Here’s a magic trick for you: How do you improve emergency department (ED) wait-time metrics while simultaneously seeing fewer patients? Simple. You wait until they leave, then don’t count them.
Recently, I wrote about euphemisms used in health care to downplay systemic failure. Let’s take a closer look at one of those: Left Without Being Seen (LWBS) – the statistical escape hatch that’s become Canadian emergency medicine’s dirtiest little secret.
The vanishing act
Let’s start with the raw numbers, because they’re genuinely breathtaking.
In 2018-19, British Columbia recorded 76,157 LWBS patients. By 2024-25? That number hit 141,961 – an 86 per cent increase in just seven years. To put that in perspective, B.C.’s population grew by roughly 11 per cent during the same period, meaning LWBS rates increased nearly eight times faster than population growth.
For context, pre-pandemic LWBS rates varied by hospital type: academic/teaching EDs averaged 3.7 per cent, regional EDs 3.4 per cent, and urban EDs 3.2 per cent. Those rates now look quaint.
Quebec managed an astounding 11.5 per cent LWBS rate in 2024-25, representing 428,676 people who walked out of EDs. Across the country, LWBS rates ranged between 4.9 per cent (Ontario) and 14 per cent (P.E.I).
But here’s where it gets interesting. These patients vanish from our performance metrics entirely. They don’t count against “time to physician initial assessment” targets. They actually improve the statistics.
Can’t meet your wait time benchmarks? No problem. Just wait a little longer. Eventually, the problem walks itself out the door.
‘Don’t worry, it’s just people with colds’
The standard reassurance has always been that LWBS patients are low-acuity – people with sniffles who got impatient. Minor stuff.
The data says otherwise.
According to the Canadian Triage and Acuity Scale (CTAS), patients are categorized from Level 1 (resuscitation – you’re dying right now) to Level 5 (non-urgent – maybe you shouldn’t be here). CTAS 2 patients are classified as “emergent” – think heart attacks, strokes, severe trauma (technically referred to as “a potential threat to life or limb”). Yet, 7 per cent of CTAS 2 patients leave without being seen – the very patients we built emergency departments to serve. For CTAS 3 (urgent) patients, 8.7 percent are gone. These aren’t people with hangnails. These are genuine emergencies, and nearly one in 10 are walking out before anyone sees them.
But sure, let’s keep pretending this is a patient behaviour problem rather than a system collapse.
The death study
In December 2024, ICES Ontario published a study that should have triggered alarm bells across every health ministry in the country. It didn’t.
Researchers compared the outcomes of Ontario adults who left emergency departments without being seen (LWBS) in 2022-23 to those from 2014-2020. Same behaviour (leaving), different time periods. The question: Are outcomes getting worse?
Answer: Yes. Significantly.
Patients who left without being seen in 2022-23 had:
- 14 per cent higher risk of death or hospitalization within seven days compared to pre-pandemic LWBS patients
- 5 per cent higher risk at 30 days.
Let that sink in. We’re not comparing LWBS patients to patients who stayed and got care. We’re comparing recent LWBS patients to earlier LWBS patients. The same action – leaving – now carries substantially higher risk of death or hospitalization within a week.
The patient profile? Median age 41; few prior hospitalizations. These aren’t frequent flyers gaming the system. These are healthy people having actual emergencies who gave up and left.
The math game
Let’s say the target is to see 90 per cent of patients within a benchmark time. Here’s how the trick works in practice:
Scenario A: 100 patients arrive. You see 85 within target. Performance: 85 per cent. FAIL.
Scenario B: 100 patients arrive. 10 leave without being seen. You see 75 of the remaining 90 within target. Performance: 83 per cent. FAIL.
Scenario C: 100 patients arrive. 20 leave without being seen. You see 72 of the remaining 80 within target. Performance: 90 per cent. SUCCESS!
Same hospital. Same staffing. Fewer patients actually seen. Better metrics.
The sicker the system gets, the more patients leave, the better our statistics look.
The sicker the system gets, the more patients leave, the better our statistics look. We’ve created a performance indicator that rewards failure.
Hospital boards and Chief Executive Officers love seeing green dashboards and meeting targets – the inconvenient truth that people may be leaving amid chest pain and dying at rates 14 per cent higher gets statistically vaporized from existence.
We’ve invented a performance measurement system where the sicker it gets, the more patients abandon hope, the shinier our metrics become. It’s not a bug; it’s a feature with a body count.
The acceleration
Ontario’s LWBS rates tell the story of a system in freefall:
- Pre-pandemic peak: 4 per cent;
- 2020-2023: Exceeded 4 per cent in 42 per cent of months;
- 2022-2023: Exceeded 4 per cent in 75 per cent of months.
This isn’t a blip. It’s a trend. And it’s getting worse.
Vancouver Island saw LWBS patients increase from 11,513 in 2018-19 to 29,997 in 2024-25 – a staggering 160 per cent increase. These aren’t statistical anomalies. This is what system collapse looks like when you measure it honestly.
The normalization
The most disturbing aspect isn’t the numbers themselves – it’s how we talk about them. LWBS has been transformed from a crisis indicator into a routine operational metric. We track it like bed occupancy or hand hygiene compliance. Just another data point in the dashboard.
We’ve created entire categories of analysis: LWBS by time of day, by day of week, by triage level, by chief complaint. We study it. We trend it. We present it at conferences.
What we don’t do is treat it like what it actually is: systemic ED care failure.
When hospitals began systematically tracking LWBS around 2010, it was meant to identify problems. Instead, we normalized them. A 3.6 per cent national rate became the baseline. Then 5 per cent. Now we’re flirting with double digits in some provinces, and the response is . . . more tracking.
The disappeared
Here’s what we know: More than 1.2 million Canadians gave up on emergency care in 2022-23 alone. Some percentage of them – we don’t know exactly how many – will die or be hospitalized within a week, at rates 14 per cent higher than just a few years ago.
We don’t follow up with most of them. We don’t track their outcomes systematically. They leave; they disappear from our metrics; our performance numbers improve.
It’s brilliant, really. We’ve turned “we failed to provide care” into a statistical category that makes us look better.
As long as patients continue to cooperate and leave without being seen, the statistics stay green, the dashboards glow and hospital boards sleep soundly. The only request is that they have the decency to die somewhere else – preferably off-site, off-record and off the quarterly report.
Collapse in the parking lot if you must, just not in the waiting room where it becomes a data problem.
