In the world of emergency department (ED) operations, metrics like “Left Without Being Seen” (LWBS) are often used as indicators of patient access and satisfaction. A low LWBS rate is generally seen as a win—it suggests that patients are staying to receive care rather than leaving due to long waits or frustration. But here’s the catch: a hospital can have an excellent LWBS rate and still be facing serious throughput challenges.
.
To understand LWBS, we first should look at “Why” patients come to the Emergency Department and what they want. There are three things that drive the patient/family in seeking Emergency Care and how they perceive that experience. In order of importance and priority:
- To see a Provider/Doctor
- To get something to help them feel better. This could be medications for pain or nausea, reassurance that they’re in a safe place, or even peace of mind that a “trusted” professional is “on the case.”
- To receive whatever tests and/or treatment is needed and move on with the next steps, meaning an efficient disposition and next steps PATIENTS can see/hear/feel/experience.
Understanding LWBS
LWBS measures the percentage of patients who leave the ED before being evaluated by a provider. It’s a critical safety and quality metric, often tied to staffing levels, triage efficiency, and wait times. Hospitals work hard to reduce LWBS through tactics like:
-
Seeing a Provider to initiate meaningful patient specific care, this is ideally managed as part of an INTAKE team and performed with a swarm process
-
Changing the mindset of “triage” being a location to being a process that is completed where the patient needs to be for best care
-
Different Tracks based on the acuity of the patients such as fast-track areas for low-acuity patients and/or a Vertical Care Process
- Real-time patient flow monitoring, leveraging technology to improve transparency
- Enhanced communication with the healthcare team
These strategies can keep patients engaged and reduce the likelihood of them walking out. But they don’t necessarily solve deeper operational issues.
.
What Is Throughput?
Throughput refers to the movement of patients through the ED—from arrival to discharge or admission. It’s a broader measure that includes:
- Door-to-doc time: How long it takes to see a provider
- Length of stay (LOS): Total time spent in the ED
- Boarding time: Time admitted patients wait for an inpatient bed
- Discharge delays: Time spent waiting for test results, consults, or transport
Throughput problems often stem from bottlenecks in diagnostics, staffing shortages, inpatient bed availability, or inefficient workflows. In reality, most hospitals have initiated workflows and improvement work that almost completely eliminates patients who LWBS. This just “moves” this metric though if the MSE component is not meaningful to the patient.
.
Checking boxes in the Electronic Medical Record does not have any impact on the patients’ perception of their needs being met. The metric we should be monitoring and tracking today should include those patients who leave AMA or Elope from the ED as they are tired of waiting. This collectively is called Left Before Treatment Complete (LBTC), and is a better indication of how the hospital is performing on throughput, and therefore patient experience.
.
The Disconnect
Here’s how a hospital can have a low LWBS rate but still suffer from poor throughput:
- Patients are staying—but waiting longer: Effective triage and engagement strategies may keep patients from leaving, but they could still be waiting hours to see a provider or get a bed.
-
Boarding clogs the system: Inpatients Boarding in the ED who are waiting hours and days to move to a Licensed Inpatient Bed, take up beds and staff time, using resources that the hospital has in place for newly arriving ED patients.
-
Staffing and resource constraints: Even with efficient front-end processes, limited staff or diagnostic delays can create backlogs.
- Metrics masking reality: A low LWBS rate might look good on paper, but if LOS and boarding times are high, patient experience and outcomes suffer.
Why It Matters
The biggest risk for every hospital is the undifferentiated patient who is waiting to be seen, or whose care is delayed for some reason. Often, patients who don’t feel well enough to wait are often the ones who leave before treatment is complete. Often, these patients have other options where they can go for treatment but not always. The collective population of patients who leave before their treatment is complete very likely includes the same percentage of patients who would be admitted. Meaning if your ED admit rate is 20%, and daily an average of ten patients Leave Before Treatment is Complete, two of those patients who leave would likely have been admitted to the hospital.
.
It is a common misperception that those who leave are “urgent care” or “not very sick”, this perpetuates the risk for the hospital when these patients leave. Also, focusing solely on LWBS can give a false sense of success. True operational health requires a balanced view of all throughput metrics. Hospitals must look beyond who stays and who leaves—and dig into how efficiently and safely patients move through the system.
.
Final Thought
Improving throughput is a complex challenge that requires cross-departmental coordination, real-time data, and continuous process improvement. A low LWBS rate is a great start—but it’s not the finish line.
.
Ready to do something about the throughput bottleneck in your facility? Click here to find the HealthLinx associate who covers your state and schedule time with them.
