Mediterranean Journal of Emergency Medicine & Acute Care

Introduction: This study aims to assess follow-up behaviors of patients who leave without being seen (LWBS) from a hybrid point of service (POS) collection model Emergency Department (ED).

Methods: A cross-sectional survey was administered to patients who LWBS from a hybrid POS collection model ED, one-week post-ED visit, at an academic tertiary care medical center in Lebanon, between June 2016 and May 2017.

Results: LWBS patients were found to be young, males, and present with conditions of lower urgency and presenting mainly with a musculoskeletal chief complaint. Majority (66.8%) left because of third party payer denial of visit coverage followed by cost of visit (12.6%) and wait times (12.6%). A greater percentage of those who LWBS due to financial reasons were male (64.1% vs 33.3%, p <0.001) and waited less (23.4 min vs 30.8 min, p=0.08) compared to those who left for non-financial reasons. The majority of LWBS patients sought medical care within the week after leaving the ED (78.4%), primarily at ambulatory clinics (89.9%) with few at emergency departments (10.1%). Few required admission to hospital (4.2%) and no mortalities were reported. A greater percentage of those who left because of financial barriers, felt the same/better after leaving the ED (82.1% vs 66.7%, p=0.03), sought care at alternate sites (82.1% vs 66.7%, p=0.03), primarily ambulatory clinics (94.1%, p=0.003), with fewer requiring admission to the hospital within one well (1.4% vs 13.3%, p=003). Irrespective of the reason for LWBS, all patients who sought care at an ambulatory clinic, did so at a different institution (100.0%).

Conclusion: While the majority of patients who left without being seen from a hybrid POS collection ED left for financial reasons, a high percentage sought care at ambulatory clinics after leaving the ED.  Larger-scale studies are needed to adequately assess the outcomes of those patients, especially in areas with limited access to primary care ambulatory services.

Unilateral calf swelling can pose a diagnostic challenge in the Emergency Department. There are several differential diagnoses for this presentation, and the management of one may be a contraindication for another. Point-of-care-ultrasound (POCUS) can be used to identify the aetiology and guide management with confidence. We present a case of an elderly patient with unilateral leg swelling in which DVT was initially suspected. However, POCUS demonstrated a ruptured Baker's cyst with associated calf haematoma. The use of POCUS by emergency physicians can avoid the consequences of unnecessary or harmful treatment and missed diagnosis of venous thromboembolic disease.