PC1022: Leaving Without Being Seen from the Pediatric Emergency Department: Analysis Before and During the COVID-19 Variant Surge

Background: Children who leave the emergency department (ED) before being seen by a medical provider are at risk of decompensation and hospitalization. The rise of delta and omicron variants during the SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic resulted in an acute surge of ED-visiting patients, both with and without COVID-19 associated illnesses. We examined the association of both patient and system characteristics with the outcome of left without being seen (LWBS).

Methods: We performed a retrospective observational study in a large, urban, pediatric emergency department, with distinct analyses for three separate time blocks: pre-COVID (January 2018 – February 2020), the beginning of the COVID-19 pandemic (March 2020 – June 2021), and the emergence of COVID-19 variants (July 2021 – December 2021). We compared descriptive statistics related to daily LWBS rates, patient demographics, and ED and hospital characteristics. Logistic and Poisson regression models were developed to evaluate the relationships between patient demographics, systemic factors, and LWBS.

Results: LWBS rates increased to 10.78% during the COVID-19 variant surge, compared to a historical pre-pandemic rate of 1.84% and a pre-surge COVID-19 pandemic rate of 1.46%. Daily LWBS rates increased across every patient demographic and triage level during the COVID-19 surge (Table 1), despite similar daily ED volume, average daily acuity level, and hourly arrivals between these time frames (Table 2). Compared to prior periods, the COVID-19 surge was associated with a dramatic increase in the number of patients boarding in the ED longer than 4 and 8 hours, an increase in the daily intensive care unit patient census, and nearly a one-third decrease in nursing full-time equivalents (FTEs). Patients who were non-Hispanic black (aOR 2.815, 95% CI 1.154 – 1.826) and patients with self-pay insurance (aOR 1.844, 95% CI 1.505 – 2.260) had higher odds of LWBS. Additionally, patients had higher odds of LWBS if they were assigned lower triage levels, arrived to the ED on a weekday, or arrived to the ED during the evening or overnight hours.

Conclusion: Since July 2021, the COVID-19 surge has been accompanied by an unprecedented increase in LWBS rates. We identified ED and hospital factors seen concurrently with LWBS, specifically high numbers of inpatients boarding in the ED and decreased nursing FTE, which may provide opportunities to prevent future spikes in LWBS during surge events. Future work is warranted to analyze patient-level associations with LWBS and develop targeted strategies to prevent at-risk patients from leaving without being seen in the future.