to-day work as emergency medicine physicians, few are as important or problematic as LWBS. As one of the Hospital Outpatient Quality metrics (OP-22) from CMS, there are strong financial and administrative incentives to provide a medical screening exam as rapidly as possible. A lower LWBS metric means more revenue and decreased liability for the hospital.
 
What is measured is what matters. We face many issues as emergency physicians, from increasingly complex patients to poor outpatient follow-up to ED crowding. Unfortunately, screening all patients rapidly prompts behavior that exacerbates these issues. The push to lower the LWBS rate has led to some very odd decisions in how care is allocated in the ED.
 
At my ED, we will often utilize non-traditional areas for our lowest-acuity patients to move them through and get them “seen.” This allows us to rapidly evaluate our least sick patients — but it means our sickest will often languish in the waiting room, waiting for a bed while we devote staff and resources to the patients with the lowest-acuity complaints.
 
If that feels wrong to you, that’s because it is.
 
The foundational skill of emergency medicine, and arguably one of the primary ways we add value to patient care, is identifying and treating the sickest who need us first. Not all patients who enter EDs are the same; some are sicker than others, and we triage them and assign resources accordingly. Why, then, do we lump all patients who leave the ED in one generic category? Should a patient who leaves with a chief complaint of “sprained ankle” really be considered the same as a patient who leaves with a chief complaint of “shortness of breath”?
 
I — and I hope most of you — would say, “Of course not.” Yet, LWBS does just this. It ignores medical nuance and works against effective patient care, which is why it is one of the more frustrating metrics we deal with. LWBS is a monolith, but our patients are not. That is why we need to restructure the LWBS metric.
 
I propose a more balanced LWBS metric, where the fraction of high-acuity patients seen is weighted relative to the fraction of lower-acuity complaints. This metric would more fairly represent the critical work of emergency medicine: seeing and treating sick patients quickly and efficiently.
 
A traditional LWBS metric is not completely without merit, because part of our role as emergency physicians is to see “anyone at any time,” but our current LWBS system is accounting for all patients in the ED equally. A more balanced, weighted metric would promote timely and quality care for those who need care more immediately, and would help disincentivize an injurious over-emphasis on metric-driven throughput.
 
While the appropriate weighting will likely be a source of considerable debate, the challenge of implementing such a metric should not be…
 
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