• Brandon Kappy, Kenneth McKinley, James Chamberlain, Gia M Badolato, Robert H Podolsky, Gregory Bond, Theresa Ryan Schultz, and Sarah Isbey.
• Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia. Electronic address: bkappy@childrensnational.org.
• J Emerg Med. 2023 Sep 1; 65 (3): e237e249e237-e249.

BackgroundLeft without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended.ObjectiveWe assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS.MethodsWe performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively.ResultsMean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am.ConclusionsLWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.Copyright © 2023 Elsevier Inc. All rights reserved.

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