“Metrics without goals are just interesting data.”
                 Charles G. Cobb, From Quality to Business Excellence, ASQ ©2003

Patients that observe a packed waiting room upon arrival or feel like they have waited too long after triage may leave and seek care elsewhere. Some, especially those that leave before triage, may have serious, time-sensitive emergencies. About 10% of all walkouts actually require admission.

LWBS rates can be classified by the degree of opportunity for improvement. There is extreme opportunity at 8%, moderate opportunity at 6%, and some opportunity at 4%. The goal should be to keep the LWBS rate under 2% at all times and strive for best practice, which is less than 1%.

The concept of Six Sigma is based upon efforts to reduce defect to under 6 Standard Deviations, or 99.9997% and not literally applicable to LWBS. The national average equates to 3 sigma (3% LWBS) and only under the best circumstances is 4 sigma (0.3% LWBS) possible. I’m quite proud of my 4 Sigma walkout rate!

There are many great reasons to target an above average LWBS rate as an opportunity for improvement. Walkouts correlate with patient risk, services dissatisfaction, and staff frustration, all of which tarnishes the hospital’s reputation in the community.

Moreover, lowering the LWBS rate by 2 percentage points – say from 5% to 3% – in an ED with 50,000 annual visits creates 100 more hospital admissions and 1,000 more billable cases each year, while reducing claims. It’s like finding a wad of cash in the pocket of a just-washed pair of jeans.

Reducing walkouts without the luxury of adding staff or space is the real challenge. Here are some proven methods:

o Adhere to a rapid (1-minute), first-stage triage process to make leaving before triage virtually impossible.

o Move ESI 2 cases to the assessment area whether or not there is bed availability (Encourage temporary double parking in the hallway of the clinical area.)

o Initiate standardized nurse-activated protocols (SNAPs) in triage to expedite patient testing and comfort measures.

o Position a midlevel practitioner in triage to prepare initial orders and discharge quick cases.

o Utilize a greeter to update waiting patients with their status and advocate for their comfort.

o Charge emergency department leaders to set a door-to-doctor (D2D) goal of less than 30 minutes. Excessive LWBS rates are a consequence of lengthy D2D times.

o Challenge a multidisciplinary team to reduce boarding hours by admitted patients, which reclaims space and staff in a cost-free manner.

o Have your ED Callback Clerk check on the wellbeing of all LWBS cases the next day. And, determine the factors that caused them to walk out so that these can be discussed at monthly ED leadership meetings.

              Email me for a list of SNAPs and LWBS references – tom@emergencyexcellence.com.