May 20, 2019
Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.
About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That’s up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.
Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.
Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.
Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.
California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.
The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.
“Most patients are sick but not critically ill,” said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. “Emergency care doesn’t equal fast care all of the time.”
When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as “leaving against medical advice or discontinued care.” The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.
Patients leaving the emergency room too soon “are deliberately putting themselves at more risk for morbidity and even mortality,” Polevoi said — a point echoed by other physicians.
Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having “tough conversations” with sick patients intent on leaving the ER, often citing pressing responsibilities.
“If you die from this,” she tells them, “you are good to no one you are caring for.”
One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.
“Guess what he came back for? A major stroke,” said Vasquez-Montez, also a clinical assistant professor at the University of Southern California’s Keck School of Medicine.
Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.
Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.
From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno’s Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.
Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a “Provider at Triage” program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital’s chief medical and quality officer. The hospital’s internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.
“When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival,” Thomas said in a statement.
When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.
“When someone requests to leave,” Brenner said, “it needs to be a priority that ranks just below a cardiac arrest.”
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.