Emergency Department (ED) attendees registered by ED staff but who leave before further assessment are referred to as ‘did not waits’ (DNWs). It is estimated that 4,000 such patients leave ED departments in Ireland every month.¹ Staff have expressed alarm and GPs have raised concern about the fear that older people in particular have about attending our EDs. 

The aim of this study was to examine how many patients from an urban general practice population did not wait to be seen and whether they subsequently presented to general practice services including out of hours. 

Methods

The Jobstown Family Practice of four GMS principals receives letters from the EDs and the local TLC (Tallaght and Clondalkin doctors on-call) out-of-hours service within a few days following a patient visit. Such letters contain the date and time seen plus clinical details including outcomes, or if appropriate, they state that the patient did not wait. We collected data on DNWs using these letters for the 12 months of August 2015 to July 2016. We checked to see if the patients re-attended the ED or out-of-hours TLC within seven days of the DNW notification. We also checked to see if they attended the practice within seven days and whether they had a medical card.

Results

For the 12-month period there were 14,943 daytime consultations in the practice. There were 524 attendances at the ED and 374 consultations with TLC out of hours, representing a total 6% of the practice population. Of the 524 ED cases there were 56 DNWs (10.6%) with 25 being male (44.6%). The majority had a medical card (83.2%) with 31 presenting to ED between 18:00 and 08:00 on weekdays and after 23:00 at weekends.

Seven of the DNWs (12.5%) revisited ED successfully within seven days. Seventeen (32%) of the 56 DNWs successfully sought GP care within seven days with 13 attending their own GP and four being seen at the out-of-hours service. One patient attended both the out-of-hours and the GP service. Therefore, 32 (57.1%) did not seek any care within seven days after leaving the ED. 

We have no records of any of the DNW group being hospitalised within the seven-day follow-up period. Of the 374 who attended TLC, there was one DNW (0.3%) who was subsequently seen within seven days by their own GP.

Discussion

In common with many deprived areas there is large amount of out-of-hours care provided for our population either from the hospital or general practice, with a total of 898 consultations at ED and TLC out of hours during the year studied, representing 6% of our consultations. 

Our DNW figure (10.6%) is higher than that found in a previous Irish study in 2009 which was 7.47%.² However, our study goes some way to confirm their findings that those with minor problems who attend at night or weekends are more likely to leave without being seen. 

It does not confirm their assertion that such patients are at serious clinical risk of adverse outcomes; however the majority of our DNW patients did not re-attend either the ED or any of our GP services even though there was no associated financial cost to them as most had medical cards.

Previous studies on DNWs have not measured the GP contribution and this study shows that nearly one-third used the GP services, which is an important safety net. Interestingly, none of our DNWs were hospitalised in the seven days afterwards.

The striking figure is that more than 57% of the DNWs did not seek care for their ailment by revisiting the ED, GP or out of hours within seven days. This could of course mean they went somewhere else and the practice was not told. This is unlikely and it can be reasonably assumed that their condition improved quickly by itself. 

The DNW figures from this small study seem to challenge the idea that they are at high risk of an adverse outcome with none being hospitalised.

Combining data

Some limitations of this study include it being undertaken in a single practice with small numbers; that we did not have access to waiting times and cannot say whether this was the main factor for DNWs. Combining the data from a number of general practices will give better outcome data on this group of patients. 

Acknowledgements

We would like to thank the doctors and staff of Jobstown Family Practice for facilitating this study.

References

1. 50,000 walk out of A&E as waiting time crisis deepens. Irish Independent 23/05/2016
2. Gilligan P et al. DNW – ‘Did Not Wait’ or ‘Demographic Needing Work’: a study of the profile of patients who did not wait to be seen in an Irish emergency department. Emerg Med J 2009 Nov;26(11):780-782