In the UK, as in most developed countries, more patients are presenting to Emergency Departments (EDs) with minor illnesses or injuries.
Critically unwell or injured patients are prioritised, whereas those who are felt to be less unwell wait longer for clinical review. Simpson et al. examined 977,907 first-time ED presentations by children aged 0-15 across thirteen acute hospital trusts (between April 2014 and March 2017), trying to figure out how many were non-urgent. 21.4% of these were felt to be non-urgent attendances. These were more common among those under one year of age and out of hours.
Emergency department overcrowding is a complex issue with multiple contributing factors. However, without additional staff or services, non-urgent visits inevitably lead to longer wait times. The recently published Lord Darzi report, commissioned by the UK government, revealed that “more than 100,000 infants waited over six hours in A&E departments in England last year.”
Previous research recognises that long waiting times increase the number of patients who leave the ED before medical review, though much of this is based on the adult population. These patients may be classified as “Did Not Wait” (DNW). Others use “Left Without Being Seen”, “Left Before Treatment”, or “Walkouts”.
In our study, patients labelled “Did Not Wait” had checked into the emergency department and assessed at the front desk. However, they may not have completed a full nursing assessment, seen a doctor, or stayed long enough for any planned tests or treatments to be finished. Patients who Did Not Wait are a feature of most EDs worldwide.
When an adult patient with decision-making capacity chooses to leave the emergency department before being seen by a doctor, that’s one issue. However, it’s a different concern when “Did Not Wait” cases involve children. Children usually aren’t the ones who decide to come to the ED, and they’re also unlikely to be the ones deciding to leave.
During busy winter months, children’s emergency departments see a rise in “Did Not Wait” cases. Let’s explore whether there are common factors among those who leave without being seen and whether this is a harmless issue, such as non-urgent cases, or a more concerning problem that may require specific interventions.
What is happening internationally?
A 2011-2012 Australian study by Blake et al. looked at “Did Not Wait” cases in a Queensland hospital and found an overall DNW rate of 4.3%. Of these, 40% were paediatric patients, and 12.4% of those children later returned to the ED. There was a disproportionate number of DNWs on Sundays, and if they presented between 4 pm and midnight,
A 2002 Canadian study by Goldman et al., conducted over four months at a children’s hospital in Toronto, reported a “Did Not Wait” (DNW) rate of 3% (7). Of the 289 children who left without being seen, only one child (0.3%) later required hospital admission.
Gaucher et al. found that children arriving in the evening and those aged between 3 months and 11 years were likelier to leave without being seen. Similarly, a study by Suastegui et al., conducted over three years (2013-2015) in Florida, found that younger children and those arriving in the evening or overnight had higher rates of “Did Not Wait” cases.
What is happening locally?
Learning about international trends sparked our curiosity about our own department. As a large tertiary Children’s Emergency Department in England, we believe our experiences could provide a valuable benchmark for others.
Which patients Do Not wait?
We collected attendance data for the Leicester Royal Infirmary Children’s Emergency Department (LRI CED) for six months, from 1 October 2023 to 31 March 2024.
The 2021 census revealed an 11.8% increase in Leicester City’s population from the 2011 census, bringing the city’s population to 368,581 and the county’s total population to 712,300. During the six months, 34,989 visits to the Leicester Royal Infirmary Children’s Emergency Department occurred, and 1,824 patients “Did Not Wait” (DNW).
Patients were excluded from the total if it was clearly noted that they had made another appointment (like seeing an out-of-hours GP), had an upcoming outpatient appointment (such as a fracture clinic visit for a known injury), or if the issue had already been resolved (for example, a foreign object removed by the patient or parent while waiting).
This resulted in a study population of 1,764, giving a “Did Not Wait” (DNW) rate of 5%. There was a significant increase in DNWs in November 2023, with 499 cases out of 6,492 total attendances, resulting in a DNW rate of 7.7% for that month. While there was little difference between the number of males and females who left without being seen, there was a notable difference in the children’s ages.
The highest proportion of “Did Not Wait” cases came from the youngest children. In October, November, and December 2023, most DNW cases were infants under one year old, while in January, February, and March 2024, the most common age was one year.
These findings are consistent with those of Gaucher et al. and Suastegui et al. They also likely align with research by Simpson et al., which showed that non-urgent attendances (NUAs) were more common among younger patients.
Further research is needed to better understand caregivers’ behaviour in these situations. However, some reasons might include young children’s low tolerance for waiting (and the frustration this causes for parents), a desire to get younger children back to bed during the night, and parents feeling reassured by their child’s improvement or lack of worsening symptoms while waiting.
Leicester is an ethnically diverse city and one of the first in the UK with a non-white majority. The largest ethnic groups are White and Asian. Based on city population data, there was a higher proportion of “Did Not Wait” patients from White backgrounds than expected. However, the Leicester Royal Infirmary Children’s Emergency Department also serves the surrounding county, where 88% of the population is White. This may explain the discrepancy.
Some studies suggest that language barriers are a major reason for leaving without being seen, but this doesn’t align with our findings, as 42-49% of the DNW cases were White British.
According to the 2019 Indices of Multiple Deprivation, Leicester ranks as the 32nd most deprived of 317 local authority districts and is significantly more deprived than its surrounding areas. In our study, 56% of patients came from the most deprived half of the population, while 44% were from the least deprived half. What impact does this have on DNWs? We’ll discuss this later.
When do these patients present?
19% of all DNWs happened on Mondays, with the fewest occurring on weekends. This contrasts with other studies that report higher DNW rates on weekends, often attributed to lower staffing levels. While weekend staffing at Leicester Royal Infirmary Children’s Emergency Department is reduced compared to weekdays, our single front-door model, where all GP and midwife referrals come through the CED, may explain the busier weekdays.
Previous research has highlighted that a disproportionate number of “Did Not Wait” (DNW) cases occur in patients arriving at the emergency department during the evening and night. Our local data supports this, showing that 56.1% of DNWs occurred in patients who checked in between 6 p.m. and midnight. In contrast, only 5.2% of DNWs occurred in those arriving between 6 a.m. and midday.
More patients visit the emergency department in the evening and early night than during the regular working hours. As a result, departments are busier, leading to longer wait times and more people leaving before being seen.
While some speculate that factors like parents waiting for a partner to return home to care for other children may contribute, there is little evidence to confirm or disprove this. The increase in DNWs between 6 p.m. and midnight also raises the question of whether children presenting during these hours are less severely ill.
What happens to patients who Do Not Wait?
Almost one in five (18%) of those who DNW returned within a week. Most re-attendances occurred in November, the month with the most DNWs.
Between 3.8% and 13.2% of patients who returned needed to be admitted for further treatment. This is significantly higher than the 0.3% reported by Goldman et al. Interestingly, although December had the lowest rate of return patients, it had the highest percentage of those requiring admission.
| Mental Health | Escalating mental health concerns |
| Medical | Repeat visits, admitted for observation of petechial rash and deranged clotting, Bronchiolitis, Viral induced wheeze, Asthma, Pneumonia, Gastroenteritis (plus background immunodeficiency), Hypoglycaemia, Tonsillitis, Pyelonephritis, Mastoiditis, Frontal lobe abscess requiring transfer to neurosurgical centre, HSP with abdominal pain, Peri-orbital cellulitis |
| Surgical | Post op ileus, Ureteric stone, Abscess requiring IV antibiotics, Abscess requiring I&D, Suspected intussusception, Intussusception (Meckels), required laparotomy and anastomosis, Appendicitis, Foreign body in eye |
The higher proportion of “Did Not Wait” (DNW) cases among preschool-aged children was also seen in those returning to the Leicester Royal Infirmary Children’s Emergency Department within a week of leaving (41% were aged 0-3). This age group also accounted for the highest proportion of admissions after returning (46%).
Patients from the most deprived 50% of the population were over-represented. 61% of return visits came from individuals in the lowest deprivation deciles. This trend continued in those requiring admission within a week of presentation.
When considering whether children who visit the emergency department during off-hours are less sick and, therefore, more likely to leave without being seen, our data suggests otherwise. If children presenting between 6 p.m. and midnight were generally less ill, we would expect fewer to require hospital admission on return visits. However, 50% of those who needed admission after re-presenting had arrived between 6 p.m. and midnight, compared to only 23% arriving between midnight and 6 a.m. or midday and 6 p.m. Just 4% came between 6 a.m. and midday. This supports the argument for increasing staffing during the busiest times of the week.
What does this mean for me?
Around 5% of the patients presenting to our large Children’s Emergency Department left before their care episode was complete.
Nearly 1 in 5 returned within seven days, and around 8% required hospital admission. This means that approximately 80% did not return. Of those who did, 92% did not require admission.
Our local data highlights that “Did Not Wait” (DNW) cases are significant, influenced by inequality, overcrowding, and peak busy times, and are more common among younger children. While most DNWs are harmless, some children did require further investigations, treatment, or even surgery after their caregivers initially chose to leave the department.
Thank you and acknowledgements to Dr Kee Wei Phang, Paediatric Emergency Medicine ST7, for their invaluable help.
References
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Goldman RD, Macpherson A, Schuh S, Mulligan C, Pirie J. Patients who leave the pediatric emergency department without being seen: a case-control study. Can Med Assoc J. 2005;172(1):39–43.
Gilligan P, Joseph D, Winder S, O’Keeffe F, Oladipo O, Ayodele T, 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;26:780–2.
Gaucher N, Bailey B, Gravel J. Who Are the Children Leaving the Emergency Department Without Being Seen by a Physician? Acad Emerg Med. 2011;18:152–7.
Suastegui C, Lozano JM, Maniaci V, Linares MYR. Comparison of the Demographics and Visit Characteristics of Patients Who Left the Pediatric Emergency Department Without Being Seen With Those Who Were Evaluated in the Emergency Department. Pediatr Emerg Care. 2021;37(6):329–33.
Council LC. Leicester – local authority profile 2023 [Internet]. Available from: https://www.leicester.gov.uk/media/inmh1feq/living-in-leicester-infographic-summary-2023.pdf
