Emergency department overcrowding and flow disruptions frequently lead to patients leaving without being seen (LWBS) or leaving against medical advice (LAMA). These phenomena disrupt continuity of care and represent substantial patient safety concerns associated with delayed diagnosis and increased morbidity. Comprehensive research addressing these pediatric patients in Türkiye is lacking. To identify the characteristics and predictors of LWBS and LAMA in a Pediatric Emergency Department (PED) and to evaluate their re-attendance rates. This retrospective cohort study analyzed visits (Jan 2020–July 2025) at a tertiary PED in Türkiye. The final analysis included all eligible visits, excluding patients older than 18 years and those with missing discharge data. Demographics, triage categories, Door-to-Physician (D2P) time, Door-to-Disposition (D2D) time, disposition status, crowding indicators, and re-attendance rates (early within 3 days; late within 7 days) were extracted from electronic health records. Multivariable logistic regression was performed to identify independent predictors of LWBS and LAMA. Of 612,911 pediatric visits, 1.4% resulted in LWBS and 0.1% in LAMA. In multivariable analysis, LWBS was independently associated with ED crowding in a dose–response pattern, high-acuity triage codes, and the pandemic period. LAMA was independent of crowding but strongly associated with night shift (aOR = 2.38; 95% CI, 1.91–2.95; P < 0.001), red-code triage (aOR = 7.09; 95% CI, 5.37–9.24; P < 0.001), and showed a progressive secular increase over the study period. LWBS patients had longer D2D times compared with all other groups (P < 0.001). No significant association was found between LWBS or LAMA and early and late re-attendance; however, patients initially admitted or transferred exhibited significantly higher re-attendance rates (both P < 0.001). Conclusions: LWBS and LAMA have distinct predictor profiles: LWBS is primarily a capacity-driven event linked to crowding, whereas LAMA is associated with the clinical decision-making process and overnight communication dynamics. High-acuity patients carry independently elevated elopement risk, indicating that interventions must adopt differentiated strategies beyond throughput optimization. <Table Float="No" ID="Taba"> <tgroup cols="1"> <colspec align="left" colname="c1" colnum="1" /> <tbody> <row> <entry align="left" colname="c1"> What is Known: • Overcrowding and prolonged waiting times in pediatric emergency departments are established global causes of treatment incompletion and safety risks. </entry> </row> <row> <entry align="left" colname="c1"> What is New: • Multivariable analysis demonstrates that high-acuity triage categories carry independently elevated elopement risk after adjustment for crowding, temporal, and pandemic-related factors. • LWBS and LAMA have distinct predictor profiles: LWBS is primarily capacity-driven with a dose–response relationship to ED crowding, whereas LAMA is independent of crowding but strongly associated with night shift and clinical decision-making dynamics. Neither LWBS nor LAMA was associated with increased early or late re-attendance rates in this cohort. </entry> </row> </tbody> </tgroup> </Table> Graphical Abstract

Leaving without being seen and against medical advice from the pediatric emergency department: a single-center retrospective cohort study in Türkiye

期刊论文
发表日期：

2026年5月12日

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Derşan Onur,
Oğuzhan Çam,
Özdemir Öztürk,
Emel Berksoy

摘要

Emergency department overcrowding and flow disruptions frequently lead to patients leaving without being seen (LWBS) or leaving against medical advice (LAMA). These phenomena disrupt continuity of care and represent substantial patient safety concerns associated with delayed diagnosis and increased morbidity. Comprehensive research addressing these pediatric patients in Türkiye is lacking. To identify the characteristics and predictors of LWBS and LAMA in a Pediatric Emergency Department (PED) and to evaluate their re-attendance rates. This retrospective cohort study analyzed visits (Jan 2020–July 2025) at a tertiary PED in Türkiye. The final analysis included all eligible visits, excluding patients older than 18 years and those with missing discharge data. Demographics, triage categories, Door-to-Physician (D2P) time, Door-to-Disposition (D2D) time, disposition status, crowding indicators, and re-attendance rates (early within 3 days; late within 7 days) were extracted from electronic health records. Multivariable logistic regression was performed to identify independent predictors of LWBS and LAMA. Of 612,911 pediatric visits, 1.4% resulted in LWBS and 0.1% in LAMA. In multivariable analysis, LWBS was independently associated with ED crowding in a dose–response pattern, high-acuity triage codes, and the pandemic period. LAMA was independent of crowding but strongly associated with night shift (aOR = 2.38; 95% CI, 1.91–2.95; P < 0.001), red-code triage (aOR = 7.09; 95% CI, 5.37–9.24; P < 0.001), and showed a progressive secular increase over the study period. LWBS patients had longer D2D times compared with all other groups (P < 0.001). No significant association was found between LWBS or LAMA and early and late re-attendance; however, patients initially admitted or transferred exhibited significantly higher re-attendance rates (both P < 0.001).

Conclusions: LWBS and LAMA have distinct predictor profiles: LWBS is primarily a capacity-driven event linked to crowding, whereas LAMA is associated with the clinical decision-making process and overnight communication dynamics. High-acuity patients carry independently elevated elopement risk, indicating that interventions must adopt differentiated strategies beyond throughput optimization.

What is Known:

• Overcrowding and prolonged waiting times in pediatric emergency departments are established global causes of treatment incompletion and safety risks.

What is New:

• Multivariable analysis demonstrates that high-acuity triage categories carry independently elevated elopement risk after adjustment for crowding, temporal, and pandemic-related factors.

• LWBS and LAMA have distinct predictor profiles: LWBS is primarily capacity-driven with a dose–response relationship to ED crowding, whereas LAMA is independent of crowding but strongly associated with night shift and clinical decision-making dynamics. Neither LWBS nor LAMA was associated with increased early or late re-attendance rates in this cohort.

Graphical Abstract